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  • Review
  • Open Access

Seroprevalence of hepatitis B and C in Nepal: a systematic review (1973–2017)

Hepatology, Medicine and Policy20183:10

https://doi.org/10.1186/s41124-018-0039-2

  • Received: 13 December 2017
  • Accepted: 28 August 2018
  • Published:

Abstract

Introduction

Hepatitis B and C represent an important co-infection for people living with HIV worldwide. Nepal wants to be part of the international mobilization for viral hepatitis elimination, and has pursued better understanding of the epidemic in its territory through scientific research.

Methods

We performed a systematic review of seroprevalence studies hepatitis B and C in Nepal following the PRISMA 2009 Flow Diagram.

Results

Fifty-four scientific publications and reports were selected for this review. Nearly a quarter of these documents have been issued in recent years and many are authored by non-governmental organizations in Nepal. The collective of information displays a wide range of alarming prevalence rates, particularly for girls and women survivors of human trafficking and a progressive participation of civil society in viral hepatitis epidemiology research in the country.

Conclusion

This paper presents a most complete review of hepatitis B and C and HIV co-infection prevalence studies in different population groups from 1973 to 2016. A comprehensive analysis of the epidemiology and apparent trends in public health research and policy making in Nepal are also addressed in this document. We expect this to be a most important tool for improvements in future interventions for both epidemics in the country.

Keywords

  • Viral hepatitis
  • Hepatitis B
  • Hepatitis C
  • Systematic review
  • Epidemiology
  • Nepal

Background

Viral hepatitis has become a leading cause of death and disability worldwide - estimated to be responsible for over 1.4 million deaths every year. Chronic viral hepatitis, mostly represented by the hepatitis B and C viruses infections (HBV and HCV, respectively), is a major cause of increasing events of high morbidity and mortality such as cirrhosis, end-stage liver disease and hepatocellular carcinoma. Both viruses are more easily transmissible than HIV [1].

The Sustainable Development Goals (SDG) establishes the year of 2030 as a desirable deadline for the end of many epidemics, including viral hepatitis. Nepal, a landlocked central Himalayan country in South Asia, has committed to the seventeen ambitious goals of SDG, and pursues to graduate from the least developed country rank by 2022. Nepal already presented remarkable achievements in infectious diseases, particularly the HIV response [24]. However, the understanding of viral hepatitis impacts to the country is limited. There is no national plan devised for the elimination of viral hepatitis and hepatitis C has only been briefly mentioned in the National HIV Strategic Plan 2016–2021 (Nepal HIVision 2020) [5].

Multiple community- and facility-based seroepidemiological surveys for viral hepatitis and co-infections have taken place in Nepal since 1973 [68]. Studies have assessed different population groups mostly in urban areas of Kathmandu Valley and to a lesser extent in other development regions.

As new National Guidelines for Viral Hepatitis are being developed, the Joint United Nations Programme on HIV/AIDS in Nepal (UNAIDS Nepal) understands this comprehensive review is a most welcome tool for future research. We expect this document to be useful for mathematical models, advocacy for key populations, improvements in public health policy, and setting priorities for successful elimination of hepatitis B and C.

Methods

We conducted a systematic review of seroprevalence studies of hepatitis B and C following the PRISMA 2009 Flow Diagram [9]. Our main sources of data for this research were: 1) PubMed (Medline), through the following search expression “((“Hepatitis B”[Mesh] OR “Hepatitis B, Chronic”[Mesh] OR “Hepatitis B virus”[Mesh] OR “Hepatitis B Surface Antigens”[Mesh] OR “Hepatitis B Antibodies”[Mesh] OR “Hepatitis B”[Text] OR “Hepatitis C”[Mesh] OR “Hepatitis C, Chronic”[Mesh] OR “Hepatitis C Antibodies”[Mesh] OR “Hepatitis C”[Text]) AND (“Nepal”[Mesh] OR “Nepal”[Text]))”; 2) reports provided by the Government of Nepal (GoN); 3) reports authored by international agencies and non-governamental organizations (NGOs); and 4) personal correspondence to authors.

Study selection

Two researchers took part in all steps of the reviewing process. We assessed our initial search results for eligibility through title, abstract and full-text analysis. Duplicates were not identified, but two publications were found to be supplemental to previously evaluated studies. One review obtained during the search presented additional data for three studies unavailable in digital media. Personal correspondences were sent to authors to obtain additional information. We could not identify any repetition of datasets.

Publications were considered eligible for inclusion if they presented own and original data (absolute numbers or percentage) for any population group, Nepalese or residing in Nepal, at any given site and time for at least one of the following outcomes of interest: 1) hepatitis B seroprevalence, active infection or exposure; and 2) hepatitis C seroprevalence as detected by anti-HCV tests.

Selected publications were excluded if full-text material could not be retrieved, if published before 1981 and if abstract could not provide sufficient information for any of the three outcomes of interest.

Data extraction

The following data were then extracted from each eligible study included in this review: year of publication, population group, site, month and/or year of data collection, sample size, numbers/percentage of positive results for hepatitis B, C, HIV and syphilis; and authors’ name.

Seven studies did not provide details of which tests were used to define active HBV infection [7, 1015]. One study identified did not provide details about which tests were used to define seroprevalence of exposition to HBV [16].

We chose to display results for every study total population and for as many subgroups as possible. Figures were obtained through full-text analysis and personal correspondence with authors. All numbers were thoroughly revised.

Results

This review selection process is depicted in Fig. 1, as adapted from the PRISMA 2009 Flow Diagram [9]. Initial search expression resulted in ninety different records with no duplicates. Forty-two citations were excluded after title, abstract and full-text screening and one citation was found to be supplemental. One report from Asian Network of People Who Use Drugs (ANPUD), one from HEPA Foundation/United Nations Office on Drugs and Crime (UNODC), one from United Nations Development Program (UNPD), two from Nepal Red Cross Society (NRCS) and six from Ministry of Health of Nepal (MoH), including the Global AIDS Response Progress Report 2015 (GARRP), were added to the group of forty-eight eligible citations, resulting in fifty-nine documents.
Fig. 1
Fig. 1

Flow of article selection for the viral hepatitis B and C prevalence studies in Nepal

Five records were excluded because full-text could not be retrieved and their abstracts did not have data on any of the three outcomes of interest. Three additional documents from 1987 to 1990, which were not listed in PubMed, were identified from a review and later included in the collective. Fifty-seven documents relevant to fifty-five relevant prevalence studies were selected for this review.

Table 1 presents the collective of viral hepatitis prevalence studies with stratified population groups according to WHO key terms.
Table 1

Studies reporting hepatitis B and C in Nepal

SN

YEAR

POPULATION, SITE, TIME

SAMPLE SIZE, N

ANTI-HIV(%)

HBV

ANTI-HCV

NOTES

AUTHOR(S)

HBSAG(%)

ANTI-HBC(%)

ANTI-HBS(%)

1

1973

Patients attending hospitals in Kathmandu during infectious hepatitis outbreak, January 1973 to October 1973

53 sera samples

0 (0.00)

Hillis A et al. [6]

2

1984

Hospitalized patients with jaundice referred to Shree Tribhubn Chandra Military Hospital, Kathmandu and Infectious Disease Hospital, Teku, 1981 to 1982

41 patients

6 (7.50)

Kane MA et al. [28]

Outpatients referred to Shree Tribhubn Chandra Military Hospital, Kathmandu and Infectious Disease Hospital, Teku, 1981 to 1982

39 patients

3

1987

Children age 0–10 years, Surkhet Valley

45 childrena

(6.6)

(22.2)

Shreshta SM. [72]

Children, teenagers and adults age 11–20 years, Surkhet Valley

65 children, teenager and adultsa

(3.0)

(46.6)

Adults age 21–40 years, Surkhet Valley

82 adultsa

(9.7)

(44.0)

Adults 41+ years, Surkhet Valley

33 adultsa

(6.0)

(25.0)

Girls and women, 0–41+ years, Surkhet Valley

(9.8)

 

Boys and men, 0–41+ years, Surkhet Valley

(4.4)

General population age 0–41+, Surkhet Valley

225 peoplea

(6.6)

(35.0)

4

1987

Tibetan children age 0–9 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

34 children

(20.0)

(32.0)a

Shrestha SM. [30]

Tibetan children, teenagers and adults age 10–19 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

79 children, teenagers and adults

(10.0)

(39.0)a

Tibetan adults age 20–29 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

106 adults

(18.0)

(55.0)a

Tibetan adults age 30–39 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

61 adults

(20.0)

(46.0)a

Tibetans age 40–49 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

95 adults

(15.0)

(36.0)a

Tibetans age 0–49 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

375 people

(16.0)

(45.0)a

Nepalese children age 0–9 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

113 children

(0.0)

(3.5)a

Nepalese children, teenagers and adults age 10–19 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

198 children, teenagers and adults

(0.5)

(5.0)a

Nepalese adults age 20–29 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

110 adults

(1.8)

(5.4)a

Nepalese adults age 30–39 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

49 adults

(0.0)

(32.6)a

Nepalese adults age 40–49 years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

25 adults

(0.0)

(16.0)a

Nepalese adults age 50+ years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

45 adults

(2.2)

(7.8)a

Nepalese age 11–41+ years, Hemza, Tashi Ling, Pokhara; Jawalkhel, Kathmandu Valley

540 people

(0.7)

(36.0)a

  

5

1988

Patients during 1983 enterically transmitted non A–non B hepatitis outbreak, Kathmandu Valley

150 patients

34 (13.60)a

Nuti M [10]

Controls during 1983 non A–non B hepatitis outbreak, Kathmandu Valley

100 people

6

1988

Lactating women from six villages of Kathmandu Valley

26 women

0 (0.00)

4 (15.38)

8 (30.77)

Reynolds RD et al. [73]

Breastfed infants age 2–6 months from six villages of Kathmandu Valley

26 infants

7

1989

Patients age 20–40 years attending four Kathmandu hospitals, Kathmandu, 1985

460 sera samples

0 (0.00)

5 (1.09)

64 (13.91)

Mertens T et al. [74]

8

1990

Children age 0–5 years

57 healthy children

0 (0.00)

5 (8.77)

Shrestha SM [75]

Children and teenagers age 6–15 years

359 healthy children ad teenagers

8 (2.23)

15 (4.18)

Teenagers and adults age 16–41 years

1788 healthy teenagers and adults

16 (0.89)

158 (8.84)

Adults, 41+ years

351 healthy adults

2 (0.57)

35 (9.97)

Girls and women, 0–41+ years

1529 healthy women

9 (0.59)

76 (7.40)

Boys and men, 0–41+ years

1026 healthy men

17 (1.65)

138 (9.02)

General population, 0–41+ years

2555 healthy individuals

26 (1.02)

23 (0.90)

214 (8.4)

9

1991

Spouses of HBsAg chronic carriers

34 people

6 (17.65)

15 (44.12)

Shrestha SM et al. [29]

Offspring of HBsAg chronic carriers

73 people

15 (20.55)

17 (23.29)

Siblings of HBsAg chronic carriers

29 people

9 (31.03)

11 (37.93)

10

1993

Children age 0–4 years, Gurkha Contingent, Singapore

177 children

64 (19.28)

161 (17.05)

213 (22.56)

Goh et al. [32]

Children age 5–14 years, Gurkha Contingent, Singapore

155 children

 

Children and adults age 15–24 years, Gurkha Contingent, Singapore

227 children and adults

Adults age 25–34 years, Gurkha Contingent, Singapore

289 people

Adults 35+ years, Gurkha Contingent, Singapore

96 people

Gurkha Community members, Gurkha Contingent, Singapore

944 people

26 (2.75)

11

1994

Patients with chronic hepatitis attending Bir Hospital, Kathmandu

20 patients

12 (60.00)

5 (25.00)

Shreshta SM et al. [26]

Patients with cirrhosis attending Bir Hospital, Kathmandu

63 patients

25 (39.68)

9 (14.28)

Patients with hepatocellular carcinoma attending Bir Hospital, Kathmandu

62 patients

20 (29.41)

6 (9.68)

Patients with chronic hepatitis, cirrhosis or hepatocellular carcinoma attending Bir Hospital, Kathmandu

145 patients

57 (39.31)

20 (13.79)

Pregnant women attending Bir Hospital, Kathmandu

83 women

0 (0.00)

3 (3.61)

Medical or paramedical personnel serving at Bir Hospital, Kathmandu

296 people

5 (1.69)

10 (3.38)

12

1994

Female sex workers, Kathmandu Valley

341 women

3 (0.88)

37 (10.85)a

Syphilis: 73 (21.41)

Bhatta P et al. [76]

13

1994

Villagers, Dharan, Sunsari; Pancha Kanya Village Development Committee, Ilam; Dhankuta Hile, Dhankuta; Basantapur Village Development Committee, Tehrathm

303 serum samples

0 (0.00)

6 (1.98)

Rai SK et al. [77]

14

1995

Villagers, Bhadrakali and Kotyang villages, 1987

676 blood samples

2 (0.29)

52 (7.69)

1 (0.15)

Nakashima K et al. [78]

15

1996

People who inject drugs

72 people

4 (5.55)

59 (81.94)

58 (80.55)

Shrestha SM et al. [25]

16

1997

People who use drugs

72 people

2 (2.78)

44 (61.11)b

43 (59,72)

Shrestha SM et al. [16]

People with chronic kidney disease

41 people

1 (2.44)

6 (14.63)b

1 (2.44)

People with chronic liver disease

145 people

57 (39.31)

74 (51.03)b

12 (8.27)

HBsAg carriers

49 people

49 (100.00)

49 (100.00)b

0 (0.00)

Healthy individuals undergoing routine check-ups

181 people

9 (4.97)

46 (25.41)b

0 (0.00)

17

1998

Patients age ≤ 15 years attending Amp Pipal Hospital, Gorkha district, 1993

101 children and adults

0/9 (0.00)

1/9 (11.11)

0/9 (0.00)

De Bruyn et al. [44]

Patients age 16–25 years attending Amp Pipal Hospital, Gorkha district, 1993

0/34 (0.00)

0/34 (0.00)

4/34 (11.76)

Patients age 26–35 years attending Amp Pipal Hospital, Gorkha district, 1993

1/20 (5.00)

0/21 (0.00)

0/21 (0.00)

Patients age 36–45 years attending Amp Pipal Hospital, Gorkha district, 1993

2/14 (14.28)

2/13 (15.38)

0/13 (0.00)

Patients age 46–55 years attending Amp Pipal Hospital, Gorkha district, 1993

1/8 (12.50)

1/8 (12.50)

0/8 (0.00)

Patients age ≥ 56 years attending Amp Pipal Hospital, Gorkha district, 1993

3/10 (30.00)

4/10 (40.00)

0/10 (0.00)

18

1999

Male villagers age ≤ 24 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

44 boys and men

0 (0.00)

1 (2.27)

1 (2.27)

Sawayama Y et al. [40]

Female villagers age ≤ 24 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

43 girls and women

1 (2.32)

1 (2.32)

0 (0.00)

Villagers age ≤ 24 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

87 people

1 (1.15)

2 (2.30)

1 (1.15)

Male villagers 25–34 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

40 men

0 (0.00)

2 (5.00)

2 (5.00)

Female villagers 25–34 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

37 women

1 (2.70)

2 (5.40)

0 (0.00)

Villagers 25–34 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

77 people

1 (1.30)

4 (5.19)

2 (2.60)

Male villagers 35–44 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

49 men

0 (0.00)

1 (2.04)

1 (2.04)

Female villagers 35–44 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

41 women

0 (0.00)

1 (2.44)

0 (0.00)

Villagers 35–44 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

90 people

0 (0.00)

2 (2.22)

1 (1.11)

Male villagers 45–54 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

29 men

0 (0.00)

1 (3.45)

2 (6.90)

Female villagers 45–54 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

44 women

0 (0.00)

2 (4.54)

1 (2.27)

Villagers 45–54 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

73 people

0 (0.00)

3 (4.11)

3 (4.11)

Male villagers 55–64 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

29 men

1 (3.45)

5 (17.24)

0 (0.00)

Female villagers 55–64 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

39 women

2 (5.13)

6 (15.38)

1 (2.56)

Villagers 55–64 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

68 people

3 (4.41)

11 (16.18)

1 (1.47)

Male villagers ≥65 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

38 men

0 (0.00)

7 (18.42)

0 (0.00)

Female villagers ≥65 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

25 women

0 (0.00)

4 (16.00)

0 (0.00)

Villagers ≥65 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

63 people

0 (0.00)

11 (17.46)

0 (0.00)

Female villagers age 15–90 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

229 women

4 (1.75)

16 (6.97)

2 (0.87)

Male villagers age 15–90 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

229 men

1 (0.44)

17 (7.42)

6 (2.62)

Villagers age 15–90 years from Bhadrakali and Kotyang villages, August 1996 to September 1996

458 people

5 (1.09)

33 (7.20)

8 (1.75)

19

2000

Healthy Nepalese Men from Eastern development region, October 1996 to March 1997

100 men

2 (2.00)

Manandhar K et al. [79, 80]

Healthy Nepalese Men from Central development region, October 1996 to March 1997

100 men

3 (3.00)

Healthy Nepalese Men from Western development region, October 1996 to March 1997

100 men

4 (4.00)

Healthy Nepalese Men from Mid Western development region, October 1996 to March 1997

97 men

4 (4.12)

Healthy Nepalese Men from Far Western development region, October 1996 to March 1997

81 men

5 (6.17)

Healthy Nepalese Men from five different development regions, October 1996 to March 1997

478 men

18 (3.76)

17 < 40 yrs. old -

20

2002

Nepalese men age 16–50 years who required medical check-ups for employment abroad, July 1999 to September 1999

2585 men

24 (0.93)

Bidya S [81]

21

2003

Boys and men < 19 years, Baba Medical Center, Kathmandu, September 2003 to June 2004

52 boys and men

0 (0.00)

0 (0.00)

Joshi SK et al. [34]

Men age 20–29 years, Baba Medical Center, Kathmandu, September 2003 to June 2004

375 men

5 (1.33)

9 (2.40)

Syphilis: 4/545

Men age 30–39 years, Baba Medical Center, Kathmandu, September 2003 to June 2004

170 men

5 (2.94)

7 (4.11)

Men age 40+ years, Baba Medical Center, Kathmandu, September 2003 to June 2004

30 men

1 (3.33)

22

2003

People who inject drugs, Siddhi Polyclinic, Dillibazaar, Kathmandu

400 people

342 (85.5)

Shrestha IL [38]

Adults without history of injection drug use, Siddhi Polyclinic, Dillibazaar, Kathmandu

400 people

3 (0.75)

23

2003

Candidates for blood donation at Blood Bank Centre, NRCS, Teaching Hospital, Bhairahawa, February 2001 to April 2003

1548 samples

2 (0.13)

7 (0.45)

2 (0.13)

Chander A et al. [18]

24

2004

Sherpa people age 15–66 years, Lukla, Solukhumbu district, 2004

103 people

2 (1.94)

25 (24.27)

23 (22.33)

Chiba H et al. [82]

25

2005

Bhutanese refugees, Beldangi 2 Extension Camp, March 1998 to July 1998

467 people

4 (0.86)

Shah BK et al. [83]

26

2006

Healthcare workers of Bir Hospital, Kathmandu, December 2001 to February 2002

145 people

2 (1.38)

21 (14.48)

Shrestha SK et al. [68]

27

2006

Male villagers, migrant-returnes from India and non-migrants, from five village development committees, Doti District, April 2001

149 people

1 (0.67)

16 (10.74)

Poudel K et al. [31]

28

2007

Patients with liver cirrhosis or hepatocellular carcinoma attending Liver Foundation Nepal clinic, January 1998 to January 2004

121 patients

48 (39.67)

85 (70.25)

15 (12.40)

Shrestha SM et al. [27]

Patients with liver cirrhosis attending Liver Foundation Nepal clinic, January 1998 to January 2004

70 patients

20 (28.57)

47 (67.14)

6 (8.57)

Patients with hepatocellular carcinoma attending Liver Foundation Nepal clinic, January 1998 to January 2004

51 patients

28 (54.90)

38 (74.51)

9 (17.65)

29

2008

Symptomatic people living with HIV/AIDS at Manipal Teaching Hospital, Pokhara, March 2004 to September 2005

54 patients

PLWH

1 (1.85)a

1 (1.85)

Dhungel BA et al. [11]

30

2008

Candidates for blood donation, NRSC, CBTS, hospital units/mobile camps all over Nepal, 2001 to 2002

72,459 blood samples

627 (0.86)

384 (0.52)

Karki S et al. [19]

Candidates for blood donation, NRSC, CBTS, hospital units/mobile camps all over Nepal, 2002 to 2003

73,758 blood samples

911 (1.23)

417 (0.56)

Candidates for blood donation, NRSC, CBTS, hospital units/mobile camps all over Nepal, 2003 to 2004

76,647 blood samples

663 (0.86)

321 (0.41)

Candidates for blood donation, NRSC, CBTS, hospital units/mobile camps all over Nepal, 2004 to 2005

82,677 blood samples

644 (0.77)

373 (0.45)

Candidates for blood donation, NRSC, CBTS, hospital units/mobile camps all over Nepal, 2005 to 2006

103,067 blood samples

887 (0.86)

366 (0.35)

Candidates for blood donation, NRSC, CBTS, hospital units/mobile camps all over Nepal, 2006 to 2007

115,720 blood samples

430 (0.37)

628 (0.54)

Candidates for blood donation, NRSC, CBTS, hospital units/mobile camps all over Nepal, 2001 to 2007

524,328 blood samples

4162 (0.82)

2489 (0.47)

31

2008

Sex trafficked women and girls assisted by Maiti Nepal, Kathmandu

246 women and girls

74 (30.08)

66/210 (31.43)a

Syphilis: 48%

Silverman J et al. [7]

32

2009

Candidates for blood donation at the Central Blood Transfusion Service, Nepal Red Cross Society (NRCS), Kathmandu, December 2006 to September 2007

33,255 individual samples

65 (0.19)

Karki S et al. [12]

People living with HIV/AIDS diagnosed during blood donation at the Central Blood Transfusion Service, NRCS, Kathmandu, December 2006 to September 2007

65 individual samples tested positive for anti-HIV

PLWH

7 (10.76)

33

2009

Pregnant women admitted in the ward of NMCTH, Kathmandu, 2001 to 2007

5602

18 (0.32)a

Shreshta P et al. [84]

34

2009

People who inject drugs on Oral Substitution Therapy (OST), Kathmandu Valley, June 2009

118 people

95 (80.50)

HEPA Foundation [85]

People who inject drugs, Kathmandu Valley, June 2009

82 people

47 (57.32)

35

2009

Male candidates for blood donation, NRCS, Central Blood Transfusion Service (CBTS), Kathmandu, March 2008 to September 2008

18,434 blood samples of male candidates

25 (0.13)

92 (0.50)

128 (0.69)

Coinfection HIV/HCV: 8/128

Shrestha AC et al. [20]

Female candidates for blood donation, NRCS, Central Blood Transfusion Service (CBTS), Kathmandu, March 2008 to September 2008

3282 blood samples of female candidates

2 (0.06)

10 (0.30)

11 (0.33)

Candidates for blood donation age ≤ 20 years, NRCS, Central Blood Transfusion Service (CBTS), Kathmandu, March 2008 to September 2008

3310 blood samples

2 (0.06)

7 (0.21)

7 (0.21)

Candidates for blood donation age 31–30 years, NRCS, Central Blood Transfusion Service (CBTS), Kathmandu, March 2008 to September 2008

9818 blood samples

12 (0.12)

45 (0.45)

75 (0.76)

Candidates for blood donation age 31–40 years, NRCS, Central Blood Transfusion Service (CBTS), Kathmandu, March 2008 to September 2008

5763 blood samples

10 (0.17)

29 (0.50)

42 (0.72)

Candidates for blood donation age 41–50 years, NRCS, Central Blood Transfusion Service (CBTS), Kathmandu, March 2008 to September 2008

2433 blood sample

3 (0.12)

19 (0.78)

13 (0.53)

Candidates for blood donation age 51–60 years, NRCS, Central Blood Transfusion Service (CBTS), Kathmandu, March 2008 to September 2008

392 blood samples

0 (0.00)

3 (0.51)

2 (0.51)

Candidates for blood donation, NRCS, Central Blood Transfusion Service (CBTS), Kathmandu, March 2008 to September 2008

21,716 blood samples

27 (0.12)

102 (0.46)

139 (0.64)

36

2010

Candidates for blood donation in Banke blood transfusion service, July 2006 to June 2007

5211

63 (1.21)a

6 (0.11)

Tiwari BR et al. [13]

Candidates for blood donation in Kaski blood transfusion service, July 2006 to June 2007

5995

21 (0.35)a

10 (0.17)

Candidates for blood donation in Morang blood transfusion service, July 2006 to June 2007

5351

47 (0.88)a

14 (0.26)

Candidates for blood donation in Banke, Kaski and Morang blood transfusion services, July 2006 to June 2007

16,557

131 (0.79)a

32 (0.19)

37

2011

People who inject drugs, age 18–40 years, 2011

40 people

7 (17.50)

ANPUD. [86]

38

2012

Children age 10–12 years born from April 2000 to April 2002, before hepatitis B vaccine introduction, Kathmandu, April 2012

1200 children

3 (0.25)

Upreti SR et al. [35]

Children age 5–6 years born from April 2006 to April 2007, after hepatitis B vaccine introduction, Kathmandu, April 2012

2187 children

3 (0.14)

39

2012

Patients with ascites attending Nepal Medical College Hospital (NMCTH), Kathmandu, September 2011 to February 2012

43 patients

2 (4.65)

Adhikari P et al. [87]

40

2013

People with one or more risk behaviors attending National Public Health Laboratory (NPHL), Kathmandu, November 2011 to May 2012

678 people

105 (15.49)

Ojha CR et al. [88]

People living with HIV/AIDS diagnosed among study population, November 2011 to May 2012

105 people

PLWH

14 (13.33)

41

2014

People living with HIV/AIDS attending B P Koirala Institute of Health Sciences (BPKIHS), Dharan; Society for Positive Atmosphere and Related Support to HIV and IDS (SPARSHA), Kathmandu; Sukhra Raj Tropical and Infectious Disease Hospital, Teku, Kathmandu, April 2010 to March 2011

108 patients

PLWH

4 (3.70)a

3 (2.78)

HBV/HCV: 0 (0.00)

Barnawal SP et al. [15]

People who inject drugs living with HIV/AIDS attending BPKIHS, Dharan; SPARSHA, Kathmandu; Sukhra Raj Tropical and Infectious Disease Hospital, Teku, Kathmandu, April 2010 to March 2011

205 patients

PLWH

24 (11.71)a

137 (66.83)

HBV/HCV: 10 (4.88)

42

2014

Women living with HIV/AIDS, 18 years or older, February to March 2010

136 women

PLWH

9 (6.61)

Poudel KC et al. [39]

Men living with HIV/AIDS, 18 years or older, February to March 2010

183 men

PLWH

129 (70,49)

People who do not inject drugs living with HIV/AIDS, 18 years or older, February to March 2010

189 people

PLWH

13 (6.88)

People who inject drugs living with HIV/AIDS, 18 years or older, February to March 2010

130 people

PLWH

125 (95.15)

People living with HIV/AIDS, 18 years or older, February to March 2010

319 people

PLWH

138 (43.26)

43

2014

Central Blood Transfusion Centre, 2012–2013

67,644 blood samples

45 (0.07)

150 (0.22)

317 (0.47)

Syphilis: 394 (0.58)

NRCS [21]

Regional Blood Transfusion Centre, 2012–2013

47,733 blood samples

40 (0.08)

188 (0.39)

126 (0.26)

Syphilis: 284 (0.59)

District/Emergency Blood Transfusion Centre, 2012–2013

61,624 blood samples

35 (0.06)

195 (0.32)

121 (0.20)

Syphilis: 118 (0.19)

Hospital Blood Transfusion Unit, 2012–2013

12,320 blood samples

3 (0.02)

32 (0.26)

21 (0.17)

Syphilis: 8 (0.06)

Total, 2012–2013

189,321 blood samples

123 (0.06)

565 (0.30)

585 (0.31)

Syphilis: 804 (0.42)

44

2014

Children age 0–15 years with acute hepatitis attending the liver clinic of Bir Hospital and Norvic International Hospital of Kathmandu, Kathmandu, January 2006 to December 2010

312 children

15 (4.81)a

Sudhamshu KC et al. [14]

45

2015

Women who inject drugs attending Recovering Nepal services submitted to HIV testing, Nepalgunj

3 women

0 (0.00)

0 (0.00)

Kinkel HT et al. [8]

Men who inject drugs attending Recovering Nepal services submitted to HIV testing, Nepalgunj

76 men

6 (7.89)

18 (23.68)

People who inject drugs attending Recovering Nepal services submitted to HIV testing, Nepalgunj

79 people

6 (7.59)

18 (22.78)

Women who inject drugs attending Recovering Nepal services, Dharan; Biratnagar

69 women

9 (13.04)

3 (4.35)

17 (24.64)

Men who inject drugs attending Recovering Nepal services, Dharan; Biratnagar

72 men

12/70 (17.14)

5 (6.94)

50 (69.44)

People who inject drugs attending Recovering Nepal services, Dharan; Biratnagar

141 people

21/139 (15.11)

8 (5.67)

67 (47.52)

Women who inject drugs attending Recovering Nepal services submitted to HIV testing, Kathmandu; Lalitpur; Chitwan

28 women

0 (0.00)

1 (3.57)

2 (7.14)

Men who inject drugs attending Recovering Nepal services submitted to HIV testing, Kathmandu; Lalitpur; Chitwan

153 men

22/108 (20.37)

2 (1.31)

113 (73.86)

People who inject drugs attending Recovering Nepal services submitted to HIV testing, Kathmandu; Lalitpur; Chitwan

181 people

22/136 (16.18)

3 (1.66)

115 (63.53)

Women who inject drugs attending Recovering Nepal services, Nepalgunj; Dharan; Biratnagar; Kathmandu; Lalitpur; Chitwan,

100 women

9 (9.00)

4 (4.00)

19 (19.00)

Men who inject drugs attending Recovering Nepal services submitted to HIV testing, Nepalgunj; Dharan; Biratnagar; Kathmandu; Lalitpur; Chitwan,

301 men

40/254 (15.75)

10 (3.32)

181 (60.13)

People who inject drugs attending Recovering Nepal services submitted to HIV testing, Nepalgunj; Dharan; Biratnagar; Kathmandu; Lalitpur; Chitwan,

354 people

49 (13.84)

People who inject drugs attending Recovering Nepal services, Nepalgunj; Dharan; Biratnagar; Kathmandu; Lalitpur; Chitwan,

401 people

92/397 (23.17)

14 (3.49)

146 (43.89)

200 (49.87)

46

2015

Patients attending Manipal Teaching Hospital, Pokhara, 2008 to 2013

25,708 individual blood samples

218 (0.85)

Supram HS et al. [89]

People living with HIV/AIDS at Manipal Teaching Hospital, Pokhara, 2008 to 2013

218 individual blood samples

PLWH

7 (3.21)

9 (4.13)

47

2015

Boys and men 15+ years who inject drugs, Sunsari, Morang and Jhapa districts, July 2015

360 boys and men

30 (8.33)

3 (0.83)

171 (47.50)

Syphilis: 4 (1.11); Syphilis History: 8 (2.22)

MoH/NCASC [90]

48

2015

Boys and men 16+ years who inject drugs, Kathmandu, Lalitpur and Bhaktapur districts, Kathmandu Valley, June 2015 to July 2015

340 boys and men

22 (6.47)

0 (0.00)

75 (22.06)

Syphilis: 0 (0.00); Syphilis History: 0 (0.00)

MoH/NCASC [91]

49

2015

Boys and men 16+ years who inject drugs, Pokhara Valley, June 2015 to July 2015

345 boys and men

10 (2.90)

6 (1.74)

45 (13.04)

-STI: 4 (1.16)

MoH/NCASC [92]

50

2015

People living with HIV/AIDS in Eastern Development Region,

140 people

PLWH

5 (3.57)

67 (47.86)

UNDP/DFID/CMDN [2, 93]

People living with HIV/AIDS in Central Development Region,

137 people

PLWH

7 (5.11)

30 (21.90)

People living with HIV/AIDS in West Development Region,

203 people

PLWH

13 (6.40)

20 (9.85)

People living with HIV/AIDS in Midwest Development Region,

51 people

PLWH

0 (0.00)

12 (23.53)

People living with HIV/AIDS in Far West Development Region,

146 people

PLWH

5 (3.42)

3 (2.05)

People living with HIV/AIDS in all Development Regions,

677 people

PLWH

30 (4.43)

132 (19.50)

People who inject drugs living with HIV/AIDS in all Development Regions,

562 people

PLWH

8 (1.42)

91 (16.19)

Sex workers living with HIV/AIDS in all Development Regions,

PLWH

(0.1)

0 (0.00)

Migrant workers living with HIV/AIDS in all Development Regions,

PLWH

(1.0)

(1.8)

Gay, Lesbian and Transgender people living with HIV/AIDS in all Development Regions,

PLWH

(0.4)

(0.4)

Non most at risk population living with HIV/AIDS in all Development Regions,

PLWH

(1.3)

(1.0)

51

2016

People who inject drugs with last 30-day frequent injection drug use attending rehabilitation centers, Kathmandu; Bhaktapur; Lalitupur; Sindupalchowk

167 people

20/87 (22.99)

Loewinger G et al. [94]

52

2016

Girls and women 16+ years who inject drugs, Kathmandu, Lalitpur and Bhaktapur districts, Kathmandu Valley, April 2016 to July 2016

160 girls and women

14 (8.75)

3 (1.87)

34 (21.25)

12 (7.50)

MoH/NCASC [95]

53

2016

Boys and men 15+ years who inject drugs, Rupandehi, Kapilvastu, Dang, Banke, Kailali and Kanchanpur districts

300 boys and men

7 (2.33)

5 (1.67)

24 (8.00)

Syphilis: 1 (0.33); Syphilis History: 5 (1.67)

MoH/NCASC [96]

54

2016

Patients who came in contact with HIV or other chronic liver disease and jaundice attending Teku Hospital, Tribhuvan University Teaching Hospital, NRCS

2700 patients

100 (3.70)

Nepal A et al. [97]

55

2016

Central Blood Transfusion Centre, 2014–2015

69,303 blood samples

21 (0.03)

192 (0.28)

224 (0.32)

Syphilis: 360 (0.52)

NRCS [22]

Regional Blood Transfusion Centre, 2014–2015

42,511 blood samples

13 (0.03)

151 (0.35)

56 (0.23)

Syphilis: 115 (0.27)

District/Emergency Blood Transfusion Centre, 2014–2015

77,016 blood samples

27 (0.03)

227 (0.29)

119 (0.15)

Syphilis: 260 (0.34)

Hospital Blood Transfusion unit, 2014–2015

28,324 blood samples

7 (0.02)

47 (0.16)

23 (0.08)

Syphilis: 25 (0.09)

Total, 2014–2015

217,154 blood samples

68 (0.03)

617 (0.28)

422 (0.19)

Syphilis: 760 (0.35)

a: Study describes seroprevalence of active HBV infection. Test(s) used in the survey is(are) not specified

b: Study describes seroprevalence of exposure to HBV. Test(s) used in the survey is (are) not specified

Table 2 presents an analysis of the reviewed data and Cochran’s Q tests performed by Weill Cornell Medical College in Qatar. Estimated prevalence and heterogeneity has been presented for five population groups: PWID, populations at intermediate risk, populations at low risk (general population), populations with liver-related conditions and special clinical populations [17].
Table 2

Findings of the meta-analyses for hepatitis C virus (HCV) prevalence measures

Populations at risk

Studies

Samples

HCV prevalence estimates

Heterogeneity measures

Total N

Total N

Mean (%)

95% CI

Q (p-value)a

τ 2b

I2 (confidence limits-%)c

Prediction interval (%)d

People who inject drugs

15

3140

45.17

26.34–64.73

1714.1 (< 0.0001)

0.1487

99.2 (99.0–99.3)

0–100

Populations at intermediate risk

12

4998

12.76

5.44–22.47

668.83 (< 0.0001)

0.0486

98.4 (97.9–98.7)

0–59.58

Populations at low risk (general population)

28

972,123

0.68

0.54–0.86

683.44 (< 0.0001)

0.2027

96.0 (95.1–96.8)

0.26–1.75

Populations with liver-related conditions

6

411

11.51

7.73–15.87

7.40 (0.1926)

0.0018

32.4 (0–72.7)

3.48–22.89

Special clinical populations

3

133

1.67

0–5.81

2.79 (0.2473)

0.0022

28.4 (0–92.6)

0–75.38

aQ: the Cochran’s Q statistic is a measure assessing the existence of heterogeneity in HCV prevalence estimates

bτ2: the estimated between-study variance in the double arcsine transformed proportions of the true HCV prevalence estimates. The back-transformed τ2 was not calculated as the methodology to do so is not currently available

cI2: a measure assessing the magnitude of between-study variation that is due to differences in HCV prevalence estimates across studies rather than chance

dPrediction interval: estimates the 95% interval in which the true HCV prevalence in a new HCV study will lie

Population groups

Candidates for blood donation account for just seven prevalence studies and yet represent approximately 90 % of the population evaluated for viral hepatitis in Nepal since 1973. This overwhelming presence of candidates for blood donation in seroprevalence studies does not contribute to the understanding of populations at increased risk of HBV, HCV and HIV co-infection in Nepal as they rarely present seroprevalence rates higher than 1 % [12, 13, 1822].

It is understood that people at increased risk of HBV, HCV and HIV co-infections should be properly represented in our review. We have succeeded to identify studies for most groups of interest: general population, children, adults, pregnant women, people who inject drugs (PWID), patients attending healthcare services, sexual and household contacts of people chronically infected by HBV, sex workers (SW), healthcare workers (HCW), migrant workers, refugees/displaced persons and survivors of human trafficking.

We found only one survey of viral hepatitis in lesbian, gay, bisexual or transgender population (LGBT), including men who have sex with other men (MSM); and another in people with history of incarceration. All collected documents only referred to drug use as injection and did not acknowledge people who use drugs (PWUD) or different methods of drug administration (e.g. smoking heroin). [23, 24].

Hepatitis B

A disease preventable by vaccination, hepatitis B has been identified in our review in forty-six studies. HBsAg (surface antigen) positive tests had highest values in PWID (1.3–81.9%), [8, 25] patients with jaundice, chronic liver disease, cirrhosis or hepatocellular carcinoma (7.5–60%); [16, 2628] sexual and household contacts of people chronically infected by HBV (6.6–31), [29] girls and women survivors of sex trafficking (30%), [7] Tibetan population living in Kathmandu Valley (10–20%) [30] and Nepalese people outside Nepal (2.7–19.3) [31, 32]. On the other hand, the overall prevalence of hepatitis B in Nepal is estimated at 0.9%, [33].

Children, adults and general population cohorts also present interesting ranges for figures of hepatitis B seroprevalence. Older age groups present higher values for HBsAg [20, 34] and children born after vaccine implementation display reduced disease prevalence. [35].

Unfortunately, only one document presents viral hepatitis prevalence in LGBT population (MSM included), but it lacks important information on sample size and number of positive tests.

Exposure to hepatitis B virus, defined by anti-HBc (antibody against core antigen), has been assessed only in one key population - PWID, in two studies nearly twenty years apart. In 1996, more than 80 % of PWID had positive results for anti-HBc [25] and in 2015, when less than 45 % had positive results for the same marker [8].

Hepatitis C

One of the most important causes of morbidity [36] and mortality, particularly for people living with HIV (PLWH), [37] hepatitis C seroprevalence has been featured in thirty-one studies, in a total of approximately one million people in Nepal. Prevalence rates range from zero to more than 80%, with highest figures found in PWID (85.5 in males; 24.6 in females), [38] PLHIV (43.3) and patients with hepatocellular carcinoma (17.6). [27, 38, 39].

Regardless of key population status, different prevalence rates have been observed in males and females [40]. Statistically significant differences according to gender can be verified in studies by Shrestha AC et al., between male and female candidates for blood donation in 2009 (0.69 vs. 0.33, respectively), [20] and Kinkel HT et a, between male and female PWID attending Recovering Nepal services in 2015 (19.00 vs. 60.13).

Age has been fundamental to the design of hepatitis C public health policies in many countries. It is known that age can relate to many factors in the epidemic: year of introduction of the virus, availability of tests and distribution of contaminated blood products, cumulative exposure (such as injection drug use, unprotected sexual activity across adult life), and status of harm reduction strategies [4143]. In Nepal, age and hepatitis C have only been featured in two studies. De Bruyn et al. found anti-HCV to be positive in 11.8% of patients age 16–65 years attending Amp Pipal Hospital at Gorkha district in 1993; and Sawayama Y et al. found 2.27% in female villagers 45–54 years from Bhadrakali and Kotyang villages in 1996 [40, 44].

HIV co-infection prevalence

The first HIV prevalence study in Nepal dates 1989, [44] 1 year after the first case of HIV was detected in the country [45]. So far, eighteen prevalence studies also assessed at some time the HIV infection in their population, almost half a million people and roughly half of the population evaluated for HBV or HCV infection since 1985, the year of debut of anti-HIV ELISA tests.

As stated previously for overall population, candidates for blood donation represent the majority of the population tested for HIV co-infection in Nepal in the fifty-five viral hepatitis prevalence studies of this review. Yet, regardless of age and/or gender subgroups, candidates for blood donation have failed to present HIV seropositivity rates above 0.2% [20, 12, 18], constituting themselves a population of low prevalence for HIV co-infection. This data must not considered a proxy for general population, as candidates for blood donation have shown to be a “poor control group for non-genetic studies of diseases related to environmentally, behaviourally, or socially patterned exposures”, [46] but a reason to pursue further detection of viral hepatitis in priority populations.

As we evaluate the remaining studied population, we find that the highest rates of HIV infection found in this review do not belong to PWID, but sex trafficked girls and women, at an approximate 30% rate of infection in 2008 (74/246) [7). This is closely followed by PWID attending Recovering Nepal services, if accounted the participation of those with previously defined HIV status, with rates as high as 23.17% in 2015. Such findings are consonant with latest numbers of Family Health International data for HIV prevalence in PWID in Kathmandu (21% in 2009) [3] and increase of HIV and sexually transmitted infections in survivors of sex traffic, particularly for Nepalese girls and women [4749].

Discussion

This review collects all available surveys performed in Nepal or with Nepalese population. It provides relevant information to policy makers, researchers and activists.

Developments of improved strategic information

It has been 44 years since the first viral hepatitis prevalence study took place in Nepal. Since then, sixty different publications, of which fifty-five are available in this review, have dedicated themselves to the better understanding of these epidemics.

Almost a quarter of these scientific publications and reports have been issued in the last 3 years. While there is still much to investigate, it is undeniable that Nepal’s civil society organizations and academia have been successful in their struggle to improve the reactive approach to viral hepatitis and HIV, shaping public health policy and visibility of key populations.

Superior strategic information and overall engagement to the epidemics lead to additional victories: the inclusion of LGBT issues in government policies, the return of harm reductions strategy in 2007, increase in donor funding for the response to HIV, and stronger ties between emerging and existing networks of key populations and representatives, healthcare professionals, academia, UNAIDS and GoN [5055]. Such echoing common voice for change lead to the preliminary discussion of National Viral Hepatitis Guidelines and negotiation of licensed generic drugs for hepatitis C treatment at a fraction of prices offered to other developing countries [41, 5659]. This recent collective represents a cornerstone for viral hepatitis in Nepal.

Gaps and key populations

It would seem to be that the shared modes of transmission of viral hepatitis and HIV, and the resulting similar epidemiological profiles, could translate into one equally successful public health intervention for both epidemics.

This is hardly the truth. Regardless of improvements in blood safety, availability of harm reduction services and assistance to sexually transmitted and reproductive tract infections, with significant drops in HIV prevalence since the last decade, many key populations sustain subpar decrease in hepatitis C numbers. Such is the case of PWID in Nepal: hepatitis C exceeds three times the HIV prevalence in several cohorts.

Since 2000, PWID, PLHIV, sex workers and LGBT have figured in no less than seventeen different viral hepatitis prevalence studies, almost a third of studies collected in this review, contributing without precedents to the national strategic information and deeper understanding of the response to public health interventions. Additional publications also developed initial data for other population groups such as refugees/misplaced persons and survivors of sex traffic.

Our research could not retrieve any studies regarding transgender population, male sex workers or incarcerated persons in Nepal.

Hepatitis B vaccine coverage and elimination of vertical transmission (EVT)

Hepatitis B is a highly contagious, yet preventable disease [60, 61]. In recent years, many countries have chosen to scale up maternal and newborn care in order to secure a generation ‘free of hepatitis B’.

Our review provided two studies depicting hepatitis B in infancy in Nepal. The first study states hepatitis B is responsible for approximately 5 % of the cases of acute hepatitis in children 0–15 years [14]. The second study describes observed benefits of hepatitis B vaccine introduction to children in Nepal in 2002.

While no routine for hepatitis B immunoglobulin in prevention of vertical transmission has been implemented in Nepal, the rates of acute hepatitis related to HBV infection in children are quite different than the prevalence values of HBV in pregnant women (0.32%), an indicator that perhaps household exposure during infancy, and not mother-to-child transmission, is the reason for new but likely overlooked exposure during infancy (households).

Commercial vaccines for hepatitis B have been available worldwide since 1981 [62]. In Nepal, however, it has only been introduced in 2002. After fifteen years and despite recommendations issued by GoN, the country still struggles to provide appropriate vaccine coverage [35, 63].

Official government reports state that from 2002 until 2009, third-dose hepatitis B vaccine coverage for children 12–23 months stood at approximately 80%. [63, 64] World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) estimate improved coverage in 20,012 and 2013, slightly above 95%. [65] Such higher vaccine coverage numbers are not homogenous in Nepal - not all municipalities have immunization plans or appropriate structure at their disposal [63, 64]. Moreover, the intervention requires timely birth-dose vaccination for a most successful response, [66] and faces many other obstacles [67].

Hepatitis B vaccine is available to healthcare workers (HCW) in many countries. In Nepal, HCW are featured in two studies as an alternative to controls, with HBsAg seropositivity rates of 1.38 and 1.69% [26, 68]. These figures are lower than the ones presented by key populations, but still higher than those of candidates for blood donation. Further investigation reveals that HCW and students in Nepal have largely mishandled biosafety procedures while at high risk of exposure to the infective agent. Studies in tertiary care centers have shown frequent needle-stick and sharps-related injuries, and incomplete or fully ignored vaccination and post prophylaxis procedures [6971].

Nevertheless, UNAIDS understands that the strengthening of the immunization plan and maternal health must be accompanied of a nationwide awareness campaign for HCW and future health professionals.

Community and the strengthening of health systems

Communities were the first responders to the HIV epidemic, nearly thirty years ago. They have continuously played an essential role in development of research, health services and shaping of public health policy worldwide, expanding their activities to sustainable and affordable vaccines and medicines for viral hepatitis.

Moreover, these collectives of advocates, researchers, clients or providers have the ability to work unisonous with marginalized populations, increasing the reach and quality of health systems and health services, often detecting overlooked issues such as stigma and discrimination. Whether leading research or promoting health services, civil society engagement improves awareness, prevention, diagnosis and retention in care. This has been the case of both viral hepatitis and HIV epidemic.

In Nepal, these initiatives are considered to be just as important as developments provided by academia, government and international agencies. It is clear that these endeavors provide a unique opportunity to fill critical gaps such as strategic information, low immunization coverage rates and elimination of mother-to-child and household transmission.

Conclusion

The present review illustrates different turning points in viral hepatitis and HIV co-infection epidemiology in Nepal. Since 1973, when the first study on viral hepatitis in the country was published, there have been many changes in the understanding of these epidemics.

These include the indirect effects of successful public health policies aimed towards HIV, such as the decrease of viral hepatitis prevalence in PWID, and their limitations, revealing overlooked population groups and issues in viral hepatitis that require public health policies of their own.

The review also allows one to witness the progressive scientific development by Nepalese researchers and institutions, and civil society representatives’ participation. Such collaboration correlates with increased number of studies and sample sizes in recent years including the survey of key populations, and will be fundamental for the success of the National HIV Strategic Plan 2016–2021 and achieving the SDG by 2030.

Declarations

Acknowledgements

We are grateful for the support provided by the Biostatistics, Epidemiology, and Biomathematics Research Core at the Weill Cornell Medical College in Qatar. The authors are also grateful for the valuable suggestions and comments by the reviewers of this article.

Availability of data and materials

All data present in this review is accessible through scientific journals and reports.

Authors’ contributions

MCMN and KB performed the systematic review. KB supervised the research and provided inputs for discussion. All authors contributed equally to the discussion, conclusion and review of this manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

This study does not require ethics committee approval or written informed consent as it relies entirely on published available data.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Authors’ Affiliations

(1)
UNAIDS Nepal, UN House, Pulchowk, Lalitpur, GPO 107, Nepal

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