Sami Ramia

HIV/AIDS among female sex workers, injecting drug users and men who have sex with men in Lebanon: results of the first biobehavioral surveys.

Objectives:To measure HIV prevalence and associated risk factors among female sex workers, injecting drug users (IDUs) and men who have sex with men (MSM) in Lebanon and the prevalence of hepatitis B virus and hepatitis C virus among IDUs. Methods and design:A cross-sectional survey of 135 female sex workers, 81 IDUs and 101 MSM was recruited using respondent-driven sampling. A structured interview was conducted by members of nongovernmental organizations working with these populations and blood was collected for serological testing. Results:HIV prevalence was 3.7% among MSM but no HIV cases were detected among female sex workers or IDUs. Among IDUs, prevalence of hepatitis C virus antibody was 51% and prevalence of hepatitis B virus surface antigen was 5%. Three-quarters of MSM had nonregular male sexual partners during the last year but only 39% reported using a condom every time. There was evidence of overlapping HIV risk: 36% of MSM and 12% of IDUs reported that they had sold sex. Previous testing for HIV was lowest among MSM (at 22%) despite their having the highest level both of knowledge about HIV and of perception of being at risk of HIV infection (67%). Conclusion:Prevention efforts at greater scale are needed to reach these at-risk populations in Lebanon. These should target MSM in particular, including access to HIV testing, but will need to address and overcome stigma. For IDUs, surveillance and prevention efforts should integrate both hepatitis C virus and HIV.

Distribution of hepatitis C virus genotypes among injecting drug users in Lebanon

BackgroundThe aim of this study is to determine the prevalence of anti-HCV among injecting drug users (IDUs) in Lebanon, to establish the current prevalence of HCV genotypes in this population and to determine whether demographic characteristics and behavioral variables differ between participants who were HCV-RNA positive and those who were HCV-RNA negative or between the different genotypes. Participants were recruited using respondent-driven sampling method. The blood samples were collected as dried blood spots and then eluted to be tested for HCV, HBV and HIV by ELISA. Anti-HCV positive samples were subjected to RNA extraction followed by qualitative detection and genotyping.ResultsAmong 106 IDUs, 56 (52.8%) were anti-HCV-positive. The two groups did not differ in terms of age, marital status, and nationality. As for the behavioral variable, there was a trend of increased risky behaviors among the HCV-RNA positive group as compared to the HCV-RNA negative group but none of the variables reached statistical significance. Half (50%) of the 56 anti-HCV-positive were HCV-RNA positive. Genotype 3 was the predominant one (57.1%) followed by genotype 1 (21%) and genotype 4 (18%).ConclusionsThe predominance of genotype 3 seems to be the predominant genotype among IDUs in Lebanon, a situation similar to that among IDUs in Western Europe. This study provides a base-line against possible future radical epidemiological variant that might occur in IDUs.

Genotypes of hepatitis C virus (HCV) among positive Lebanese patients: comparison of data with that from other Middle Eastern countries

Recently we identified hepatitis C virus (HCV) genotype 4 as the principle genotype among Lebanese thalassaemics. In an attempt to confirm the predominance of genotype 4 in Lebanon and perhaps in the Middle East, genotyping was attempted on 142 HCV-infected Lebanese patients from five different hospitals in the country. These included 38 HCV-positive patients with symptomatic liver disease who were referred to gastroenterologists and 104 HCV-positive patients with no symptoms of liver disease: 27 patients with thalassaemia, 30 patients on haemodialysis, 32 multi-transfused and 15 intravenous drug users. HCV genotyping was performed on PCR HCV RNA-positive samples using a commercial line probe assay (LiPA; Innogenetics, Ghent, Belgium). HCV genotype 4 is found to be the predominant genotype among HCV-infected Lebanese patients (ranging from 34.2% to 53.3%) followed by 1a (ranging from 12.5% to 43.3%) and 1b (ranging from 8.0% to 34.4%). In patients with symptomatic liver disease, however, genotype 4 (34.2%) was preceded by genotype 1a (39.5%). The predominance of HCV genotype 4 in our population (45.7%) confirms the predominance of HCV genotype 4 in Lebanon and most of the Arab countries in the Middle East but contrasts with data reported from non-Arab Middle Eastern Countries as can be seen from the literature review. Implications of genotyping for clinical outcome of HCV infection, response to treatment as well as for vaccine development are discussed.

Current prevalence of hepatitis delta virus (HDV) infection and the range of HDV genotypes in Lebanon

Recently the prevalence of hepatitis B virus (HBV) genotypes and the association between these genotypes and the clinical status of HBV-infected patients were recently investigated in the Lebanese population. The aim of the additional study reported here was to determine the current prevalence of hepatitis delta virus (HDV) infection and the range of HDV genotypes in this Lebanese population. Two hundred and fifty-eight HBsAg-positive patients (107 asymptomatic blood donors, 92 with chronic hepatitis, 24 with cirrhosis, 15 with hepatocellular carcinoma, 20 patients on haemodialysis) from ten medical centers in Lebanon were tested for antibody to hepatitis D virus (anti-HDV). Those testing positive were analysed further for HDV-RNA and for genotyping by reverse transcriptase-polymerase chain reaction (RT-PCR) and restriction fragment length polymorphism (RFLP). Three samples (1.2%) were anti-HDV positive and out of these, only one was HDV-RNA positive (0.6%) and was analysed as HDV genotype I. Our results point to a low endemicity of HDV in the Lebanese population which is in sharp contrast to data reported from Lebanon 20 years ago and to the situation in neighbouring Arab and non-Arab countries in the Mediterranean region. HDV genotype I seems to be the predominant genotype in Lebanon and the Middle East.

Hepatitis A virus in the Middle East and North Africa region: a new challenge.

During the past three decades, a gradual shift in the age of infection with hepatitis A virus (HAV) from early childhood to adulthood has been observed. There is a general lack of updated data on HAV burden of disease, incidence and age‐specific seroprevalence in countries of the Middle East and North Africa (MENA) region. The aim of this article is to review the published data on anti‐HAV seroprevalence, an important tool to monitor infections rates, in countries of the MENA region and associated risk factors including water and socioeconomic data when available. Data on anti‐HAV seroprevalence were found for 12 of 25 MENA countries. We show that MENA countries, similar to other areas in the world, have a clear shift in HAV incidence with a decline among young age groups and an increase among adults and older individuals. This would likely be associated with increased morbidity and increased risks of outbreaks among younger age groups. Consequently, the continuous surveillance of hepatitis A cases and the inclusion of hepatitis A vaccine in the expanded immunization programmes are needed in countries of the MENA.

Occult hepatitis B virus infection in Lebanese patients with chronic hepatitis C liver disease

Occult hepatitis B virus (HBV) infection, characterised by the presence of HBV infection with undetectable hepatitis B surface antigen (HBsAg), was investigated in 98 Lebanese patients with chronic hepatitis C liver disease and 85 control subjects recruited from eight institutions in different parts of the country. The prevalence of occult HBV infection ranged from 11.9% to 44.4% in hepatitis C virus (HCV)-infected patients and it increased with increasing severity of the liver disease. The overall rate of HBV DNA in our 98 HCV-infected patients was 16.3%. On the other hand, the rate of HBV DNA was 41.0% in anti-HBc alone positive patients compared to only 7.1% in healthy controls who were also anti-HBc alone positive (p < 0.001). Moreover, the prevalence HBV DNA increased with increasing severity of the liver disease, but this increase was only marginally significant and, perhaps, could have been significant if more patients were involved in the study. Although Lebanon is an area of low endemicity for both HBV and HCV, occult HBV infection is common in HCV-infected patients. The presence of HBV DNA, therefore, presents a challenge for the effective laboratory diagnosis of hepatitis B, particularly if polymerase chain reaction (PCR)-based HBV detection methods are not used.

Occult hepatitis B virus infection in HIV-infected Lebanese patients with isolated antibodies to hepatitis B core antigen

Summary The presence of hepatitis B virus (HBV) serological markers have been investigated in 101 Lebanese patients (69 men, 32 women; mean age 32.7 ± 1.7 years) infected with human immunodeficiency virus type 1 (HIV-1). Seven patients (6.9%) were HBsAg carriers compared with 54 patients (53.5%) who had no evidence of exposure to HBV infection. Twenty-four patients (23.8%) had anti-HBc alone as a serological marker compared with four patients who were positive for anti-HBs alone and 12 patients (11.9%) who were anti-HBc and anti-HBs-positive. Occult HBV infection (presence of HBV DNA in the absence of HBsAg) is found to be relatively high (28.7%) in HIV-infected Lebanese patients and the overwhelming majority (83.3%) of those who were positive for anti-HBc alone had a detectable HBV DNA in their serum. However, none of our HIV-positive patients with occult HBV infection had abnormal alanine aminotrasferase level, which also raises the question as to whether occult HBV plays a role in the aetiology of liver disease in HIV-infected patients. Further, studies on the association between HBV DNA levels and markers of liver function in addition to data on liver biopsy would help in answering this question.

Hepatitis B Virus and Hepatitis C Virus Infections among Female Sex Workers and Men Who Have Sex with Men in Lebanon: Prevalence, Risk Behaviour and Immune Status

BACKGROUND The aim of our study was to study the prevalence of and the risk behaviours associated with the hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among two high-risk groups: female sex workers (FSW) and men who have sex with men (MSM). Furthermore, since vaccination is a key component of HBV prevention programs, the immune status of HBV infection in these two high-risk groups was evaluated. METHODS Participants included in this study were part of a bio-behavioural surveillance study done to assess HIV prevalence among four vulnerable groups in Lebanon. Participants were recruited using a respondent-driven sampling method. The total number of eligible participants were 101 MSM and 103 FSW. Blood samples were collected as dried blood spots and then eluted to be tested for HCV, HBV and HIV by enzyme-linked immunosorbent assay. RESULTS None of the 204 individuals tested has been exposed to HCV. In the 101 MSM, only one (0.99%) was an HBsAg carrier and one (0.99%) was confirmed as anti-HIV-positive. Among FSW, 30% showed they were immune to HBV compared with only ~10% among MSM. The distribution of socio-demographic characteristics and potential risk factors in both groups were shown. CONCLUSION Our results highlight the urgent need to raise awareness among FSW and MSM and their health care providers of the availability and benefits of HBV vaccination in Lebanon. In addition, and due to the absence of vaccines against HCV and HIV, education programs aiming at behavioural changes should be intensified.

Hepatitis C virus infection in the Middle East and North Africa "MENA" region: injecting drug users (IDUs) is an under-investigated population.

PurposeInvestigation of the injecting drug users (IDUs) population is becoming extremely critical and timely in light of the recent evidence that IDUs now act as the core of hepatitis C virus (HCV) epidemics in developed countries. The purpose of this article, therefore, is not only to review the epidemiology of HCV in the Middle East and North Africa (MENA) region, but also to see whether IDUs were adequately studied and whether harm reduction strategies to be applied for their protection have been set.MethodsA literature review was carried out of articles published within the last decade on HCV infection.ResultsThe gathered data showed that the population of IDUs is severely under-investigated throughout the whole region, possibly due to religious and cultural impediments.ConclusionIn order to reduce the risk of HCV infection in IDUs, a set of recommendations are advanced emphasizing the urgent need for bio-behavioral studies in this population in order to help identify the source and mode of transmission and the genotypes of HCV involved. These results may allow the development of effective and, yet, socially acceptable intervention strategies. We believe that the role which IDUs play in sustaining HCV infection is also an under-investigated topic in many developing countries. Similar reviews and, hence, interventions should be initiated in these regions.

The relaxation exercise and social support trial- resst: study protocol for a randomized community based trial

BackgroundStudies suggests a possible link between vaginal discharge and common mental distress, as well as highlight the implications of the subjective burden of disease and its link with mental health.Methods/DesignThis is a community-based intervention trial that aims to evaluate the impact of a psycho-social intervention on medically unexplained vaginal discharge (MUVD) in a group of married, low-income Lebanese women, aged 18-49, and suffering from low to moderate levels of anxiety and/or depression. The intervention consisted of 12 sessions of structured social support, problem solving techniques, group discussions and trainer-supervised relaxation exercises (twice per week over six weeks). Women were recruited from Hey el Selloum, a southern disadvantaged suburb of Beirut, Lebanon, during an open recruitment campaign. The primary outcome was self-reported MUVD, upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Intent to treat analysis will be used.DiscussionThe results will indicate whether the proposed psychosocial intervention was effective in reducing MUVD (possibly mediated by common mental distress).Trial RegistrationThe trial is registered at the Wellcome Trust Registry, ISRCTN assigned: ISRCTN: ISRCTN98441241