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Is there a need to include HIV, HBV and HCV viruses in the Saudi premarital screening program on the basis of their prevalence and transmission risk factors?
  1. F M Alswaidi,
  2. S J O'Brien
  1. School of Translational Medicine, Occupational and Environmental Health Research Group, University of Manchester, UK
  1. Correspondence to Dr Fahad M Alswaidi, School of Translational Medicine, University of Manchester, Stopford Building, Oxford Road, Manchester M13 9PT, UK; f_alswaidi{at}hotmail.com

Abstract

Background In January 2008, the Saudi Arabian health authority included mandatory testing for HIV, HBV and HCV viruses in the premarital screening program. Epidemiologically, there were few justifications for their inclusion as disease prevalences and distributions are poorly understood in the population. This study aims to provide information about HBV, HCV and HIV prevalences and risk factors for disease transmission and so produce evidence for informed decision-making on the inclusion of these infectious diseases in the screening program.

Methods This is a cross-sectional descriptive study embedded in the existing national premarital screening program for thalassaemia and sickle cell disease to estimate the prevalence of HIV, HBV and HCV infections (n=74 662 individuals), followed by a case-control study to identify risk factors responsible for infection transmission (n=540).

Results The average HIV prevalence is 0.03%, 1.31% for HBV and 0.33% for HCV. Sharing personal belongings particularly razors, blood transfusions, cuts at barbershops and extramarital relationships showed the highest significant associations with the transmission of these viruses.

Conclusion The prevalences of HIV, HBV and HCV in Saudi Arabia are among the lowest worldwide. However, all the important risk factors associated with transmitting these viruses are significantly present in the Saudi community. Saudi Arabia is financially capable of screening for these infections in the mandatory premarital program and of providing medical care for the discovered cases, but focusing on the health education programs may offset the need to mandatory testing.

  • Premarital
  • screening
  • HIV
  • HBV
  • HCV
  • Saudi Arabia

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There are an estimated 33 million cases of HIV worldwide with 95% of cases in developing countries.1 Approximately 1.8 billion people have serological evidence of hepatitis B virus (HBV) infection with 350 million estimated to have chronic infection; at least 500 000 of these patients die from liver malignancy and cirrhosis.2 The WHO estimates that 170 million individuals worldwide have the hepatitis C virus (HCV).3 These infections pose a heavy financial burden on nations; HCV infection treatment in the United States alone is estimated to exceed US$600 million per year.3

Disease prevalence, availability of appropriate medical care, health education and public awareness are important factors for implementing a screening program. Some international associations like the Bill Clinton HIV Initiative and United Nations Program on HIV/AIDS suggested that HIV screening should be mandatory in countries with a prevalence of 5% or more.4 Cultural attitudes and individual knowledge are important for the success of screening, and uptake is often low where prevalence rates are high.5–7 HIV testing has a broader impact for those planning to marry.6 In some communities, cultural values clash with premarital HIV testing and confidentiality. However, mandatory HIV screening has been incorporated into premarital screening programs in some states in the USA and Malaysia,8 9 although it has since been discontinued in the USA. China implemented mandatory premarital HBV testing due to its 10% HBsAg carrier prevalence.10 However, ethical and cost-effectiveness issues make mandatory HIV screening controversial.

Premarital screening in Saudi Arabia

In 2003, the Ministry of Health (MOH) of Saudi Arabia implemented free compulsory premarital screening and counseling for sickle cell disease (SCD) and thalaessemia.11 To facilitate the tests, 123 healthcare centres, 70 laboratories and 20 counseling and education clinics were established throughout the country. Their success in implementing the program prompted the MOH to start testing for HIV, HBV and HCV infections in January 2008.12 Couples with negative results are notified that they can marry without additional procedures, while positive cases must undergo affirmative tests. The testing is mandatory, but being positive does not prevent marriage. Counseling sessions aim to provide education to prevent infection transmission. HIV and HCV positive couples are encouraged to avoid marriage; for HBV, the healthy partner is advised to be vaccinated.

These diseases were included in the screening program even though there is scant epidemiological evidence concerning their prevalence and distribution in Saudi Arabia. The decision to include HIV, HBV and HCV in the Saudi program was a Royal decision. According to the regulations in Saudi Arabia, this Royal decree cancels the need for consent in such a screening program, with the main justification for this being public interest. In 2004, the MOH announced that there were 11 000 HIV carriers overall, of which 2005 were Saudis (prevalence 0.011%).13 The male-to-female ratio being 3:1 and 78% of cases were between 15 and 49 years.13 According to an 18-year HIV surveillance program, heterosexual contact among Saudis caused 37.9% of cases, blood transfusion accounted for 25%, 6.5% was through perinatal transmission, 2.5% were from homosexual and 0.8% from bisexual contact, 1.3% were from intravenous drug abuse and 26% from unknown causes.14 Infection through blood transfusion was eradicated in 2001 due to pre-transfusion screening.13 A study of blood donors found that the prevalence of HBsAg was 1.4% and that anti-HCV was 0.2% among Saudis.15

HBV, HCV and HIV infections have no cure and scant permanent remission possibilities, high mortality rates, lengthy infectious periods, high risks to the spouse or offspring and costly treatments. Early diagnosis optimises treatment and transmission prevention. This makes them ideal candidates for inclusion in a screening program.

Our study aims to provide prevalence data and information on the risk factors for transmission in the specific target group of both men and women Saudis who are at the age of marriage (between 15 and 60 years old) and are sexually active. These data are not currently available in Saudi Arabia, so providing evidence for informed decision-making concerning the continuing inclusion of these diseases in the national screening program.

Materials and methods

Study design

This was a cross-sectional descriptive study embedded in the existing national premarital screening program to estimate the prevalence of HIV, HBV and HCV infections, with a case-control study to identify transmission risk factors. A case is defined as any individual with a positive result for HBV, HCV or HIV from premarital testing between January and May 2008. Controls are individuals who underwent the same tests during that period with negative results.

Sampling technique

No significant seasonal variation in the prevalence of these diseases was expected. There were about 284 000 people included in the screening program annually. This was approximated to 300 000 individuals (the study population) in order to simplify the sample size calculation of the prevalence study; the sample sizes required to achieve valid prevalence results were estimated as follows: HBV, 4600; HCV, 9500; HIV, 27 500. StatCalc (Epi Info software) calculated sample sizes. However, since testing for HBV, HCV and HIV infection is mandatory, everyone tested between January and May 2008 was included in the prevalence estimation to get larger and more representative sample. This resulted in 74 662 individuals being included in the prevalence study over these 4 months.

After May 2008, data were gathered from MOH headquarters and peripheral centres to generate a list of names and phone numbers. Telephone numbers were identified for 694 positive cases and 1844 negative controls, which formed the sampling frame that we chose the cases and controls. There were no duplicates on this list, as they were identified by their National Identification numbers. We interviewed 540 individual cases and controls, with 270 individuals in each group. This was the maximum number of individuals that we could interview given the limited time and resources of the study. If the exposure (%) of control is 20% and the least OR to be detected is 2.0, the least power will be approximately 87%. Generally, all three viruses can be transmitted during sexual intercourse, by exposure to contaminated blood and through intravenous drug abuse, but the proportion of transmission is different for each virus. Therefore, we assumed that all three viruses are similar enough in their manner of transmission to pool them together in calculating the sample sizes as well as in the analysis. EpiCalc (Epi Info Software) was used to calculate the sample size. The sampling process is outlined in figure 1.

Figure 1

Selection of cases and controls. A. Total study population. B. Sampling population (based on results; positive and negative). C. Sampling frames (based on availability of phone numbers). D. Study sample (random selection of cases and controls). *All available 24 HIV cases were included.

Data collection

Data were gathered from the General Directorate for Communicable Diseases, MOH, in Riyadh to estimate disease prevalence. A team of four researchers conducted telephone questionnaires. Assistants underwent a training course on the questionnaire, informed consent and how to interview participants. The interviews used a closed-ended questionnaire about risk factors for infection transmission. The study gained ethical and administrative approvals from the Saudi Ministry of Health prior to its commencement.

Data processing and analysis

Data at the MOH database were reviewed to estimate the distribution of these infections. Prevalences were calculated based on the number of positive cases divided by the number of tests done between January and May 2008.

After generating frequency distributions for all variables, they were grouped according to their potential aetiological relationship to outcome: (1) demographic factors, (2) respondents' medical condition, (3) barbershop services and (4) sexual intercourse. Proportionally, HBV cases are more than HCV and HIV cases; therefore, the results predominantly represent HBV cases. Specific risk factors for HIV and HCV transmission are less likely to be picked up in the analysis. It is known that HIV is mainly transmitted by sexual intercourse, whereas HBV is transmitted by sexual intercourse and contact with contaminated blood and HCV is transmitted by exposure to contaminated blood and intravenous drug abuse. However, all three viruses share the same modes and risk factors for transmission, but the proportion of infection/transmission is different for each virus.

Bivariate analyses were performed to identify the association of each variable with disease outcome. Multivariate logistic regression analyses observed the adjusted effect of each variable, including demographic variables, on outcome while controlling for all other entered variables. Partial or complete confounding effects of all the factors were controlled but not measured. The stepwise backward Wald method was used to identify the minimum number of predictors that were significantly associated with outcome; variables were then removed sequentially from the model starting with the variables showing the least association in the first step. The stepwise process continued until all the remaining variables showed a statistically significant adjusted OR with the outcome. The probability used for a variable to enter the model was 0.05 and 0.10 for removal. In the second phase of multivariate analysis, all variables that exhibited statistically significant associations in the first phase were summated in the logistic regression model using stepwise backward Wald technique, and adjusted ORs were calculated while controlling for all other entered variables.

Results

Prevalence

In the assigned period, 74 662 individuals tested for HIV, HBV and HCV were carried out across Saudi Arabia. There were 1251 (1.67%) positive results; the highest rate of positive tests was in Riyadh (15.8%), while the lowest rate was in Qunfudah (0.75%). Ages of cases ranged from 15 to 63 years. Men accounted for 73.2% HBV cases, 76% HCV and 79.2% HIV (table 1). The average prevalence was 0.03% for HIV, 1.31% for HBV and 0.33% for HCV.

Table 1

Positive results by sex from premarital screening of infectious diseases in the regions of Saudi Arabia, January–May, 2008

Demographic information

Age of respondents

The frequencies of cases versus controls for each age group are presented in table 2A. The minimum age for both cases and controls was 15 years, with mean ages being 31 (9.5) years for cases and 27 (6.3) years for controls. Respondents >30 years had a higher risk of infection than younger respondents (OR=3.83; table 2A).

Table 2

Relationship of demographic variables on the transmission of HBV, HCV and HIV disease in the study groups

Sex

Of the cases, 80.7% were men compared to 78.9% controls. Men were at an insignificantly higher risk of disease than women (OR=1.12; table 2B).

Educational status

Fewer cases had bachelor (30.4%) and secondary level education (35.2%) than controls (33.3% and 45.6%, respectively). However, relatively higher proportions existed for intermediate (18.5%), primary education (13.3%) and illiteracy (2.6%) among cases compared to controls (table 2C).

Occupational status

The majority of cases and controls had no occupational contact with human blood (93% cases; 94.8% controls). More cases (6.3%) worked with potential exposure to human blood (police, fire brigade) compared to controls (2.6%). Fewer cases (0.7%) were health professionals compared to controls (2.6%). Respondents with potential exposure to blood were at a significantly higher disease risk (OR=2.48), but health professionals had an insignificantly lower risk (OR=0.29; table 2D).

Marital status

Compared to respondents who had never married, divorcees/widow(er)s had a significantly higher disease risk (OR=3.76); married respondents were at an even greater risk (OR=4.69; table 2E).

Infected contacts

A higher proportion of cases (40.4%) had close contacts suffering from HBC, HCV and HIV compared to 6.7% of controls (table 2F). These included close family members and friends, due to their likelihood of close physical contact.

Chronic illness

More cases (9.3%) suffered from chronic illnesses like SCD, diabetes mellitus and renal failure compared to controls (2.6%). The respondents with chronic illnesses had significantly higher risks for HBV, HCV and HIV (OR=3.83; table 3A).

Table 3

Relationship of medical condition and practices of the respondents on the transmission of HBV, HCV and HIV

Blood transfusion

Over 10% of cases had received a blood transfusion compared to 0.7% of controls. The respondents who had received blood transfusion were at a higher risk of contracting disease (OR=15.5; table 3B).

Injections

Only 48.9% of cases had received a prescribed injection compared to controls (53%); 5.6% of cases received non-prescribed injections (0.7% controls). Respondents who had prescribed injections were at an insignificantly lower disease risk (OR=0.85; table 3C,D). Non-prescribed injections were associated with a higher risk of infection (OR=7.88; table 3D).

Accidental needle injury

A higher proportion of cases (7.2%) received a blood-contaminated sharps injury compared to controls (0.8%). The respondents with sharps injuries had a much higher disease risk compared to respondents without such injuries (OR=10.25; table 3E).

Dental work

Of cases, 61.5% underwent dental work or oral surgery compared to 50% of controls. Analysis showed that such cases were at a statistically significant higher risk of viral disease (OR=1.60; table 3F).

Other surgical procedures

In comparison to controls (14.1%), a higher proportion of the cases (23.3%) had undergone surgical procedures, leaving the latter with a significantly higher disease risk (OR=1.86; table 3G).

Cutting injuries

A relatively higher proportion of the cases had received single or multiple cuts (7.8% and 45.6%, respectively) at barbershops or beauty parlours compared to controls (3.3% and 13.3%, respectively). Respondents with single injuries had a significantly higher risk of disease (OR=4.17), and those who received multiple injuries had a much greater disease risk (OR=6.10; table 3H).

Acne puncturing

Over 3% of both cases and controls had undergone acne puncturing in barbershops; a higher percentage of cases (20.0%) had multiple treatments (4.4% of controls). Compared to respondents that had not had acne punctured, the respondents who had one episode had an insignificantly higher disease risk (OR=1.20), whereas respondents that had multiple puncturings had a significantly higher risk (OR=5.42; table 3I).

Hijamah (cupping–bloodletting therapy)

Of cases, 8.5% had Hijamah once compared to 5.2% controls; 5.6% of cases had multiple treatments (3.7% of controls). Both single and multiple Hijamah experiences were at an insignificantly higher risk of disease (OR=1.74; OR=1.59, respectively; table 3J).

Incarceration

In comparison with controls (6.8%), 16% of cases were incarcerated in prison for longer than 24 h. These respondents were at a significantly higher disease risk (OR=2.62; table 3K).

Extramarital intercourse

Out of cases, 9.4% had extramarital intercourse compared to 3.1% controls. A higher disease risk was observed in the respondents with extramarital relationships (OR=3.29; table 3L).

Intravenous drug users

Only 1.9% of cases were intravenous drug users (IVDUs); no controls were IVDUs. No significant association was found between IVDU and disease risk (p value=0.06; table 3M).

Sharing razors

A relatively larger proportion of cases (5.9%) shared razors compared to controls (0.4%), with a significantly higher disease risk (OR=16.95; table 3N).

Sharing toothbrushes

Only 3.0% of cases shared toothbrushes compared to 0.4% of controls, but they had a higher risk of infection (OR=8.21; table 3O).

Sharing nail-cutters

A higher proportion of cases (67.7%) shared nail-cutters compared to controls (47%), with a significantly higher risk of disease (OR=2.36; table 3P)

Foreign travel

Although the respondents (33% cases; 28.9% controls) who travelled abroad were at higher disease risk, this remained statistically insignificant (OR=1.21; table 3Q).

Outcomes after premarital screening

Among cases, 224 (83%) stated that their spouses-to-be are free of infections. Out of these, 77% decided to continue with the marriage. About half of the positive cases (53%) received education regarding hepatitis viruses and HIV from program staff (table 4). There were 57 couples in total that decided not to marry after undergoing the premarital testing program, including 50 positively testing cases and seven controls. The reasons for this included 18 (31.6%) cases of HBV, 9 (15.8%) cases of HCV, 23 (40.4%) cases of HIV and 7 (12.3%) marriages were cancelled due to other reasons.

Table 4

What happened after premarital screening testing for cases and controls?

Risk factor associations after logistic regression

The study factors which had the highest associations with disease transmission were “sharing razors” (OR=11.13) and “infected contacts” (OR=10.9). Other risk factors in descending order of association were “blood transfusion” (OR=8.30), “accidental needle injury” (OR=7.45), “multiple acne puncturings” (OR=5.04), “chronic illness” (OR=4.92), “cut from barbershops” (OR=4.74), “multiple cuts” (OR=3.88), “married” (OR=4.31), “divorce/widow(er)” (OR=4.74), “extramarital intercourse” (OR=2.92) and “dental work/oral surgery” (OR=1.60; table 3).

Discussion

Prevalence of HIV, HBV and HCV

From the premarital screening program, the prevalence of HIV infection (0.03%) in Saudi Arabia is slightly higher than the official figure (0.011%) but is still comparatively low. The prevalences of HBC and HCV are among the lowest rates in the world.1 15–17 Recent study evaluated prevalence of these viruses among marrying individuals in Sivas, Turkey and showed similar demographics and HBV prevalence in this study.18 There were minimal variations between infections across different regions of the Kingdom. However, HBV and HCV infection rates are slightly higher in areas with endemic hereditary blood diseases, namely Makkah and Qunfudah, possibly reflecting the influence of blood transfusions. HIV infections were reported in nine regions out of 20, and 23% were in densely populated Riyadh.

The public strongly approve of a premarital screening program,19–22 but social and familial commitments make it difficult to ask partners to undergo premarital testing. In general, the level of public health information in Saudi Arabia is poor. Recently, the MOH launched an educational TV channel. A further advantage of mandatory testing is to increase the public awareness of these infections, which may in fact decrease the need for mandatory screening in the near future.

The screening program has begun its second year. The approximate annual cost for viral testing is estimated to be 3 750 000 Saudi Riyal (SR; 780 000 GBP). Operating expenses triple the cost to 11 250 000 SR (2 million GBP). However, the MOH budget for 2009 was 52 billion SR (9.3 billion GBP),23 so the cost for the viral screening program is relatively insignificant. Data about care expenses of AIDS and hepatitis patients in Saudi Arabia are not available to estimate the program's cost-effectiveness.

Risk factors

Limitations

This study was limited, as although the modes of transmission of HIV, HBV and HCV are similar, each virus has its own infectivity rate. An independent study for each virus would yield more reliable results regarding risk factors for transmission of infection.

Demographic effects

The principle aim of the program is to prevent infections being transmitted to healthy people. At present, there are no official data about marriages with an infected partner. In our study, of these individuals, 77% either have married or intended to marry. This high rate of risky marriages could be due to the social and familial commitments among Saudis which were not investigated in this study.

The fact that older participants had more infection prevalence could be explained by more years of exposure to the force of infection. Prevalence of these diseases almost always grows with age. An additional hypothesis worth exploring is that older participants may have been exposed to transfusion before widespread screening. Men have a higher infection risk, which resembles patterns in developed countries; men are usually more sexually active and more likely to be IVDUs.24

Educational levels seem to have a disproportionate association with risk of infection. In Saudi Arabia, the protective effect of education seems to be minimal but still has an influence.

Respondents who work in direct contact with human blood showed a significantly higher risk of acquiring infections. This finding is logical and agrees with similar studies worldwide.25

Estimates for IVDU rates are often inaccurate, but generally, addiction rates are increasing in Saudi.26 IVDUs had no statistical association with the risk of acquiring the viruses in our study. Incarceration for more than 24 h was twice as common in cases compared to controls (16%: 6.8%), potentially due to the higher number of IVDUs in this group as regionally27 and globally documented.28–30

Medical history

Chronic illnesses that necessitate blood transfusions and frequent blood tests, such as SCD, thalassaemia and renal failure, caused a significantly higher risk of infection. A blood transfusion increases the risk of contracting HIV, HBV or HCV by eight times.

Having non-prescribed medical injections at private pharmacists is commonplace; for example, patients may receive analgesic or anti-malarial injections, but such respondents in our study had seven times higher risk of infection.

Health professionals, who suffer needle-stick injuries, a rare but significant mode of HIV, HBV and HCV transmission, are seven times more likely to have viral infections in our study. Surgical procedures, especially dentistry and oral surgeries, are a common mode of transmitting HBV, HCV and HIV in developing countries.30 32 The risk of transmitting viruses through surgical procedures is lower in Saudi Arabia than other countries in Asia and Africa.32 Hijamah, the unique traditional medical practice among Muslim and Chinese cultures that involves cupping and bloodletting,33 carried no significant risk for disease transmission.

Sharing personal belongings

Sharing razors and toothbrushes is a major risk factor in transmitting hepatitis.25 This risky behaviour could be due to factors such as low income, poor education and lack of health awareness. Sharing razors showed the highest significant risk (11 times) associated with transmission of infections after adjusting for possible confounders.

Sexual relationships

The commonest mode of HIV transmission (75–85%) is through sexual contact,25 predominantly through heterosexual intercourse.34 The modes of HBV transmission are similar to HIV infection, but HBV is up to 100 times more infectious as it is infectious for approximately a week outside the host30; HCV transmission through sexual activity is uncommon.35 In this study, those who have had a sexual relationship are four times more likely to acquire a viral infection. In Saudi Arabia, extramarital relationships are prohibited religiously, and transgressors may be penalised by capital punishment. Such affairs happen rarely and secretly. Surprisingly, 10.4% of the respondent cases stated that they have had extramarital relationships, compared to 3.1% of controls. This is higher than the estimated extramarital affair rates in more liberal Muslim communities, including London (5%) and Berlin (8%).36 Polygyny is common among Saudis and could contribute to infections spreading between family members. Finally, being in close contact with any infected person is the second highest significant risk factor for virus transmission.

Conclusion

The prevalences of HIV, HBV and HCV in Saudi Arabia are among the lowest worldwide. This study shows that all the important risk factors for viral transmission are present, the most significant being sharing razors, acne puncturing and cuts at barbershops, blood transfusions and chronic illnesses. People who were married previously, had extramarital intercourse or were in contact with an infected person had a higher risk of infection.

Despite the low prevalences, the lack of the effective health education and presence of significant infection risk factors, and the affordable cost of such a screening program, support the inclusion of these viruses in the mandatory premarital screening program of Saudi Arabia. Adequately trained manpower and funds may be provided to allow testing centres to collect confidential data voluntarily regarding basic demographic and behavioural risk factors such as age, sex, IDUs, hijamah, extramarital sex, contact with female sex workers and results of previous testing for HIV, HCV and HBV.

Policy recommendations

  1. Saudi Arabia may continue mandatory testing and counseling for HIV, HBV and HCV for at least four more years to raise the public awareness of these diseases.

  2. The program should be re-evaluated and revised if necessary after 5 years, possibly converting the testing to be optional.

  3. Further investigations are needed to identify the factors responsible for the high rate of risky marriages due to these infections.

  4. Strengthen the mandatory role of the counselling clinic in delivering educational messages to infected individuals and couples.

  5. Health education campaigns in the public media to promote public awareness of risk factors.

  6. Targeted educational campaigns to at-risk groups: patients' contacts, barbers, health professionals, schools and colleges students.

  7. Strict enforcement of preventive measures at places at high risk of transmitting these diseases, such as barbershops and health facilities.

What is already known on this subject

  • A compulsory premarital screening program already exists in Saudi Arabia for hereditary haematological diseases.

  • The prevalence and distribution of HBV, HCV and HIV are not well understood.

  • Early diagnosis optimises treatment and transmission prevention.

What this study will add to the literature

  • Highlights about the Saudi mandatory premarital screening for HIV, HBV and HCV.

  • The prevalences of HIV, HBV and HCV in Saudi Arabian regions are described based on a systematic review of a representative population sample.

  • Common risk factors for transmission of these diseases in Saudi Arabia and their significance with regards to risk of infection are based on a systematic survey.

Acknowledgments

We are thankful to Dr Ali Alwadey, Dr Ibrahim Alzahrani and Dr Nasser Alhamdan from the Saudi Field Epidemiology Training Program (FETP) for their remarkable help in conducting the study. Also, we would like to thank the reviewers of JECH for their valuable comments.

References

Footnotes

  • Funding This work was fully supported and approved by the Saudi Ministry of Health (MOH). Field work started in Saudi Arabia after coordination between Ministry of Higher Education and MOH.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the MOH and the Training and Scientific Missions Committee for Civil Servants in Saudi Arabia.

  • Provenance and peer review Not commissioned; not externally peer reviewed.