Journal of Virus Eradication 11 (2025) 100600
Contents lists available at ScienceDirect
Journal of Virus Eradication
journal homepage: www.sciencedirect.com/journal/journal-of-virus-eradication
Original research
HIV PrEP programmes as a framework for diagnosing and treating HBV
infection in adolescents and young adults in KwaZulu-Natal, South Africa
Gloria Sukali a,b,c , Jacob Busang a , Jaco Dreyer a , Thandeka Khoza a , Marion Delphin c ,
Nonhlanhla Okesola a , Carina Herbst a , Elizabeth Waddilove c , Janine Upton a, Janet Seeley a,d,e,
Collins Iwuji a,f, Motswedi Anderson a,c,g, Philippa C. Matthews b,c,h,i,* ,
Maryam Shahmanesh a,b,h,i
a
Africa Health Research Institute, KwaZulu-Natal, South Africa
b
Division of Infection and Immunity, University College London, Gower Street, London, WC1E 6BT, UK
c
The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
d
Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
e
School of Nursing and Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
f
Department of Global Health & Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK
g
Botswana Harvard Health Partnership, Gaborone, Botswana
h
Department of Infectious Diseases, University College London Hospital, Euston Road, London, NW1 2BU, UK
A R T I C L E I N F O A B S T R A C T
Keywords: Background: Guidelines for Hepatitis B treatment released by the World Health Organization in 2024 include the
HIV potential for use of dual therapy, combining tenofovir with either emtricitabine or lamivudine. These fixed-dose
HBV combinations are also used for Pre-Exposure Prophylaxis (PrEP) in people at risk of Human Immunodeficiency
Hepatitis B
Virus (HIV). We hypothesize that pre-existing HIV PrEP programmes can support access to HBV testing and
South Africa
treatment.
Infection
Prevention Methods: At the Africa Health Research Institute (AHRI) in KwaZulu Natal, South Africa, we evaluated PrEP
Prevalence uptake and retention amongst adolescents and young adults aged 15–30 years. We reviewed HBV status,
Diagnosis acceptance of PrEP and retention in follow-up between June 2022–Sept 2024.
Decentralisation Results: 15847 adolescents and young adults received an assessment in the community, of whom 3481/15847
Treatment (21.9 %) were eligible for sexual health prevention interventions. 3431/3481 (98.6 %) accepted HBV screening,
PrEP of whom 21/3431 (0.6 %) tested positive for HBsAg. These 21 individuals had not previously been aware of their
sexual health
HBV status, but one was already on antiretroviral therapy for HIV infection. Amongst the others, 16/20 (80 %)
reproductive health
were considered eligible for PrEP, and 15/16 started PrEP. When investigating retention in care, among 15
triple elimination
individuals due for a refill, 8/15 (53.3 %) returned at least once.
Conclusion: Sexual reproductive health and PrEP programmes provide an opportunity for HBV testing and
treatment. However, attrition from the care cascade at each step highlights the pressing need for interventions
that address barriers to sustainable delivery of long-term care.
1. Introduction and mortality, and to reduce transmission. Tenofovir disoproxil fuma
rate (TDF), the first line agent, is included in the World Health Orga
High profile global goals have been established for the elimination of nisation (WHO) essential medications list, and should be widely
hepatitis B virus (HBV) as a public health threat, with specific targets for accessible and affordable (global benchmark price US $2.40/month).2
the year 2030.1 Nucleos/tide analogue (NAs) agents are offered to those However, the practical reality is that TDF is not available - or incurs
deemed at the highest risk of chronic liver disease to reduce morbidity unacceptable out-of-pocket costs - for many high-prevalence
* Corresponding author. The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK.
E-mail address: (P.C. Matthews).
i
Joint senior.
https://doi.org/10.1016/j.jve.2025.100600
Received 4 March 2025; Received in revised form 30 May 2025; Accepted 3 June 2025
Available online 6 June 2025
2055-6640/© 2025 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
, G. Sukali et al. Journal of Virus Eradication 11 (2025) 100600
populations, including those in the WHO African region, which now (AYA) engaging with sexual health screening and PrEP services, and to
account for >60 % of new HBV infections.2 determine the uptake of PrEP for people testing HBV surface antigen
In March 2024, the WHO published new guidelines for HBV,3 which (HBsAg)-positive.
simplify and widen treatment eligibility criteria, and for the first time
include a conditional recommendation for dual therapy when tenofovir 2. Methods
monotherapy is not available (either as TDF or as Tenofovir Alafena
mide, TAF). This provides flexibility for tenofovir to be prescribed as 2.1. Study setting and research cohorts
part of fixed-dose combination therapy, together with either lamivudine
(3TC) or emtricitabine (FTC), collectively termed ‘XTC’.3 In many set We developed a collaboration between programmes at AHRI (Fig. 1).
tings, Tenofovir/XTC is more affordable and accessible than TDF mon The ‘EVOLVE-HBV’ study started in 2023 as a collaboration between
otherapy as a result of its widespread procurement for HIV treatment. AHRI and University College London (UCL) and the Francis Crick
These fixed-dose combinations are also used as Pre-Exposure Prophy Institute in the UK, to describe HBV epidemiology in the KZN popula
laxis (PrEP) in adolescents/adults who are at risk of HIV acquisition. tion, characterize the clinical and laboratory features of HBV infection,
PrEP therefore offers the combined benefit of HBV treatment and HIV and engage with local communities and healthcare providers to imple
prevention.4 Evidence in small cohorts also suggests PrEP could be used ment sustainable care pathways to diagnosis and treatment.11,14 This
as prevention for HBV, when vaccination is not available.5 Such ap study is approved by the University of KwaZulu-Natal (UKZN)
proaches may be of particular strength in African settings, where HBV Biomedical Research Ethics Committee (BREC) (ref. 00004495/2022) in
programmes can build on expertise, infrastructure and resources that SA, and UCL ethics committee in the UK (ref. 23221/001 EVOLVE-HBV).
have been developed for tackling HIV.6 To explore the role and impact of programmes providing HIV PrEP
In South Africa (SA), HIV and HBV infection are co-endemic.7,8 HIV for tackling HBV infection in AYA aged 15–30 years, we used a frame
has been tackled through scale-up of education, screening and treat work established by ‘Thetha nami ngithethe nawe’ (‘Talk to me and I’ll
ment, leading to proactive community engagement and robust access talk to you’ in IsiZulu),15 which is a stepped-wedge cluster-randomised
pathways to diagnosis and treatment. Antiretroviral therapy (ART) has controlled trial to investigate the effectiveness, implementation and cost
been available free of charge through the South African government. In effectiveness of peer-led social mobilisation into decentralised HIV and
comparison, HBV infection has been neglected,9,10 with poor awareness, sexual reproductive health (SRH) services, approved by UKZN BREC
high stigma, and low access to interventions for prevention, diagnosis (ref. 473/2019).15 Young people in the community are engaged by peer
and treatment.11–13 navigators and offered a needs assessment. Those at risk of sexually
We here describe the results of a collaboration between translational transmitted infection (STI) or HIV are referred for review in nurse-led
research studies for provision of HIV-PrEP and HBV care pathways, mobile clinics that provide testing and treatment, offer contraception,
based at the Africa Health Research Institute (AHRI) in KwaZulu-Natal preconception care, and tailored HIV prevention. Oral daily PrEP is
(KZN), South Africa. We aimed to gather preliminary data to explore offered to those who are at risk of acquiring HIV, based on national
the prevalence of HBV infection among adolescents and young adults criteria for assessment (Box 1), and willingness to engage with taking
Fig. 1. Schematic structure of studies at the Africa Health Research Institute (AHRI) to investigate frameworks for delivery of sexual health services and
HIV pre-exposure prophylaxis (PrEP) as a foundation for delivering testing and treatment for HBV. A: Location of study sites; map shows South Africa with the
KwaZulu-Natal province coloured gold and the two AHRI sites of Durban and Somkhele highlighted. B: Collaboration between PrEP studies and HBV program. C:
Pathway offered to adolescents and young adults showing HBV screening, assessment, offer of PrEP and follow-up. Created in BioRender. Matthews, P. (2025);
https://BioRender.com/a8bec78.
2
Contents lists available at ScienceDirect
Journal of Virus Eradication
journal homepage: www.sciencedirect.com/journal/journal-of-virus-eradication
Original research
HIV PrEP programmes as a framework for diagnosing and treating HBV
infection in adolescents and young adults in KwaZulu-Natal, South Africa
Gloria Sukali a,b,c , Jacob Busang a , Jaco Dreyer a , Thandeka Khoza a , Marion Delphin c ,
Nonhlanhla Okesola a , Carina Herbst a , Elizabeth Waddilove c , Janine Upton a, Janet Seeley a,d,e,
Collins Iwuji a,f, Motswedi Anderson a,c,g, Philippa C. Matthews b,c,h,i,* ,
Maryam Shahmanesh a,b,h,i
a
Africa Health Research Institute, KwaZulu-Natal, South Africa
b
Division of Infection and Immunity, University College London, Gower Street, London, WC1E 6BT, UK
c
The Francis Crick Institute, 1 Midland Road, London, NW1 1AT, UK
d
Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
e
School of Nursing and Public Health, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
f
Department of Global Health & Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK
g
Botswana Harvard Health Partnership, Gaborone, Botswana
h
Department of Infectious Diseases, University College London Hospital, Euston Road, London, NW1 2BU, UK
A R T I C L E I N F O A B S T R A C T
Keywords: Background: Guidelines for Hepatitis B treatment released by the World Health Organization in 2024 include the
HIV potential for use of dual therapy, combining tenofovir with either emtricitabine or lamivudine. These fixed-dose
HBV combinations are also used for Pre-Exposure Prophylaxis (PrEP) in people at risk of Human Immunodeficiency
Hepatitis B
Virus (HIV). We hypothesize that pre-existing HIV PrEP programmes can support access to HBV testing and
South Africa
treatment.
Infection
Prevention Methods: At the Africa Health Research Institute (AHRI) in KwaZulu Natal, South Africa, we evaluated PrEP
Prevalence uptake and retention amongst adolescents and young adults aged 15–30 years. We reviewed HBV status,
Diagnosis acceptance of PrEP and retention in follow-up between June 2022–Sept 2024.
Decentralisation Results: 15847 adolescents and young adults received an assessment in the community, of whom 3481/15847
Treatment (21.9 %) were eligible for sexual health prevention interventions. 3431/3481 (98.6 %) accepted HBV screening,
PrEP of whom 21/3431 (0.6 %) tested positive for HBsAg. These 21 individuals had not previously been aware of their
sexual health
HBV status, but one was already on antiretroviral therapy for HIV infection. Amongst the others, 16/20 (80 %)
reproductive health
were considered eligible for PrEP, and 15/16 started PrEP. When investigating retention in care, among 15
triple elimination
individuals due for a refill, 8/15 (53.3 %) returned at least once.
Conclusion: Sexual reproductive health and PrEP programmes provide an opportunity for HBV testing and
treatment. However, attrition from the care cascade at each step highlights the pressing need for interventions
that address barriers to sustainable delivery of long-term care.
1. Introduction and mortality, and to reduce transmission. Tenofovir disoproxil fuma
rate (TDF), the first line agent, is included in the World Health Orga
High profile global goals have been established for the elimination of nisation (WHO) essential medications list, and should be widely
hepatitis B virus (HBV) as a public health threat, with specific targets for accessible and affordable (global benchmark price US $2.40/month).2
the year 2030.1 Nucleos/tide analogue (NAs) agents are offered to those However, the practical reality is that TDF is not available - or incurs
deemed at the highest risk of chronic liver disease to reduce morbidity unacceptable out-of-pocket costs - for many high-prevalence
* Corresponding author. The Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK.
E-mail address: (P.C. Matthews).
i
Joint senior.
https://doi.org/10.1016/j.jve.2025.100600
Received 4 March 2025; Received in revised form 30 May 2025; Accepted 3 June 2025
Available online 6 June 2025
2055-6640/© 2025 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
, G. Sukali et al. Journal of Virus Eradication 11 (2025) 100600
populations, including those in the WHO African region, which now (AYA) engaging with sexual health screening and PrEP services, and to
account for >60 % of new HBV infections.2 determine the uptake of PrEP for people testing HBV surface antigen
In March 2024, the WHO published new guidelines for HBV,3 which (HBsAg)-positive.
simplify and widen treatment eligibility criteria, and for the first time
include a conditional recommendation for dual therapy when tenofovir 2. Methods
monotherapy is not available (either as TDF or as Tenofovir Alafena
mide, TAF). This provides flexibility for tenofovir to be prescribed as 2.1. Study setting and research cohorts
part of fixed-dose combination therapy, together with either lamivudine
(3TC) or emtricitabine (FTC), collectively termed ‘XTC’.3 In many set We developed a collaboration between programmes at AHRI (Fig. 1).
tings, Tenofovir/XTC is more affordable and accessible than TDF mon The ‘EVOLVE-HBV’ study started in 2023 as a collaboration between
otherapy as a result of its widespread procurement for HIV treatment. AHRI and University College London (UCL) and the Francis Crick
These fixed-dose combinations are also used as Pre-Exposure Prophy Institute in the UK, to describe HBV epidemiology in the KZN popula
laxis (PrEP) in adolescents/adults who are at risk of HIV acquisition. tion, characterize the clinical and laboratory features of HBV infection,
PrEP therefore offers the combined benefit of HBV treatment and HIV and engage with local communities and healthcare providers to imple
prevention.4 Evidence in small cohorts also suggests PrEP could be used ment sustainable care pathways to diagnosis and treatment.11,14 This
as prevention for HBV, when vaccination is not available.5 Such ap study is approved by the University of KwaZulu-Natal (UKZN)
proaches may be of particular strength in African settings, where HBV Biomedical Research Ethics Committee (BREC) (ref. 00004495/2022) in
programmes can build on expertise, infrastructure and resources that SA, and UCL ethics committee in the UK (ref. 23221/001 EVOLVE-HBV).
have been developed for tackling HIV.6 To explore the role and impact of programmes providing HIV PrEP
In South Africa (SA), HIV and HBV infection are co-endemic.7,8 HIV for tackling HBV infection in AYA aged 15–30 years, we used a frame
has been tackled through scale-up of education, screening and treat work established by ‘Thetha nami ngithethe nawe’ (‘Talk to me and I’ll
ment, leading to proactive community engagement and robust access talk to you’ in IsiZulu),15 which is a stepped-wedge cluster-randomised
pathways to diagnosis and treatment. Antiretroviral therapy (ART) has controlled trial to investigate the effectiveness, implementation and cost
been available free of charge through the South African government. In effectiveness of peer-led social mobilisation into decentralised HIV and
comparison, HBV infection has been neglected,9,10 with poor awareness, sexual reproductive health (SRH) services, approved by UKZN BREC
high stigma, and low access to interventions for prevention, diagnosis (ref. 473/2019).15 Young people in the community are engaged by peer
and treatment.11–13 navigators and offered a needs assessment. Those at risk of sexually
We here describe the results of a collaboration between translational transmitted infection (STI) or HIV are referred for review in nurse-led
research studies for provision of HIV-PrEP and HBV care pathways, mobile clinics that provide testing and treatment, offer contraception,
based at the Africa Health Research Institute (AHRI) in KwaZulu-Natal preconception care, and tailored HIV prevention. Oral daily PrEP is
(KZN), South Africa. We aimed to gather preliminary data to explore offered to those who are at risk of acquiring HIV, based on national
the prevalence of HBV infection among adolescents and young adults criteria for assessment (Box 1), and willingness to engage with taking
Fig. 1. Schematic structure of studies at the Africa Health Research Institute (AHRI) to investigate frameworks for delivery of sexual health services and
HIV pre-exposure prophylaxis (PrEP) as a foundation for delivering testing and treatment for HBV. A: Location of study sites; map shows South Africa with the
KwaZulu-Natal province coloured gold and the two AHRI sites of Durban and Somkhele highlighted. B: Collaboration between PrEP studies and HBV program. C:
Pathway offered to adolescents and young adults showing HBV screening, assessment, offer of PrEP and follow-up. Created in BioRender. Matthews, P. (2025);
https://BioRender.com/a8bec78.
2
