A new hepatitis delta virus hotspot in Ethiopia: A multicenter study

OBJECTIVES: Ethiopia is endemic for hepatitis B virus (HBV), but co-infection with hepatitis D virus (HDV) is considered uncommon. We investigated HDV prevalence and its clinical implications among HBV-infected individuals in various regions of Ethiopia. METHODS: A cross-sectional study was conducted among 5383 hepatitis B surface antigen-positive adults at four HBV treatment centers from December 2021 to December 2023. Anti-HDV was analyzed using an Enzyme-Linked Immunosorbent Assay method, and HDV RNA using a quantitative PCR assay. Kruskal-Wallis rank sum tests were used to compare liver injury markers. RESULTS: Anti-HDV seroprevalence was low in Jigjiga (11/1003; 1.1%), Adama (68/2167; 3.1%), and Jimma (40/890; 4.5%), but high in Dubti (248/1323; 18.7%). Corresponding viremic HDV infection was 2/1003 (0.2%), 23/2166 (1.1%), 10/889 (1.1%), and 161/1322 (12.2%), respectively. All the sequenced HDV strains were genotype 1. HDV RNA-positive individuals had higher median alanine aminotransferase (51 vs 32 vs 25 U/L, P < 0.001), aspartate aminotransferase (AST) (49 vs 32 vs 26 U/L, P < 0.001), AST-to-platelet ratio index (0.55 vs 0.36 vs 0.28, P < 0.001) and liver stiffness (8.1 vs 5.7 vs 5.2 kPa, P < 0.001) compared to anti-HDV-positive HDV RNA-negative and anti-HDV-negative patients. CONCLUSION: The Afar region of Ethiopia is a hotspot for HDV infection, challenging the notion that HDV is uncommon in East Africa.