By Mzukona Mantshontsho
In South Africa, there has historically been a higher burden of Hepatitis B among children exposed to or living with Human Immunodeficiency Viruses (HIV).
Approximately 3.4 to 3.9 million South Africans live with chronic Hepatitis B, and 400,000 to 600,000 people are living with Chronic Hepatitis C.
According to Wikipedia, human immunodeficiency viruses (HIVs) are two species of Lentivirus (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive.
Hepatitis B is a significant public health threat and a major cause of morbidity and mortality globally. Chronic Hepatitis B Virus (HBV) infection can lead to long-term complications including cirrhosis and hepatocellular carcinoma.
Globally, approximately 254 million people are chronically infected with HBV, with an estimated 1.1 million HBV-associated deaths reported in 2022. Hepatitis B is transmitted either vertically (pregnancy, peripartum, birth and breastfeeding) or horizontally through direct contact with infected blood or blood products.
I reached out to The National Institute For Communicable Disease for some background information and they had the following:
Hepatitis B and Hepatitis C Co-Infection in Children in South Africa
“Recent epidemiological evidence shows that Hepatitis B infection among South African children has declined substantially following the introduction of routine infant immunisation, though it remains relevant in the context of HIV exposure.
“Pre-vaccination studies reported hepatitis B surface antigen (HBsAg) prevalence of 5–10% in children, largely due to perinatal and early childhood transmission.
“More recent paediatric studies, including cohorts of HIV-infected and HIV-exposed uninfected children, demonstrate a marked decline in prevalence to below 1–2%, reflecting vaccine impact. However, children born to mothers with HIV remain at increased risk of HBV exposure and vertical transmission, with HIV co-infection associated with impaired immune response to vaccination and higher likelihood of chronic infection.
“Emerging data from recent South African cohorts (2023–2025) further highlight gaps in vaccine-induced immunity and delayed immunisation among HIV-infected children, reinforcing the need for strengthened birth-dose strategies and integrated maternal-child interventions.
“In contrast, Hepatitis C prevalence among South African children remains consistently low, generally below 0.5%, even in high HIV-burden settings.
“Paediatric HCV infection occurs predominantly through vertical transmission, with transmission rates estimated at 5–6% in HCV-mono infected mothers and increasing to 10–15% in the presence of HIV co-infection.
“Although local paediatric data are limited, available studies indicate that chronic HCV infection in children is rare following confirmatory RNA testing. However, HIV-exposed children may have altered immune responses, potentially reducing spontaneous viral clearance and increasing vulnerability to chronic infection.
“The absence of routine antenatal HCV screening and limited paediatric surveillance in South Africa contribute to under diagnosis, underscoring the importance of integrating HCV screening into existing HIV prevention of mother-to-child transmission (PMTCT) programmes and expanding access to direct-acting antiviral therapies in children.
“South Africa has made significant progress in reducing hepatitis B infections among children, thanks to routine infant immunisation programmes. However, recent antenatal studies show that hepatitis B remains a concern among pregnant women, with prevalence rates around 6%.
“This means that vertical transmission from mother to child is still a major risk, especially in HIV-endemic communities where co-infection can weaken vaccine responses. Experts emphasise the importance of timely birth-dose vaccination within 24 hours of delivery and maternal antiviral treatment during pregnancy, which together can dramatically cut transmission rates and protect newborns.
“By contrast, hepatitis C infections remain rare in South African children, with antenatal prevalence consistently below 1%. Transmission occurs mainly from mother to child, and while chronic infection in children is uncommon, HIV co-infection increases the risk of persistence.
“The absence of routine antenatal screening for hepatitis C means many cases go undetected, limiting opportunities for early intervention.
:Health specialists are calling for hepatitis C testing to be integrated into existing HIV prevention programmes, alongside expanded access to modern antiviral treatments, to ensure that mothers and children receive comprehensive protection,” concluded The National Institute For Communicable Disease.
I spoke to Dr. Edina Amponsah-DaCosta who was Head of a study run from 2022 – 2025 in Cape Town on Viral Hapatitis in Children living with HIV.
According to Dr. Edina Amponsah-DaCosta, “Limited evidence on the burden of Hepatitis B virus (HBV) infection among children living with HIV (CLWH), HIV-exposed uninfected (HEU) and HIVunexposed uninfected (HUU) children hinders progress towards eliminating Hepatitis B.
Methods: “This study used secondary data and archival sera (N = 671) from children <13 years old attending health facilities in the Western Cape, South Africa.
“Hepatitis B vaccine coverage was assessed using vaccination records for doses 1 to 3 by 12 months of age. Timely uptake was defined as receipt of a dose from 4 days before to 28 days after the recommended age.
“Serological markers of infection and immunity were measured using Elecsys test kits (Roche Diagnostics, Germany).
“Logistic regression was performed to assess factors associated with incomplete and delayed vaccination,” according to Dr. Edina Amponsah-DaCosta.
“The study used blood samples from children. The samples were collected for infectious disease research from 2012 – 2016. Parents and caregivers of the children consented to the samples being used for research purposes as long as their personal information was not linked. There weren’t any significant challenges to testing the samples and identifying samples that test positive for viral hepatitis as the laboratory processes are well established.
“This is because both viruses are transmitted and acquired via similar routes. Encouragingly, this burden has declined over time, largely due to the Department of Health’s expansion of antiretroviral therapy programmes and the inclusion of free, universal hepatitis B vaccination in the national immunization schedule for the past 30 years!
“Some challenges remain, unfortunately. Our research work suggests that hepatitis B vaccine coverage among children who are HIV-exposed or living with HIV is still not on par with coverage in children without HIV.
“This points to underlying systemic barriers that need to be addressed to ensure equitable access to prevention services. For example, families affected by HIV might not always access preventive services like immunization on time because of competing health priorities.
“In some cases, transportation costs to immunization centres, stigma within the communities or negative experiences at health facilities, could create barriers. Furthermore, when children living with HIV are not on treatment, their bodies cannot always respond to the hepatitis B vaccine and develop the protection they need which leaves them at risk.
“In terms of impact, when hepatitis B is not prevented or treated, it can lead to long-term liver complications including liver cancer in adulthood. The good news is that where children are diagnosed early, there are effective treatment and care options available, and many can go on to live healthy, full lives.
“The Department of Health is taking important steps to strengthen prevention and care. These include increasing screening for hepatitis B among pregnant women (including those living with HIV) to reduce mother-to-child transmission.
“The Department is also increasing efforts towards improving early vaccine access and uptake, including a dose of the hepatitis B vaccine which is given at birth for those babies who are most at risk. Our findings highlight disparities in timely hepatitis B vaccine uptake and coverage, emphasizing the need for targeted interventions ensuring timely
vaccine uptake among HIV-exposed children,” concluded Dr. Edina Amponsah-DaCosta.
Policy from the National Department of Health, to avoid this Viral Hepatitis.
The Department of Health provides free vaccination against hepatitis B for all infants. Vaccination ensures that the children remain protected and do not develop hepatitis B. For those who are already infected as adults, screening and treatment are available from health facilities.
How has Antenatal care surveillance evolved, and what comes next?
Antenatal care (ANC) services provide convenient access to healthy women who are sexually active and can serve as a proxy for the general population with respect to HIV surveillance. Since 1990, South Africa has conducted antenatal care HIV and syphilis sentinel surveillance (ANCHSS) surveys among pregnant women attending ANC services, which have become an important component of HIV surveillance in the country.
The main aim of the annual–biennial surveys was to estimate HIV prevalence by age and location (province and district) over time and to generate input data for models used to produce national HIV prevalence and incidence estimates for planning and resource allocation. These models include Spectrum, Thembisa, and Naomi.
Over time, the objectives, inclusion criteria, sampling procedures, and data collection methods have evolved in response to changes in surveillance needs and global HIV monitoring guidelines.
This report reviews the objectives of past ANCHSS surveys and methodological changes over time, and discusses opportunities for using routine ANC and vertical transmission prevention data for HIV surveillance among pregnant women.
Results of past ANC surveys
At the national level, HIV prevalence measured in the survey increased rapidly from 0.8% in 1990 to 22.8% in 1998. Prevalence then rose more slowly, reaching 30.2% in 2005, and remained around 30% until 2022, when it declined to 27.5%.
Future Directions?
Since the late 1990s, concerns have been raised about ANCHSS, including unlinked anonymous HIV testing, duplicate testing, lack of consent, survey costs, and limited integration with routine ANC and vertical transmission prevention (VTP) data systems.
With near-universal HIV testing and increasing ANC coverage, there have been calls since 2013 to transition to HIV surveillance using routine ANC and VTP data, provided quality is sufficient.
The 2017 assessments showed high agreement between survey and routine HIV results, but data completeness, quality assurance, and standardisation were sub-optimal. Further assessments and improvements are needed before a national transition can occur, while sentinel surveys remain useful for capturing indicators not available through routine data.
Pre-vaccination studies reported hepatitis B surface antigen (HBsAg) prevalence of 5-10% in children, largely due to perinatal and early childhood transmission. More recent paediatric studies, including cohorts of HIV-infected and HIV-exposed uninfected children, demonstrate a marked decline in prevalence to below 1-2%, reflecting vaccine impact.
Hepatitis C prevalence among South African children remains consistently low, generally below 0.5%, even in high HIV-burden settings, although testing for hepatitis C in children is very limited in South Africa.
Chronic Viral Hepatitis Messaging for parents, teachers, caregivers, and siblings
Key facts:
• Chronic hepatitis B and C do not usually affect a child’s growth, learning, or daily activities.
• The viruses are spread through blood, not through hugging, playing, sharing food or using toilets.
• Hepatitis B is vaccine-preventable and included in the South African Expanded Programme on Immunisation (EPI) schedule.
• Standard precautions for blood and body-fluid should be applied to all children, not only those with a known condition.
• Most children with chronic viral hepatitis live long, healthy lives with routine monitoring and care.
How Parents shoud assist Children:
• Attend all follow-up appointments and keep a simple record of your child’s diagnosis, clinic, and immunisations.
• Talk to your child in an age-appropriate way; reassure them that their condition is manageable and not their fault.
• Ensure household members are tested for hepatitis B and vaccinated to protect the family
• Disclosure is a private family decision; share only with those who need to know, and ask for confidentiality.
• Encourage a healthy diet, sleep, and exercise; avoid unprescribed medications or remedies that may affect or stress the liver.
• Discuss alcohol use early and openly with adolescents, as it worsens liver damage or disease.
• Seek counselling or support if feelings of guilt, worry, or isolation arise.
How Teachers and School Staff should assist Children:
• Include the child fully – there is no public-health reason to restrict school, sport, or outings.
• Apply standard precautions to every child: use gloves for blood or body fluid spills; clean and cover cuts appropriately (waterproof dressing).
• Keep any disclosed diagnosis strictly confidential.
• Be flexible about clinic-related absences and help the child catch up discreetly.
• Promote a supportive environment and actively prevent bullying.
How Caregivers should assist Children:
• The child can eat, bath, hug, and play normally – no special precautions for daily care.
• If the child is injured, apply the same standard precautions as for any child.
• Do not share toothbrushes, razors, nail clippers, or earrings – a rule for the whole household.
• Help with clinic visits and medicines if you manage the child’s routine.
• Keep the child’s health information private and speak about the condition to the child calmly and positively.
• If your hepatitis B status is unknown, consider testing and vaccination – speak to your clinic or doctor for guidance.
How Siblings should assist Children:
• Reassure siblings that they cannot get hepatitis from playing, hugging, or sharing meals.
• Explain simply that their brother/sister has a virus that the doctors check on, and that they cannot catch it by playing or sharing meals.
• Encourage vaccination for hepatitis B if not already done.
• Teach the same household habits: own toothbrush, own razor, own nail clippers.
• Encourage kindness, support, and respect for privacy.
When to seek Medical Advice?
Contact the treating clinic or doctor promptly if the child develops:
• Yellowing of the skin or eyes (jaundice), dark urine, or pale stools
• Persistent tiredness, poor appetite, or weight loss
• Abdominal pain or swelling
• Easy bruising or bleeding
• Confusion or unusual drowsiness
• Any needlestick injury, bite, or significant blood exposure.
In Conclusion:
Parents, teachers, caregivers, and families all have an important role to play. Supporting children involves ensuring they attend routine health visits, receive all recommended vaccinations, and are supported in adhering to treatment where needed. Equally important is creating an environment that is free from stigma, where children feel safe, supported, and able to thrive.
To children who may be living with these conditions, the key message is one of hope: with the right care and support, it is entirely possible to lead a healthy and fulfilling life.
Image Supplied By Dr. Edina Amponsah-DaCosta, as she is based in Cape Town.
