Hepatitis B in Ethiopia: viral load, affordability, and patient perspectives at a tertiary hospital in Addis Ababa, Ethiopia

Abstract

Background

Hepatitis B virus (HBV) is a leading cause of liver infections, which can lead to chronic illness and, in some cases, liver cancer. It affects millions of people worldwide, with a particularly high burden in Africa, especially Ethiopia. Despite its prevalence, access to HBV viral load testing is limited, and its affordability has not been well documented, particularly in Ethiopia, making it challenging to diagnose and treat the disease effectively. Therefore, this study aimed to quantify the HBV viral load, assess affordability, knowledge, attitudes, and practices related to the disease, and identify various determinants associated with these parameters.” study aimed to quantify the HBV viral load, affordability, knowledge, attitudes, and practices related to this disease among HBV-infected patients at St. Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia, in 2024.

Methods

A cross-sectional study was conducted from January to April 2024 using quantitative and qualitative data from 256 participants. Affordability was assessed using household income and expenditure on HBV viral load (VL) tests, with VL quantification performed using the Cobas^®6800. Knowledge, attitudes, and practices (KAPs) were measured using a Likert scale. Data management and analysis were conducted using SPSS version 25, with a significance level set at p < 0.05.

Results

A total of 256 participants were included in this study, 53.1% of whom were females. Compared with female participants, male participants demonstrated a significantly greater likelihood of having a high viral load (AOR = 2.49, 95% CI: 1.26–4.92, p = 0.01). Individuals with co-infections exhibited a substantially increased likelihood of having a high viral load (AOR = 8.38, 95% CI: 3.76–12.29, p < 0.01). Regarding KAP concerning HBV infection, 50% of the participants demonstrated good knowledge, and 38.3% exhibited a positive attitude, and 57.8% reported good practices. Urban residents (AOR = 0.11, 95% CI: 0.02–0.60, p = 0.01), higher-income earners (AOR = 0.14, 95% CI: 0.05–0.43, p < 0.01), and individuals who had undergone viral load testing within the previous month (AOR = 0.01, 95% CI: 0.09–0.17, p < 0.03) all demonstrated significantly lower odds of experiencing catastrophic expenditures.

Conclusion

This study highlights the importance of tailored HBV management strategies, including targeted interventions and comprehensive infection prevention and control. Enhancing public health education and reducing financial barriers to HBV diagnosis and care, especially for vulnerable populations, remain crucial.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-025-12124-6.

Introduction

Hepatitis B virus (HBV) is a small DNA virus that replicates in the liver cells of humans and causes viral hepatitis [1]. It is the primary cause of viral hepatitis in less developed regions, leading to chronic liver disease, cirrhosis, and hepatocellular carcinoma (HCC) [2]. HBV and hepatitis C virus (HCV) are responsible for 80% of HCC cases [3]. Chronic hepatitis B (CHB) significantly increases the risk of mortality from cirrhosis and liver cancer. Globally, approximately 296 million people are affected by hepatitis B, resulting in 820,000 annual fatalities [4]. In Africa, 6.1% of the adult population is affected, with sub-Saharan Africa bearing a significant burden [3]. The prevalence in Ethiopia is high, with 35.8% of chronically ill patients testing positive for HBsAg [5, 6].

Early detection and treatment are crucial due to the often asymptomatic nature of the disease in its initial stages [7]. Measuring the HBV load is essential for determining when to start antiviral treatment and assessing its effectiveness [8]. The relationship between viral load and liver pathology is a key focus in CHB diagnosis and treatment [9, 10]. Challenges in managing HBV include financial burdens, limited access to testing, and long waiting periods, particularly in resource-limited regions such as Ethiopia [11, 12]. Factors influencing HBV progression include immune response, age, sex, viral genotype, and environmental elements [12, 13]. Females are less likely to develop HCC, possibly due to the effects of estrogen [14]. Age also plays a significant role in predicting fibrosis progression and is crucial in CHB treatment [15].

Hepatitis B virus (HBV) levels in patients can vary due to factors such as pregnancy, organ transplantation, and HIV co-infection. During pregnancy, HBV DNA levels may fluctuate without a consistent pattern. Organ transplant recipients on immunosuppressive medications and HIV-positive patients often experience increased HBV replication and more rapid liver disease progression [16, 17]. Affordable HBV testing in many developing nations for measuring HBV levels is needed, as current global systems are too expensive [11]. Testing HBsAg-positive individuals for HBeAg or HBV load and providing maternal antiviral prophylaxis is not very effective in preventing perinatal transmission [18].

Due to low HBV vaccine uptake and a high risk of blood exposure, health profession trainees are at high risk of HBV infection [19]. In Ethiopia, there is insufficient understanding and inappropriate behavior regarding HBV among the population, including healthcare practitioners [20]. HBV poses a significant global health challenge, affecting more than 6 million children under 5 years of age and more than 2 billion people worldwide, with 248 million developing chronic infections. Cirrhosis or liver cancer accounts for 15% to 25% of chronic HBV cases, contributing to more than 800,000 fatalities globally in 2017 [21].

One of the major challenges in HBV diagnosis and management is technological and financial barriers. Advanced technologies for quantifying viral load exist but are costly and require trained personnel, limiting access in low- and middle-income nations [22]. In Ethiopia, where the prevalence of HBV is significantly higher than the global average, the scarcity of equipped laboratories exacerbates this challenge [23]. Moreover, in many parts of the world, especially in developing countries, diagnosis relies on serologic tests with limited sensitivity in predicting prognosis. Real-time advanced techniques for assessing viral load are crucial for treatment decisions but are hindered by constraints in developing nations, particularly in Ethiopia [24]. Likewise, evaluating testing affordability is crucial in resource-limited settings and can inform healthcare policies. Understanding patients’ knowledge, attitudes, and practices is essential for developing awareness campaigns and behavior interventions.

Thus, this study investigated the HBV load, the affordability of testing, and patient knowledge, attitudes, and practices. This study provides valuable data for public health initiatives, patient care, and policy development, especially within Ethiopia’s healthcare system and global efforts to combat HBV.

Materials and methods

Study design, period, and settings

An institutional based cross-sectional study design with qualitative and quantitative data. Our quantitative data encompasses both data from retrospective and prospective, whereas the qualitative was collected mainly in a way of prospectively. The study was conducted from January to April 2024 at St. Paul Hospital Millennium Medical College (SPHMMC). The hospital has more than 2800 clinical, academic, administrative, and support staff members who work at the institution. The hospital teaches medical students and has been performing basic and applied research in addition to providing medical specialty services to patients who are referred from all over the nation. The hospital accommodates more than 700 inpatient beds, and on a daily average, 1200 emergency and outpatient patients are seen. The hospital has centralized laboratory services encompassing hematology, clinical chemistry, serology and virology, parasitology, urinalysis, transplant laboratories, blood banks, maternity and child health laboratories, microbiology, and infertility laboratories. Each laboratory service uses different advanced instruments, including a Cobas 6800 (Roche Company, Basel, Switzerland) and interfaced laboratory information systems. According to the data from the gastrointestinal (GI) department of the hospital, more than 598 HBV-infected patients were receiving treatment in the hospital. St. Paul’s Hospital was selected for this study because it has the highest HBV patient load of any other hospital in the country [25].

Study population

The study population consisted of HBsAg-positive patients aged 18 years or older who were receiving follow-up care at SPHMMC. Only those who provided informed consent were included in the study. However, incomplete data, such as mislabeling, insufficient samples, incorrect test tubes, inappropriate samples, tests, and loss to follow-up, were excluded from the study.

Sample size determination and sampling technique

Sample size determination

For the quantitative analysis, the sample size was calculated using a 50% assumed prevalence of adequate knowledge, attitudes, or practices related to HBV, as there was no specific published literature available in the study area. The sample size was determined using the single population proportion formula, and an additional 10% was added to account for potential non-respondents.

ni = (1.96)² × 0.5(1-0.5)/(0.05)² =384. However, since the actual number of HBV-positive patients available for chronic follow-up, which was the source population for the study, was 598 and less than 10,000, using the following correction formula for finite population.

=384/(1+384/598) =233. After considering 10%, the minimum sample size was 256.

where nf = corrected sample size

ni = uncorrected

N = total number of all the source population

w = absolute precision (w = 5%)

p = estimated population proportion (50%)

Z α/2 = 95% confidence interval from the normal table for a given value (1.96)

For the qualitative study, data saturation was achieved after interviewing 25 participants, selected based on purposive sampling to ensure diversity in gender, age, and residence. Saturation was determined when consecutive interviews no longer yielded new themes or insights relevant to the research questions. These participants were selected according to specific criteria, including being HBsAg-positive, aged 18 or older, and having been under follow-up care at SPHMMC. The diversity of participants allowed for a comprehensive understanding of the phenomenon under investigation.

Sampling technique

A simple random sampling technique was used to ensure a rigorous and unbiased selection of participants. Additionally, purposive sampling was applied to prioritize participants based on clinical characteristics, such as HBV viral load status, disease progression, and follow-up history. Consecutive sampling was then employed to include eligible participants who met the study criteria during the data collection period. This dual-sampling strategy aimed to enhance the study’s precision and relevance by combining the benefits of random selection with purposive selection, thereby optimizing the selection process for a more nuanced and insightful analysis.

To ensure simple random sampling, the first participant was selected using the lottery method from among patients who had appointments on the same day. Each eligible patient’s unique identification number was written on identical slips of paper, mixed thoroughly, and one was randomly drawn. Subsequent participants were then selected using a computer-generated random number list from the full roster of eligible patients attending the follow-up clinic during the study period.

Data collection and measurement

The data collection process for this study was designed to comprehensively capture insights into HBV dynamics through a combination of methods. Baseline results for HBV viral load levels were meticulously extracted from existing documents and the laboratory information system. These data, spanning a specified timeframe, offered valuable insights into patients’ past viral load levels, contributing to a thorough understanding of the virus’s trajectory.

Laboratory data were collected in real time during the study period. Additionally, patients’ clinical histories were systematically recorded using a checklist, with pertinent information extracted from medical records and interviews, the 2nd and the 3rd viral load level was quantified in prospective way and the quantification results of patients’ HBV viral load were documented, providing a contemporaneous perspective on the virus’s dynamics and allowing for a dynamic analysis of changes over time.

To complement the quantitative findings, qualitative data were collected through in-depth interviews (IDIs), while structured questionnaires provided the quantitative data. The questionnaires, which included written consent and included socio-demographic variables, provided additional context to the numerical data. The IDI was organized by selecting participants based on specific criteria and was guided by trained moderators to explore participants’ knowledge, attitudes, and practices related to HBV infection prevention and test the affordability of VL. During IDI, we used a tape recorder for audio recording. Thematic analysis was applied to identify key patterns and themes that emerged from the qualitative data, enriching the overall understanding of the study.

The questions used to measure the participants’ KAP about HBV infection included various items. Specifically, the questions assessing attitudes toward HBV infection were structured using a Likert scale.

Economic aspects were assessed through inquiries included in the structured questionnaires, specifically focusing on participants’ total household income and expenditures related to the HBV load. This comprehensive approach aims to evaluate the affordability of the test.

To ensure inclusivity, individuals meeting the study’s inclusion criteria were permitted to independently complete all questionnaire sections. Assistance was provided via the data collectors when needed, and the data collectors conducted interviews employing a meticulous approach to ensure a comprehensive understanding of the factors under investigation. By integrating both retrospective and prospective data collection methods, coupled with a robust qualitative approach through IDI, this comprehensive procedure aims to provide a nuanced understanding of HBV dynamics, economic implications, and preventive measures, contributing to a holistic analysis of the study objectives.

An English version of the questionnaire for the study is available as a supplementary file (Supplementary File S3).

Laboratory testing

The Cobas^® 6800 analyzer, a state-of-the-art diagnostic tool, utilizes advanced automated real-time Polymerase Chain Reaction (PCR) technology to precisely measure HBV DNA levels in a patient’s blood, providing critical insights into disease progression and treatment efficacy. For optimal sample integrity, blood was collected in EDTA tubes, and viral DNA was isolated through plasma centrifugation. The Cobas^® 6800 automates the entire workflow, including sample preparation, nucleic acid amplification, and fluorescence-based detection, ensuring highly accurate and reliable results. This technology is exceptionally sensitive, capable of detecting viral activity at levels as low as 10 IU/mL, making it indispensable for monitoring low-level viremia. Additionally, its high-throughput capability allows for rapid and accurate processing of large sample volumes, enhancing its utility in both clinical and research settings.

Quality assurance

The study’s reliability was ensured through comprehensive quality control measures at every laboratory stage. Prior to data collection, the tool underwent pretesting for accuracy and consistency. A 5% pretest of the study population preceded actual data collection. Daily feedback and corrections from the investigators ensured the proficiency of the data collector. Regular checks ensured data completeness, accuracy, and clarity. The data collectors received thorough training for uniformity and accuracy. Cross-checks were conducted daily to verify checklist completeness and eliminate redundancy. Primary investigators closely monitored the data collection process to maintain data integrity and reliability. A comprehensive quality assurance framework covering the pre-analytical, analytical, and post-analytical stages was strictly followed.

Pre-analytical data quality control

During the pre-analytical phase, blood specimens were meticulously labeled with patient names, medical record numbers (MRNs), and dates to avoid any identification errors. An appropriate volume of blood and anticoagulant was used to maintain the specimen’s quality. Attention was given to check for hemolysis, clotting, and specimen contamination, and a waiting period of 10 to 15 min was used to stabilize the serum and separate the jell from the blood.

Analytical data quality control

During the analytical phase of the quality control program, routine checks of instruments and reagents were performed, with control samples for the Cobas 6800 analyzer (this system supports an automated and integrated workflow to run polymerase chain reaction (PCR)-based nucleic acid testing (NAT)) run at defined intervals for monitoring. The analytical process involved a thorough check for any issues related to the instrument, reagents, or sample preparation. Every day before the sample was run, low, medium, and high concentrations of control reagent were added to a Cobas 6800 analyzer to maintain reagent quality and preventive maintenance.

Post-analytical data quality control

In the post-analytical stage, the accuracy of the results was verified before release, and correlations with clinical information were made to ensure relevance and consistency. The entire process was documented, including interpretations and correlations with clinical information.

Data analysis and interpretation

Data entry, coding, cleaning, sorting, and analysis were conducted using SPSS version 25, a robust statistical software. To characterize the study population, frequencies and summary statistics were employed, providing a comprehensive overview of relevant variables. Bivariate and multivariate logistic regression analyses were performed to assess the impact of independent variables on the dependent variable. The odds ratio (OR) was also used to interpret the degree of association between variables. An OR < 1 indicates a lower likelihood of the outcome occurring in the exposed group compared to the reference group, whereas an OR > 1 suggests a higher likelihood of association. Statistical significance was determined with a p-value threshold of less than 0.05.

The participants’ knowledge, attitudes, and practices were evaluated based on the mean scores from the questions they answered, with scores above the mean indicating good knowledge, attitudes, and practices from the designed questionnaires. A Likert scale was used to measure responses, allowing for a more nuanced assessment of participants’ perspectives. Additionally, the affordability of VL tests was assessed by comparing the cost from participants’ household income. Participant expenses above 40% of their income for the VL test were considered catastrophic expenditures. This strategic approach ensures a meticulous examination of the study findings, employing both statistical rigor and practical benchmarks for meaningful interpretation.

Operational definition

• I.Affordability: - ability to pay for HBV-infected patients for the quantification of HBV DNA at SPHMMC (center of financial inclusion definition).
• II. Attitude
  1. Positive attitude: when the study participants are able to give above the mean for the given attitude item question [19].
  2. Negative attitude was defined as the point at which the study participants gave a score below the mean for the given attitude item [19].
• III. Knowledge
  1. Good Knowledge: This is when the study participants are able to answer correctly above the mean of the questions in knowledge items [19].
  2. Poor knowledge: when the study participants answered less than the mean of the questions in the knowledge items [19].
• IV.Patients who were lost to follow-up were hepatitis B virus-infected patients who terminated their treatment [26].
• V. Practice
  1. Good practice: This is when the study participants can answer correctly above the mean of the questions in practice items [19].
  2. Poor practice was defined as follows: when the study participants answered less than the mean of the questions on the knowledge items [19].
• VI.Low viral load: HBV amount < 20,000 IU/ml (American Association for the Study of Liver Diseases (AASLD) Guidelines).
• VII.High viral load: HBV amount >20,000 IU/ml (AASLD).
• VIII.Catastrophe expenditures are expenses for medical issues for more than 40% of household income (WHO definition) [27].

Results

Socio-demographic characteristics of the study participants

A total of 256 participants were enrolled, 53.1% (136/256) of whom were female, with an average age of 37.96 years and a standard deviation of 10.4 years. Among the study participants, 31.3% (80/256) were between 33 and 40 years old. A total of 59.8% of the study participants lived in urban areas (Table 1).

Table 1.

Socio-demographic characteristics of the study participants at the SPHMMC from January to April 2024 (n = 156)

Variables		Number	Percentage
Gender	Male	120	46.9
	Female	136	53.1
Age group in years	18–24	16	6.3
	25–32	72	28.1
	33–40	80	31.3
	41–48	49	19.3
	49–56	29	11.3
	57–64	5	2.0
	> 65	5	2.0
Residence	Urban	153	59.8
	Rural	103	40.2
Educational status	Illiterate	31	12.1
	Primary school	77	30.1
	Secondary school	72	28.1
	Diploma	33	12.9
	Degree and above	43	16.8
Household income in ETB per month	< 3000	81	31.6
	3000–5000	85	33.2
	5000–10,000	52	20.3
	> 10,000	7	2.7
	Have no regular income	31	12.1

NB: Percentages may not total exactly 100% due to rounding, ETB = Ethiopian birr

Factors associated with a high HB viral load

Various factors were considered and statistically analyzed to assess the level of HBV viral load associated with different conditions. Both COR and AOR, along with their 95% CI and corresponding p-values, were utilized. Gender showed a significant association with VL, with males being 2.49 times more likely to have a high VL level compared to females (COR = 2.49, 95% CI: 1.45, 4.25, p < 0.01;AOR = 2.49, 95% CI: 1.26, 4.92, p = 0.01). Age did not display a significant association with VL level; individuals under 38 years had a COR = 1.31, 95% CI: 0.72, 2.39, p = 0.38) compared to those aged 38 years or older. Pregnancy status also did not 22 exhibit a significant association with VL level; pregnant women had a COR = 0.50, 95% CI: 0.20, 1.27, p = 0.84 compared to non-pregnant women.

Co-infection is significantly associated with a higher VL level. Individuals with co-infections are much more likely to have a high VL level, with a COR = 8.38, 95%CI: 3.76, 12.29, P < 0.01; AOR = 8.94, 95%CI: 4.65, 17.17, p < 0.01 (Table 2).

Table 2.

Association of the average HB viral load with factors at SPHMMC from January to April 2024 (n = 256)

Variables		Viral load level
		Low VL level	High VL level	Chi-square value	COR(95%CI)	P value	AOR(95%CI)	P value
Gender	male	68(56.7)	52(43.3)	< 0.01*	2.49(1.45–4.25)	< 0.01*	2.49 (1.26–4.92)	< 0.01*
	female	104(76.5)	32(23.5)		1		1
Age in years	< 38	50(71.4)	20(28.8)	0.46	1.31(0.72–2.39)	0.38
	≥ 38	122(65.6)	64(34.4)		1
Pregnant	pregnant	17(65.4)	9(34.6)	0.22	0.50 (0.20–1.27)	0.84
	Non pregnant	87(79.1)	23(20.9)		1
Co-infection	Co-infection	29(36.7)	50(63.3)	< 0.01*	8.38(2.76–12.29)	< 0.01*	8.94 (4.65–17.17)	< 0.01*
	Non-Co infection	104(75.4)	34(26.6)		1		1
Alcohol drinker	Alcohol drinker	12(48.0)	13(52.0)	0.05	2.01 (1.78–4.94)	0.04*	2.44 (0.89–6.68)	0.08
	Non-alcohol drinker	160(69.3)	71(30.7)		1		1
Smoker	smoker	2(40.0)	3(60.0)	0.41	0.32 (0.05–1.94)	0.21
	Non smoker	170(67.7)	81(32.3)		1

NB: VL = viral load, 1 = reference, AOR = adjusted odds ratio, COR = crude odds ratio, 95% CI = confidence interval. ^* indicates significance

Study participants’ knowledge of HBV

The knowledge of respondents about the early detection, transmission, and prevention of HBV exhibited the quantity and proportion of participants who responded “Yes,” “No,” or “Not sure” to several inquiries regarding HBV. Overall, there are differences in knowledge regarding several facets of HBV. There are noticeable gaps in understanding, especially regarding the route of transmission, even though a substantial number of respondents correctly identified that HBV can cause liver cancer or cirrhosis (26.60%) and can be transferred by unsafe sex (42.60%). For instance, only a small percentage (15.60%) of respondents correctly identified that HBV is not spread through casual handshaking and transmitted by contact with open wounds (20.70%). Similarly, there was a variable level of knowledge on laboratory testing (55.10%) and HBV post-exposure prophylaxis (5.90%). This result highlights the significance of focused instruction (Table 3).

Table 3.

Study participants’ knowledge of HBV at SPHMMC from January to April 2024 (n = 256)

Knowledge question	Yes N (%)	No N (%)	Not sure N (%)
Can HBV lead to cirrhosis or liver cancer?	68(26.60)	99(38.70)	89(34.80)
Is hand shaking a casual way for HBV to spread?	40(15.60)	123(48.00)	93(36.30)
Can an open wound contact transmit HBV?	53(20.70)	108(42.20)	95(37.10)
Is it possible for contaminated blood or bodily fluids to spread HBV?	77(30.10)	90(35.20)	89(34.80)
Can unprotected sexual contact spread HBV?	109(42.60)	76(29.7)	71(27.70)
Is it possible for contaminated water to spread HBV?	72(28.10)	102(39.8)	82(32.10)
Is HIV 50–100 times less contagious than HBV?	19(7.40)	156(60.9)	81(31.6)
Are you aware of the post-exposure prophylaxis for HBV?	15(5.90)	147(57.40)	94(36.70)
Do you believe that HBV does lab testing?	141(55.10)	54(21.10)	61(23.80)

NB: - HBV = Hepatitis B virus

Attitude level of participants toward HBV

A significant proportion agreed that all patients should be tested for HBV before receiving healthcare (48.4%) and that HBV viral suppression is effective (39.1%). However, 56.3% expressed discomfort in taking care of people with HBV, and 32.8% lacked confidence in post-exposure prophylaxis as a preventative measure. Additionally, 36.7% expressed no concern about being infected with HBV (Table 4).

Table 4.

Attitudes of participants toward HBV at SPHMMC from January to April 2024 (n = 256)

Attitude-based questions	Strongly agree N (%)	Agree N (%)	Disagree N (%)	Strongly disagree N (%)	Not sure N (%)
No fear of having an HBV infection	29(11.3)	94(36.7)	105(41.0)	14(5.5)	14(5.5)
Every patient should have an HBV test before receiving medical care.	34(13.3)	124(48.4)	64(25.0)	11(4.3)	23(9.0)
I find it uncomfortable to care for those who have HBV.	22(8.6)	47(18.4)	144(56.3)	25(9.8)	18(7.0)
Prophylactic measures after exposure can help avoid HBV infection.	30(11.7)	39(15.2)	84(32.8)	57(22.3)	46(18.0)
HBV viral suppression is effective	92(35.9)	100(39.1)	39(15.2)	8(3.1)	17(6.6)

Practice level of the study participants with regard to HBV

The majority of participants (93.4%) stated that they had tested for HB viral load. On the other hand, 6.6% of respondents said they had never tested for HBV before becoming infected.

A sizable percentage of participants (69.1%) admitted to encountering difficulties or impediments when trying to obtain or recommend HBV load testing. Regarding workplace safety, 60.9% of participants mentioned that they had been injured by a needle stick, underscoring the risks that come with working in the medical field.

On the other hand, 39.1% said they had never had a needle stick injury. Responses on the following safety procedures were evenly divided: 50.4% of respondents confirmed that sharps should be disposed of properly after usage or operation, whereas 49.6% reported that sharps should be disposed of properly (Table 5).

Table 5.

Level of practice among the study participants toward HBV at the SPHMMC from January to April 2024(n = 256)

Practice-based questions	Yes N (%)	No N (%)
Have you ever tested HBV regularly before being infected?	239(93.4)	17(6.6)
Are there any challenges or barriers you face in accessing or promoting Hepatitis B viral load testing?	177(69.1)	79(30.9)
Have you ever been injured by a needle stick?	156(60.9)	100(39.1)
After using or performing a procedure, do you dispose of sharps properly?	129(50.4)	127(49.6)

Overall KAP levels of the study participants

The respondents’ KAP about HBV differed noticeably from one another. Only 50% of respondents had a high (above the mean) understanding of HBV, while the remaining 50% had poor knowledge (below the mean). Regarding attitudes, a sizable percentage of respondents (61.7%) had a negative opinion (below the mean) about HBV, in contrast to 38.3% who had positive attitudes (above the mean). In terms of practices related to HBV, the majority (57.8%) had well (above the mean) practice despite the general lack of thorough information and unfavorable attitudes, while 42.2% engaged in malpractice which is below the mean (Fig. 1).

Fig. 1.

KAP levels of the respondents about early detection, transmission, and prevention of HBV at SPHMMC from January to April 2024

Factors associated with KAP toward HBV infection

In this study, we performed a regression analysis to determine the relationships between the selected demographic variables and the KAP of the participants toward HBV infection, transmission, and control mechanisms. (Table 6A and 6B)

Table 6B.

Univariate and multivariate analyses of factors associated with practice toward HBV infections (n = 256)

Variables		Practice level
		Good practice	Mal practice	COR(95%CI)	P value	AOR(95%CI)	P Value
Gender	male	61(50.83)	59(49.17)	1.72(1.04–2.83)	0.03*	1.72(1.04–2.83)	0.03*
	Female	8(64.0)	49(36.0)	1		1
Age	< 38 years	87(62.6)	52(37.4)	1.54(0.93–2.51)	0.09	1.54(0.93, 2.53)	0.09
	≥ 38 years	61(52.1)	56(47.9)	1		1
Residence	Urban	89(58.2)	64(41.8)	1.04(0.63–1.72)	0.89	1.04(0.63–1.72)	0.89
	Rural	59(57.3)	44(42.7)	1		1
Educational status	Illiterate	13(41.9)	18(58.1)	0.39(0.15-1.00)	0.05	0.39(0.15-1.00)	0.05
	Primary school	46(59.7)	31(40.3)	0.80(0.37–1.73)	0.56	0.80(0.37–1.73)	0.56
	Secondary school	44(61.1)	28(38.9)	0.84(0.38–1.85)	0.67	0.84(0.38–1.85)	0.67
	Diploma	17(51.5)	16(48.5)	0.57(0.23–1.44)	0.23	0.57(0.23–1.44)	0.23
	Degree and above	28(65.1)	15(34.9)			1

NB: − 1 = Reference, AOR = adjusted odds ratio, COR = crude odds ratio, 95% CI = confidence interval, *= statically significant

Table 6A.

Univariate and multivariate analyses of factors associated with knowledge and attitude toward HBV infections (n = 256)

Variables	Good Knowledge	Poor Knowledge	COR(95% CI)	P Value	AOR(95% CI)	P Value	Positive attitude	Negative attitude	COR(95%CI)	P Value	AOR(95%CI)	P Value
Gender
Male	60(50.0)	60(50.0)	1.00(0.61–1.63)	1.00	1.00(0.61, 1.63)	1.000	48(40.00)	72(60.00)	0.90(0.53–1.45)	0.60	1.15(0.69–1.90)	0.35
Female	68(50.0)	68(50.0)	1		1		50(36.8)	86(63.2)	1		1
Age
< 38 years	73 (52.5)	66(47.5)	1.25(0.76–2.04)	0.38	0.911(0.345, 2.407)	0.851	55(36.9)	94(63.1)	0.58(0.35–0.96)	0.04*	1.73(1.04–2.88)	0.04*
≥ 38 years	55 (47.0)	62(53.0)	1		1		53(45.3)	64(54.7)	1		1
Residence
Urban	81(52.9)	72(47.1)	1.34(0.81–2.21)	0.25	1.34(0.81–2.21)	0.252	54(35.3)	99(64.7)	0.73(0.44–1.22)	0.23	0.73(0.44–1.22)	1.81
Rural	47(45.6)	56(54.7)	1		1		44(42.7)	59(57.8)	1		1
Educational Status
Illiterate	3(9.7)	28(90.3)	0.03(0.01–0.12)	< 0.01*	0.09(0.01–27.98)	0.10	20(64.5)	11(35.5)	3.77(1.42–9.97)	0.01*	0.91(0.34-2.45)	0.91
Primary School	37(48.1)	40(51.9)	0.25(0.10–0.58)	< 0.01*	0.218(0.049,0.965)	0.06	27(35.1)	50(64.9)	1.12(0.51–2.47)	0.78	1.26(0.57–2.82)	0.86
Secondary School	34(47.2)	38(52.8)	0.24(0.10–0.56)	< 0.01*	0.557(0.180,1.719)	< 0.01*	27(37.5)	45(62.5)	1.24(0.56–2.76)	0.59	1.05(0.45-2.42)	0.57
Diploma	20(60.6)	13(39.4)	0.41(0.15–1.11)	0.08	0.33(0.06–1.33)	0.19	10(30.3)	23(69.7)	0.90(0.34–2.40)	0.83	3.41(1.17,9.93)	0.03
Degree and Above	34(79.1)	9(20.9)	1		1		1(32.6)	29(67.4)	1		1

NB: − 1 = Reference, AOR = adjusted odds ratio, COR = crude odds ratio, 95% CI = confidence interval, *= statistically significant

Affordability of the HBV viral load test

The affordability of HBV quantification testing and financial difficulties were the main reasons for delayed testing in the diagnostic system. Specifically, 34.8% (89 out of 256) of patients underwent the HBV VL test once a month, while majority, 65.2% (167 out of 256), had the VL test twice in the past month. Regarding HBV quantitation, a large majority (78.1%) reported facing financial difficulties when undergoing the HBV VL test. Among them, 47.3% admitted to postponing or skipping the VL test due to these financial concerns. The majority of respondents (93.4%) said that their financial situation was affected by the cost of HBV quantitation testing, and 89.1% considered the test to be expensive. When asked who pays for the test, 68.0% of respondents said that they do, and 32.0% mentioned that their family covers the cost (Table 7 and S1).

Table 7.

Questions for the assessment of HBV viral load test affordability (n = 256)

Questions		Number	Percentage
how often do you get HBV quantification tests in the last one month	Once	89	34.8
	Twice	167	65.2
Do you face any financial challenges with getting HBV quantification tests	Yes	200	78.1
	No	56	21.9
Who usually covers the cost of the test of HBV viral load?	Self	174	68.0
	Family	82	32.0
Have you ever delayed or skipped HBV quantification testing due to financial concerns	Yes	121	47.3
	No	135	52.7
Does the cost of HBV quantification testing influence you economically	Yes	239	93.4
	No	17	6.6
Do you think that the cost for hepatitis B virus quantification is costly?	Yes	228	89.1
	No	28	10.9

Factors influencing the expenditure on HBV viral load testing

Factors associated with catastrophic expenditure (≥ 40% of income) on HBV VL tests were examined to assess the affordability and challenges related to the cost of HBV diagnostic tests. Urban residents were significantly less likely to experience catastrophic expenditures than rural residents were (AOR = 0.108, 95% CI: 0.019, 0.603, p = 0.011), indicating that living in urban areas protects against high healthcare costs. The frequency of testing also plays a role; individuals tested once a month face lower odds of catastrophic expenditures than those tested twice (AOR = 0.140, 95% CI: 0.045, 0.432, p = 0.001), suggesting that more frequent testing increases the financial burden. Additionally, participants with a monthly income over 10,001 ETB were significantly less likely to incur catastrophic expenses than were those with no income (AOR = 0.006, 95% CI: 0.001, 0.169, p = 0.003), highlighting the protective effect of higher income. Gender, age, educational status, and intermediate income level did not show significant associations with catastrophic expenditures. These findings indicate that geographical location, frequency of medical testing, and income level are key determinants of the financial burden associated with HBV VL testing, emphasizing the need for targeted public health interventions to mitigate costs, particularly for rural and lower-income populations (Table 8).

Table 8.

Factors influencing the expenditure on HBV viral load testing (n = 256)

Variables		Expense for HB VL		COR(95%CI)	P value	AOR(95%CI)	P value
		Catastrophic expenditure (≥ 40%)	Non Catastrophic expenditure (< 40%)
Gender	Male	106(46.3)	14(51.9)	0.80(0.36–1.77)	0.58
	Female	123(53.7)	13(48.1)	1
Age	< 38	129(53.9)	10(58.8)	1.12(0.50–2.48)	0.79
	≥ 38	110(46.1)	7(41.2)	1
Residence	urban	128(55.9)	25(92.6)	0.101(0.02–0.44)	0.02*	0.11(0.019 − 0.60)	< 0.01*1
	Rural	101(44.1)	2(7.4)	1
Educational status	Illiterate	29(12.8)	2(7.4)	26.20(0.01-30.00)	1.00
	Primary school	70(30.7)	7(25.9)	2.00(0.45–4.34)	0.56
	Secondary school	60(26.4)	12(44.5)	0.81(0.88–2.35)	0.70
	Diploma	31(13.6)	2(7.4)	5.189(0.59–45.41)	0.14
	Degree and above	37(16.3)	6(22.2)	1
frequency of HBV VL tests in the past one month	Once	70(30.6)	17(63.0)	0.259(0.11–0.59)	< 0.01*	0.14(0.05–0.43)	< 0.01*
	Twice	159(69.4)	10(37.0)	1
Monthly Income of participants in ETB	> 3000	79(34.5)	2(7.4)	1.724(0.37–20.24)	0.33
	3001–5000	77(33.6)	8(29.6)	0.664(0.133–3.312)	0.62
	5001-10,000	43(18.8)	9(33.3)	0.330(0.07–1.64)	0.18
	> 10,001	1(0.4)	6(22.2)	0.01(0.01–0.15)	< 0.01*	0.01(0.01–0.17)	0.01*
	Have no income	29(12.7)	2(7.4)	1

NB: -1 = Reference, AOR = adjusted odds ratio, COR = crude odds ratio, 95% CI = confidence interval, ETB = Ethiopian body, * statically significant

Patient perspectives on the affordability of HB viral load testing

Knowledge about laboratory tests, transmission, and prevention of HBV

The respondents exhibited a broad range of understanding regarding HBV laboratory tests, transmission routes, and preventive measures. While some display a solid grasp of HBV testing procedures and transmission through blood contact and sharing sharp objects, others highlight preventive strategies such as abstaining from unprotected sex and avoiding sharing sharp materials. However, a notable subset of respondents lacked in-depth knowledge about HBV, its laboratory testing methods, various modes of transmission, and the array of preventive measures available.

I only know there is a laboratory test for HBV, but I don’t know details about the test. I am not sure about the transmission. However, HBV may be transmitted by blood contact, by the use of sharp materials together with infected individuals, or by unprotected sex. Even if it is difficult to protect ourselves from HBV, we can prevent it by abstaining from unprotected sex.

Knowledge about HBV and practices related to how to acquire the hepatitis B virus

Responses from participants showcase a range of uncertainty regarding the acquisition of HBV. While some individuals confidently attribute their infection to specific conditions such as blood contact, exposure to sharp objects, or sexual transmission, others express uncertainty about the exact mode of transmission. This variance in understanding underscores the complexity of HBV transmission and the need for comprehensive education on its various routes of acquisition.

I don’t remember how I got infected with HBV, but it may be either by blood contact or exposure to sharp materials.

Participant attitudes toward HBV and the importance of VL quantification

A notable lack of understanding is observed among respondents regarding HBV viral load quantification. While some individuals undergo regular tests, they do so without a full comprehension of the significance behind these assessments. This highlights a crucial gap in knowledge in which individuals may participate in testing without fully understanding the implications of their results. Bridging this gap through comprehensive education and communication about the importance of viral load quantification is essential to ensure informed decision-making and effective management of HBV infections.

Even though I have HBV VL regularly, I don’t understand anything about the viral load.

Some respondents exhibited diverse perceptions regarding the importance of monitoring the HBV load. While some recognize its significance for guiding treatment decisions and preventing disease progression, others lack a detailed understanding of its importance. Particularly noteworthy is the recognition among respondents that monitoring viral load is crucial, especially for individuals with co-infections. This highlights the importance of tailored education and communication strategies to ensure that all individuals affected by HBV understand the rationale behind viral load monitoring and its role in managing the infection effectively.

I believe that knowing the viral load of the virus in the blood has its importance; specifically, I don’t know what those important are.

Regularly knowing the VL in the body is important for individuals who have co-infection.

The affordability of the cost of the HBV viral load test

Many respondents expressed concerns about the prohibitively high cost of HBV viral load testing, which creates significant financial burdens, especially for individuals with low incomes. Frustration and concern are palpable among some respondents regarding the exorbitant costs, with many suggesting the urgent need for price reductions to enhance accessibility. Patients unanimously agree that the cost of HBV VL tests is excessively high, whether the tests are conducted in private or governmental laboratories. This widespread sentiment underscores the urgent need for policy interventions aimed at reducing costs and improving affordability to ensure equitable access to essential HBV testing services.

I find the cost of the HBV VL test is too high for me to afford. On this occasion, I would like to remind the concerned party to reduce the price of the HBV VL test.

Even though the cost is lower relative to private institutions, it is too expensive for low-income patients.

Discussion

Quantifying the viral load of HBV is essential for diagnosing and monitoring HBV infection and evaluating treatment effectiveness by measuring the genetic material of HBV in the blood. In this study, which was conducted at the SPHMMC, a majority of the HBV-infected individuals receiving treatment were females. This trend, also noted in studies from Mozambique and Zambia by Gilles W. et al. [28], may be attributed to greater healthcare engagement among women, particularly during pregnancy check-ups and follow-up visits, leading to higher detection rates. Conversely, studies in Nigeria by Iregbu KC et al. [1] and Chinwe O. et al. [29] reported higher infection rates among males, possibly due to greater financial resources for testing.

The present study revealed significant associations between viral load and sex, with males being more likely to have a high viral load (COR = 2.485, 95% CI: 1.454–4.248, p = 0.001; AOR = 2.488, 95% CI: 1.258–4.921, p = 0.009). This suggests that males are approximately 2.5 times more likely to have a high degree of infectiousness than females. Similar findings were reported in studies from Nigeria by Iregbu KC et al. [1] and China by Jing et al. [8]. The higher viral load in males may be influenced by estrogen in females, which could lower viral replication, and behavioral factors such as higher rates of alcohol consumption and smoking among males, which can impact HBV replication and disease progression. However, a study by Chinwe O. et al. [29] in Nigeria revealed no significant differences in viral load between sexes, indicating the need for further research to understand these discrepancies.

In the present study, co-infection or other disease conditions were significantly associated with a greater degree of infectiousness (high VL), with an AOR of 8.94 (95% CI: 4.65–17.17, p < 0.01). This suggests that co-infected individuals were significantly more likely to have a high VL even after adjusting for other factors. A previous study in Northeast Ethiopia revealed that individuals with co-infections had significantly greater viral loads, with those exceeding 1000 copies/ml being 6.53 times more likely to be co-infected with HBV than those with undetectable viral loads (AOR = 6.53, 95% CI: 1.87–22.72) [30]. Another study in Ethiopia highlighted the interactions between HBV and the host immune response, emphasizing that co-infections can complicate HBV clinical outcomes, leading to increased viral loads and increased risk of liver complications such as cirrhosis and HCC [31]. This is due to immunosuppression caused by co-infection with different illnesses [32].

Alcohol consumption showed a borderline significant association with the degree of infectiousness (COR = 2.01, 95% CI: 1.78–4.94, p = 0.04), consistent with findings from previous studies by Cargiulo T [33].

This study revealed that 26.6% of participants correctly identified that HBV can cause liver cancer, and 42.6% knew that it could be transmitted through unprotected sex. Only 5.9% were aware of post-exposure prophylaxis, and 20.7% knew that the virus could be transmitted through open wounds. More than half (55.1%) knew that the virus could be detected through laboratory tests, indicating a moderate understanding among participants. The mean knowledge level was 31%, with half of the participants scoring below the mean (poor knowledge) and the other half above the mean (good knowledge). This result contrasts with studies in Bahirdar, Ethiopia, where 65.6% had good knowledge and 34.4% had poor knowledge [20], and in Northwest Ethiopia, where 80% had good knowledge and 20% had poor knowledge [19]. In Khartoum, Sudan, 58% knew about HBV [34]. Contextual and systemic variables may have contributed to the reduced HBV knowledge shown in this study when compared to others. Participants may be have limited access including poor internet connectivity, low use of health communication platforms, or a dearth of health education resources in local languages may limit participants’ access to trustworthy and current health information. Additionally, they may not have received enough formal education on infectious diseases, especially if health-related subjects are not taught in their schooling or if community outreach initiatives do not prioritise health-related issues. In their daily lives, HBV can also be seen as a low-priority issue, particularly if there aren’t many obvious instances or firsthand accounts of the illness in their close social groups. Their will to actively seek knowledge or take preventative action may be weakened by this perceived low danger. Knowledge levels can also be greatly impacted by regional or community-specific variations in the execution and efficacy of public health interventions, health education campaigns, and general education standards. The gap in HBV knowledge and comprehension may be exacerbated by socioeconomic level, cultural values, and the ability of the health system to reach out.

However, the findings of this study were higher than those in Thailand, where only 19.85% had good knowledge [35]. This discrepancy may be because the Thai study involved migrant individuals who may have limited information about medical issues due to language barriers and limited health educational resources on HBV.

Regarding the attitudes of respondents about HBV infection in this study, nearly half (48.4%) agreed that all patients should be tested for HBV before receiving healthcare, and 39.1% believed that HBV viral suppression is important for understanding current medical treatment. However, 32.8% lacked confidence in post-exposure prophylaxis as a preventative measure for HBV. Overall, 38.3% of respondents had a positive attitude toward HBV infection, while 61.7% had a negative attitude. This result is lower than those of studies conducted in Bahirdar, Ethiopia (40.3% positive, 59.7% negative) [20], Gondar, Ethiopia (43.8% positive, 56.2% negative) [36], and Jordan (40% positive, 60% negative) [37]. There could be a number of reasons for the decreased HBV attitude seen in this study when compared to others. It’s possible that the study’s participants were not exposed to many focused health education or awareness campaigns about infectious diseases like HBV. Additionally, they may believe that HBV is less relevant or dangerous in their day-to-day life, which may lessen their desire to learn more or take preventative measures. The observed attitude gap may also be caused by variations in general education levels, the efficacy of public awareness initiatives in various contexts, and access to reliable health information. However, this study’s findings showed a better attitude toward HBV than a study in Northwest Ethiopia (17% positive, 83% negative) [19] and Thailand (24% positive) [35]. This may be because HBV-infected individuals often engage with support groups and healthcare providers, fostering a more positive attitude.

In terms of practice, this study showed that the majority of participants (93.4%) were tested for HBV viral load, indicating a proactive approach to tracking HBV infection status. However, 6.6% had never been tested for HBV before infection. A significant percentage (69.1%) encountered difficulties or impediments when trying to obtain or recommend HBV viral load testing, and 60.9% had experienced needle stick injuries, highlighting the risks in the medical field. Overall, 57.8% of participants demonstrated good practices, while 42.2% reported malpractice due to HBV infection. This percentage is lower than that reported in studies in Sudan (73% good practice) [34] and Jordan (63.9% good practice) [37], possibly due to differences in healthcare infrastructure, public health policies, education, economic conditions, and cultural factors. The study participants in Sudan were health professionals, which may explain the higher good practice rates. However, this study’s findings showed better practices than studies in Bahirdar, Ethiopia (34.8% good practices) [20], Gondar, Ethiopia (26.8% good practices) [19], Northwest Ethiopia (30.9% good practices) [19], and Thailand (43% good practices) [35]. The better practice of HBV management in Addis Ababa compared to that in Gondar and Bahirdar may be due to superior healthcare infrastructure, greater access to healthcare services, more effective public health initiatives, and higher levels of education and awareness. The study in Thailand involved migrants who may have limited information about medical issues due to language barriers and limited health educational resources.

The majority of participants (89.5%, 229/256) experienced catastrophic expenditures on HBV viral load tests, meaning that the costs were at least 40% of their household income, based on WHO guidelines. The remaining 10.5% (27/256) had non catastrophic expenses, falling below the 40% threshold. This result aligns with the literature on catastrophic health expenditures, particularly in low- and middle-income countries where specialized medical tests often impose significant economic burdens. For instance, studies have shown that high healthcare costs frequently lead to catastrophic spending and impoverishment [38, 39], and households in countries with insufficient health insurance or public financing are particularly vulnerable to such financial shocks [40]. WHO reports further emphasize the risk of out-of-pocket health expenditures pushing households into poverty and limiting access to essential health services [41]. These findings underscore the urgent need for improved health financing policies to protect households from financial hardship and ensure equitable access to essential healthcare services.

The study also revealed that participants living in urban areas (Addis Ababa) were significantly more able to afford the cost of viral load tests than were those living in rural areas (AOR = 0.108, 95% CI: 0.019–0.603, p = 0.011). This finding is consistent with other studies highlighting significant urban‒rural disparities in healthcare utilization and financial protection in Ethiopia [34]. Additionally, individuals with a monthly income exceeding 10,001 ETB had a significantly lower likelihood of experiencing catastrophic expenses (AOR = 0.006, 95% CI: 0.001–0.169, p = 0.003). Previous studies have shown a strong association between higher income levels and a reduced risk of catastrophic health expenditures, as higher income earners generally have greater financial resources to cover healthcare expenses, including diagnostic tests, thereby reducing their vulnerability to catastrophic spending [39, 40].

Strengths and limitations of the study

This study uses a robust mixed-methods design, a substantial sample size, and the thoughtful integration of affordability and knowledge-attitude-practice (KAP) assessments, offering a multifaceted perspective on HBV management in Ethiopia. While the cross-sectional approach provides valuable insights, it inherently limits causal interpretation. Additionally, the single-site setting may constrain broader applicability, and reliance on self-reported data introduces potential for response bias. The absence of biochemical or longitudinal clinical follow-up further narrows the interpretive scope of laboratory-related findings.

Conclusion and recommendations

In summary, this study provides useful insights into HBV viral load patterns, affordability of testing, and patient knowledge, attitudes, and practices at SPHMMC. Male gender, co-infection, and alcohol consumption were found to be associated with higher viral loads, while lower income and rural residence were linked to greater financial hardship related to HBV testing.

The findings highlight the need for strengthened health education, improved access to affordable viral load testing, and interventions addressing high-risk behaviors. However, given the cross-sectional nature and contextual limitations of this study, these associations should be interpreted with caution. Future longitudinal and multi-center studies are recommended to confirm these findings and to inform policy aimed at reducing HBV-related health and economic burdens in Ethiopia.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CHB

Chronic Hepatitis B

DNA

Deoxyribonucleic acid

IDI

In-Depth Interview

HBsAg

Hepatitis B Surface Antigen

HBV

Hepatitis B Virus

HCC

Hepato Cellular Carcinoma

HCV

Hepatitis C Virus

HIV

Human Immune Virus

IU/ml

International Unit per Milliliter

KAP

Knowledge Attitude and Practice

LIS

Laboratory Information System

PCR

Polymerase Chine Reaction

SPHMMC

St. Paul’s Hospital Millennium Medical College

SPSS

Statistical Package For Social Science

VL

Viral Load

WHO

World Health Organization

Author contributions

Conceptualization: KD, AS. Data curation: KD, AS, RD. Formal analysis: KD, AS, RD. Investigation: KD, AS, RD. Methodology: KD, AS, RD. Project administration: KD, AS, RD, AF, YA. Resources: KD, AS. Software: KD, AS, AF. Supervision: RD, AS. Validation: KD, AS, RD, AF.YA. Visualization: KD, AS, RD, AM, YA. Writing of the original draft: KD, AS, RD. Writing, review & editing: KD, AS, RD.

Funding

Not applicable.

Data availability

All data sets used in this study are included in this manuscript.

Declarations

Ethics approval and consent to participate

The study was conducted after an ethical letter was obtained from the Research and Ethics Committee of the Medical Laboratory Sciences Department, College of Health Sciences Addis Ababa University (DRERC/746/24/MLS), and a support letter was requested and acquired by SPHMMC. Informed written consent was obtained from the caretakers before enrollment in the study. Then, the objective of this research was explained to the study participants, and those willing to participate were included. To ensure the confidentiality of the data, the study subjects were identified using codes, and unauthorized persons were not able to access the collected data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.