This study aimed to describe the clinical, immunological, and virological characteristics of newly diagnosed HBV clients and assess their eligibility for antiviral treatment based on the current WHO guidelines [23]. The median age of the participants in this study of 34 years is comparable to the results of previous studies that were also focused on adult HBV patients ≥ 18 years. In a meta-analysis of 30 peer reviewed publications with a population pool of over 100,000 Ghanaians, the authors reported the highest prevalence of HBV infection amongst patients aged between 16 and 39 years [13].In sub-Saharan Africa, HCC has been reported to develop at a mean age of 33 years [24].Individuals aged between 31 and 40 years have been linked with a five-fold increase in the risk of HBV infection relative to other age groups (P=0.009). The age range reported in this study represents both the reproductive and most productive age groups in the Ghanaian society and may imply loss of productivity due to absence from work for hospital visits and other economic activities among these patients.

There were 42 more females than males in our study population, representing 19.1% of the total number of study participants. Two previous studies also reported a trend of higher numbers of females compared to males in their studies involving patients with hepatitis B infection [25, 26]. This study found a female to male ratio of 1.5:1 which can be partly accounted for by the disparity in the general health seeking behavior among both sexes [27]. Women are more at risk of contracting STIs than men [28]. This translates into a higher likelihood of disease transmission from men to women than vice versa [28]. Another study confirmed the existence of gender disparity in the prevalence of infections caused by HBV [29]. HBV infection is classified as a viral sexually transmitted disease together with other infections such as HIV, HCV, HPV and HSV. Majority of the patients (65.0%) were sexually active whereas the remainder were inactive. Sexual contact is key in the transmission HBV infection among adults in areas with very high prevalence rates including Ghana. In Ghana, mother-to-child transmission, unprotected intercourse, and transfusion of contaminated blood are the three main ways that HBV is spread [30].

In our study, we found that 63.3% of the patients did not have any knowledge about the status of their partners. This finding is not in keeping with the current WHO recommendation of routine screening of partners of all patients diagnosed with HBV [31]. Infection of an individual with HBV puts all close associates and immediate contacts such as spouses, sexual partners, and household members at a high risk of getting infected. Disclosure of one’s positive HBsAg status to such exposed close contacts is vital in the prevention or alleviation of the risk of transmission of HBV infection.

The disclosure of positive HBV status is very important for several reasons. First, it provides an opportunity for the diagnosed individual to receive social support [32]. Close contacts may be more likely to observe social protocols that will reduce their risk of being infected (such as not sharing personal items like razor blades, nail cutters, tooth brushes or anything that could have trace amounts of blood on them) and might be even more open to HBV vaccination. Further studies are needed to explore the impact of HBV status disclosure on the adoption of preventive measures and vaccination uptake among family members and close associates of infected patients in the Ghanaian setting. Knowledge of the positive diagnosis of a close contact is also an indication for HBsAg testing which will help in detecting positive cases in family groups. Disclosure can also motivate other seropositive family members to seek care thereby reducing their chance of developing cirrhosis and HCC.

In a study published in 2020 that investigated the disclosure of CHB status among HBV infected patients in Ghana, it was reported that patients were more likely to disclose their status under some conditions and for some reasons than others [33]. Reasons for disclosure included the desire to have close contacts tested and vaccinated, willingness to confide in the target of disclosure and the need for social and/or financial support. On the contrary, non-disclosures were on account of phobia for stigmatization and past undesirable experiences associated with disclosure.

Most of the participants were initially diagnosed via voluntary testing (62.7%) followed by health worker recommendation (25.0%). Similar findings were reported in a previous study that demonstrated that individuals with HBV infection were diagnosed because of self or physician-initiated testing, testing during screening programs and ANC testing [26, 34]. The findings of this study indicate that voluntary testing for HBsAg among the adult population is very important in HBV infection case detection. Community based or opportunistic screening undoubtedly remains an effective tool in picking up positive cases in the general population.

In our study, we found that majority of the patients (60.9%) were not aware of the HBsAg status of their immediate family members. Out of those who knew the status of their family members (n=85), majority (n=45, 52.9%) had family members who were known to be seropositive for HBsAg. Therefore, the actual number of patients with a positive family history for HBV infection is likely to be far greater. These findings suggest that intrafamilial spread of HBV infection may be a potential mode of transmission in Ghana, and further studies are needed to fully elucidate this theory.

The overall prevalence rate of HBsAg positivity was 20.5% among household members of patients which is comparable to the rate of 23.3% reported in Iran [35]. A 2024 study in Mwanza, Tanzania however reported a much lower HBV prevalence rate of 5.4% among household contacts of index cases [36]. After testing positive for sexually transmitted diseases like HIV and HBV, some individuals are more prone to concealing their diagnosis than seeking medical attention due to stigmatization [37]. CHB infection is an incurable disease and hence, some people may not want to be associated or tagged with this diagnosis. A qualitative study on chronic hepatitis B stigma in Ghana found that people with hepatitis B experience societal stigma underlined by the belief that HBV is a highly contagious and severe disease as well as the notion that HBV infection arises due to curses [38]. The question of “the most probable source of transmission” arises when individuals test positive for STIs. Some HBV positive patients may not wish to disclose their status to their close contacts which will prompt them to get tested. If this testing turns out positive, they would likely be viewed as the source of the infection in the household simply because they were diagnosed first, though it could be the other way around. Nondisclosure of HBsAg positive status to close contacts increases their risk of contracting the disease. It also robs them of an indication for testing and treatment as well as possibly HBV vaccination if eligible.

The median time interval between patient’s initial diagnosis and presentation at the specialist clinic was 8.5 months (IQR 3.0-22.5). Majority (61.8%) were seen < 1 year whereas 8.6% were seen > 5 years after initial diagnosis. The reasons for this delay in presentation at the specialist clinic may be associated with both patient and primary care provider factors. In several African countries including Ghana, many patients who test positive for HBsAg during opportunistic screening are unable to afford the additional tests or the cost of therapy because it must be paid for out-of-pocket [10, 13, 39]. As a result, a lot of patients who test positive for HBV do not proceed immediately to seek medical care or do not complete the required initial evaluation to determine what needs to be done for them. In Ghana, anecdotal evidence suggests that some patients resort to traditional and/or herbal remedies for the initial management of STIs such as HIV, HCV, and HBV as well as other health conditions including cancer, diabetes, hypertensive heart disease and bronchial asthma[40-42]. As a result of this exploration and experimentation with unorthodox medicine it is possible that some patients may present late to the hospital after all other avenues have failed or when there is disease progression.

According to the WHO, as of 2019, 10.5% of all the people estimated to be HBsAg positive already knew their positive status whereas only 22% of those diagnosed were receiving medical care [4]. This points to the fact that a huge proportion of HBV infected patients do not receive medical care after their diagnosis. Additionally, certain impediments to HBV treatment and care have been reported including barriers relating to sociocultural beliefs and health systems. These sociocultural beliefs include the perception that HBV is a spiritual disease and a form of punishment from God. On the individual level, some patients take HBV infection for granted owing to the absence of specific symptoms of CHB [33]. Furthermore, the financial burden of hospital-centered treatment for HBV infection is considerably high and even prohibitive for some patients [43]. In Ghana, unlike patients with HIV or HBV/HIV coinfection, HBV mono-infected patients must pay for their medications out of pocket in addition to the cost of their routine investigations such as LFT, HBV immunological profile and hepatitis B viral load. The inclusion of medications, laboratory analysis and other investigations under the National Health Insurance Scheme (NHIS) could potentially remove this barrier at least partially if not completely. Similar to findings in other countries such as Burkina Faso and Australia, the delay in seeking care for HBV infection could also be because of stigmatization (or fear of it thereof), lack of knowledge and misconceptions about HBV treatment as well as long queues and waiting times at treatment facilities [44, 45].

Hepatitis B infection is known to be self-limiting in 95% of adult cases and 5-15% of cases among children under five years. According to WHO, 6.6 million (22%) of the people diagnosed with HBV were on treatment as of 2019. The percentage of patients diagnosed with HBV in Ghana who require treatment as well as the proportion of these treatment eligible patients who receive the required treatment is unknown. In 2021 the proportion of CHB patients worldwide who required treatment was about 12 - 25% (WHO 2021). There is no specific treatment for acute hepatitis B unless the patient has acute hepatic failure, but for most patients, antiviral treatment for CHB is lifelong. This has direct cost implications and potential financial toxicity.

Treatment for viral hepatitis in Ghana is based on the National Guidelines for Prevention, Care and Treatment of viral hepatitis which is in line with the treatment recommendations of the World Health Organization. Approved antiviral agents for treatment of HBV infection in Ghana include Tenofovir disoproxil fumarate, Entecavir, pegylated interferon and Emtricitabine among several others. The treatment eligibility rate of 6.4% reported in this study is much lower than the reported rate of 46.8% in the United States [46]. This low rate implies that a significant proportion of the patients were diagnosed at a stage of the disease that required close monitoring but did not warrant the immediate initiation of expensive antiviral therapy which is not affordable for many patients.

Early and appropriate initiation of therapy for HBV infection is important in the reduction of the risk of transmission and development of fatal long-term complications. To be able to accomplish the WHO goal of eliminating viral hepatitis by the year 2030, it is important to not only precisely estimate treatment eligibility rates but also to ensure high treatment rates. To the best of our knowledge based on currently available literature this is the first study that evaluates treatment eligibility (rate) among HBV infected patients seeking medical care in the Central Region of Ghana. Evaluation of treatment rate i.e., proportion of patients eligible for treatment who receive antiviral treatment was beyond the scope of this study and remains an outstanding question for future studies.