Street adolescents in low income setting exposed to hepatitis B and C, and disadvantaged by lifestyle: a Togolese cross-sectional study – BMC Public Health

This study to describe the prevalence of viral hepatitis B and C among street adolescents, also documented the lifestyle, i.e. sexual practices and drug use among these adolescents in Togo. This is a particularly hard-to-reach population for which very few data exist in West Africa. To our knowledge, this is the first study on hepatitis B and C in this population in West Africa.

In terms of sexual practices, almost 70% of street adolescents surveyed were sexually active, and of these, almost a third had accumulated more than 5 sexual partners since their first experience, while only 29.4% had used a condom at last sexual intercourse. Condom use among street adolescents in Togo is therefore relatively more inconsistent than that recorded in the population of adolescents aged 15 to 19 in sub-Saharan Africa [18]. In fact, according to a 2018 systematic review and meta-analysis of studies carried out in sub-Saharan Africa, the prevalence of condom non-use was estimated at 60% [18]. This low condom use, combined with multiple sexual partners, exposes street adolescents to poor sexual and reproductive health outcomes. These outcomes include unwanted pregnancies, abortions, and STIs, including HIV and viral hepatitis [19]. In addition to the non-use of condoms and the multiplicity of partners, other factors need to be taken into account when referred to sexual and reproductive health among adolescents, in particular drugs use [20].

The present study reported a significant pattern of cannabis, cocaine, glue solvents and tramadol use. While cannabis has been reported as the main substance used by street adolescents in other studies [21], this is not the case for cocaine. There are three possible explanations for such a high rate of cocaine used reported, which in fact is supposed to be an inaccessible substance for street adolescents: (i) the first element is due to the fact that street adolescents, through their activities, may be in contact with the adult mafia circles where these drugs are distributed. As a reminder, West Africa is now recognized as a hub for international cocaine traffic [22]; (ii) the second element is related to an information bias linked to the way the question on cocaine use was formulated. During the interviews, in order to document cocaine use, adolescents were asked whether they ever consumed or snorted “white powder”. In the street environment, this can lead to confusion, especially as tramadol, which is generally a white tablet, is sometimes crushed and snorted to obtain faster, more intense effects [23]. Although rare and poorly described in comparison with other substances, this type of consumption does occur with tramadol and can lead to even greater health risks for adolescents [23, 24]. Also, in sub-Saharan Africa and Togo in particular, tramadol, which is sold retail on the streets, is more accessible than other substances, which are generally more expensive [25]; (iii) A third element, also linked to information bias, is that the term “sniffed” used when documenting cocaine use led to confusion with sniffing glue solvents, and thus to over-reporting. In fact, like tramadol, glue solvents contained in glue are very easily accessible substances on the streets of sub-Saharan Africa. These last two hypotheses are in accordance with several studies that have reported a clear difference in consumption habits between street adolescents in low- and middle-income countries and street adolescents in developed countries. According to these studies, street adolescents in developed countries consume more hard and injectable drugs, which are not commonly used by those in low- and middle-income countries. [26,27,28].

In addition to the risk of STI’s linked to unsafe sexual relations facilitated by the drug consumption, other health risks are to be feared for these adolescents. In the case of tramadol, neurotoxic complications linked to oxidative stress have been described [29]. Elsewhere, glue solvents inhalation has been associated with an increased risk of sudden death and chronic visceral damage [30]. Inhalant abuse in general is also associated with desocialization in adolescents and young adults, which in the case of street adolescents could make social reintegration processes more difficult [30]. Interventions targeting this population in Togo must take these data into account in order to identify use and prevent complications linked to these drugs in this population.

This study also aimed to estimate the prevalence of viral hepatitis B and C among street adolescents in Togo. Overall, nearly one street teenager in 10 has been in contact with HBV, with 3.7% showing active infection. Although this prevalence is relatively high, it remains low compared with that observed in adult populations in Togo, where prevalence studies report estimates ranging from 15 to 35% [31, 32].

Also, immunity against HBV (anti-HBs Ab+) was observed in only 19.4% (n = 58) of adolescents, including 8.0% (n = 24) of vaccinated profiles. These results could be explained by the fact that the hepatitis B vaccine was introduced into Togo’s Expanded Program on Immunization in 2008, and to have benefited from such an intervention one would have had to have been born in 2008 or later, and therefore aged 13 or under at the time of the survey. However, we surveyed adolescents aged 13 to 19. Thus, the present study reports nearly 80% of street adolescents with no immunity to HBV. In view of the risky sexual behavior reported among this population in the present study, it is necessary, indeed urgent, to plan targeted HBV vaccination campaigns for this population. The data reported in this study, which is the only one in Togo to have estimated the prevalence of HBV markers among street adolescents, could serve as a basis for planning such an activity.

While it is possible to vaccinate to protect against HBV, this is not yet the case for HCV. Today, prevention against HCV is based on behavioral approaches, in particular a healthy lifestyle, better access to screening and improved quality of care for people at risk [33, 34]. Unfortunately, these approaches are difficult to apply to street adolescents, for whom a healthy lifestyle remains illusory and access to health services is limited. In the present study, 14 street adolescents had an HCV serology positive, corresponding to a prevalence of 4.7%. This observed prevalence is almost identical to that reported in Africa, where the prevalence of viral hepatitis C has been estimated at 5.3% [35]. This prevalence needs to be put into perspective, as although it may appear low, it is still higher than that reported in other WHO regions [35]. For a population such as street adolescents, who enter sexual life at an early age, have multiple partners, have low condom use and abuse various substances, there is a need to strengthen the interventions carried out by NGOs for these populations. This means going beyond HIV and integrating viral hepatitis prevention into the intervention package.

This study is one of the first to estimate the prevalence of viral hepatitis markers among street adolescents in sub-Saharan Africa, as well as their addictive and sexual behaviors. The results of this study tend to confirm that this is a population vulnerable to STIs, particularly viral hepatitis, due to their lifestyle. However, this study has some limitations, notably the absence of viral load estimates for viral hepatitis B and C to confirm possible viral replication for possible treatment eligibility. Also, the assessment of drugs use was probably subject to an information bias in the case of cocaine (considering the cost of this drug), which was probably confused with sniffing tramadol or sniffing solvents contained in glue. Another difficulty we encountered is related to the documentation of alcohol consumption, as the main existing tools are difficult to apply to street adolescents [36, 37].