What are the recommendations for screening and prevention of hepatitis B and C in commercial sex workers?

Hepatitis Screening and Prevention in Commercial Sex Workers

Commercial sex workers should undergo hepatitis B and C screening based on individual risk assessment, with universal hepatitis B vaccination strongly recommended given the intermediate-to-high prevalence of infection in this population.

Hepatitis C Screening Approach

Risk-Based Testing Strategy

The CDC guidelines classify persons with multiple sex partners or sexually transmitted diseases as having uncertain need for routine HCV testing, noting that while this population appears to have increased risk for HCV infection, insufficient data exist to recommend routine testing based on sexual history alone 1. However, this creates an important clinical decision point:

• When commercial sex workers present for care, providers should take complete risk histories to ascertain the need for HCV testing, particularly focusing on:

  • History of injection drug use (the strongest risk factor) 1
  • History of blood transfusions 2
  • Cocaine use (particularly intranasal) 2
  • Presence of other STDs 1
  • Tattoos or body piercing in unregulated settings 1

• Testing should be offered when any of these additional risk factors are present, as the combination of sex work plus other exposures substantially increases HCV risk 1

Testing Protocol When Indicated

• Initial screening with anti-HCV antibody testing 1
• Positive enzyme immunoassay results require confirmation by supplemental anti-HCV testing 1
• If HCV RNA testing is desired for earlier diagnosis, it may be performed at 4-6 weeks 1

Hepatitis B Screening and Prevention

Universal Vaccination Recommended

All commercial sex workers should receive hepatitis B vaccination, as this population demonstrates:

• Intermediate prevalence of HBV infection (9.3-23.1% in various studies) 3, 2, 4
• Alarmingly low vaccination rates (only 28% with serological evidence of vaccination) 2
• High susceptibility rates (61.5% susceptible to HBV infection) 3

Screening Protocol

Before vaccination, test for:

• Hepatitis B surface antigen (HBsAg) 1
• Anti-HBc (antibody to hepatitis B core antigen) 1

This pre-vaccination testing identifies:

• Current infection (HBsAg positive) - requiring medical management rather than vaccination
• Past infection with immunity (anti-HBc positive, HBsAg negative) - vaccination unnecessary
• Susceptible individuals (both negative) - requiring immediate vaccination

Risk Factors Requiring Heightened Surveillance

Commercial sex workers at particularly high risk for HBV include those who are 2:

• Older than 40 years
• Single
• Have history of blood transfusion
• Use cocaine
• Ignore symptoms of sexually transmitted infections

Vaccination Implementation

• Both standard and accelerated hepatitis B vaccination schedules are effective in this population, with no significant difference in adherence (p=0.52) 3
• All vaccinated participants achieved protective antibody titers 3
• Hepatitis A vaccination should also be offered when appropriate 1

Coinfection Considerations

HIV Coinfection

• Commercial sex workers with known HIV-positive status have significantly higher rates of both HBV (AOR=1.64) and HCV (AOR=2.85) 5
• All HIV-positive sex workers should be screened for both hepatitis B and C 5

Syphilis Coinfection

• Syphilis positivity strongly predicts HCV infection (AOR=4.38) 5
• Coinfection rates are substantial: among HIV-infected sex workers, 23% had syphilis coinfection and 38% had HBV coinfection 4

Critical Pitfalls to Avoid

1. Do not wait for routine screening protocols - the "uncertain need" classification for HCV testing should not prevent testing when sex work is combined with other risk factors 1

2. Do not assume vaccination coverage - studies show only 28% of sex workers have evidence of HBV vaccination despite high susceptibility 2

3. Do not overlook non-injection drug use - cocaine use (even non-injection) is associated with hepatitis B positivity 2

4. Do not ignore age-related risk - older sex workers (>40 years) and those who started sex work at older ages (20-24 or >25 years) have significantly higher HBV rates 2, 5

Counseling and Risk Reduction

When providing services to commercial sex workers 1:

• Provide comprehensive risk-reduction counseling
• Address condom use (38.5% never use condoms in one study) 6
• Discuss contraceptive methods (25.6% use no contraceptive method) 6
• Ensure confidentiality of test results 1
• Provide information about transmission routes, including that HCV sexual transmission risk is lower than for HBV 1