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. (27), 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. (28) 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. (28) 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) (29). 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 (30). This is due to immunosuppression caused by co-infection with different illnesses (31).
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. (32).
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 (33). These differences may be due to the study participants, as the mentioned studies involved health professionals and medical students who may have greater awareness of HBV infection. However, the findings of this study were higher than those in Thailand, where only 19.85% had good knowledge (34). 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) (35), and Jordan (40% positive, 60% negative) (36). The differences may be due to the study participants; this study involved HBV-infected individuals, while the other studies involved health professionals who generally have a better attitude toward the virus. The study in Gondar involved pregnant women who may have a heightened sense of responsibility and concern about infections, including HBV. 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) (34). 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) (33) and Jordan (63.9% good practice) (36), 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) (34). 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 (37, 38), and households in countries with insufficient health insurance or public financing are particularly vulnerable to such financial shocks (39). WHO reports further emphasize the risk of out-of-pocket health expenditures pushing households into poverty and limiting access to essential health services (40). 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 (33). 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 (38, 39).