JECH Online First, published on October 12, 2009 as 10.1136/jech.2009.

093302

Title: Is there a need to include HIV, HBV and HCV viruses in the Saudi premarital
screening programme on the basis of their prevalence and transmission risk
factors?

Authors: Fahad M Alswaidi and Sarah SJ O’Brien,

The University of Manchester, School of Translational Medicine, UK

Correspondence to:
Fahad M Alswaidi, PhD student
The University of Manchester,
School of Translational Medicine,
Stopford Building,
Oxford Road,
M13 9PT,
United Kingdom
f_alswaidi@hotmail.com

Word count: 3690

Abstract: 239

Tables: 3
Figures: 1

1
Copyright Article author (or their employer) 2009. Produced by BMJ Publishing Group Ltd under licence.
ABSTRACT

Background: In January 2008, the Saudi Arabian health authority included

mandatory testing for HIV, HBV and HCV viruses in the premarital screening
programme. Epidemiologically, there were few justifications for their inclusion as
disease prevalences and distributions are poorly understood in the population. This
study aims to provide information about HBV, HCV and HIV prevalences and risk
factors for disease transmission, and so produce evidence for informed decision-
making on the inclusion of these infectious diseases in the screening programme.
Methods: This is a cross-sectional descriptive study embedded in the existing
national premarital screening programme for thalassaemia and sickle cell disease to
estimate the prevalence of HIV, HBV and HCV infections (n = 74,662 individuals),
followed by a case-control study to identify risk factors responsible for infection
transmission (n = 540).
Results: The average HIV prevalence is 0.03%, 1.31% for HBV and 0.33% for HCV.
Sharing personal belongings particularly razors, blood transfusions, cuts at
barbershops and extramarital relationships showed the highest significant associations
with the transmission of these viruses.
Conclusion: The prevalences of HIV, HBV and HCV in Saudi Arabia are among the
lowest worldwide. However, all the important risk factors associated with transmitting
these viruses are significantly present in the Saudi community. Saudi Arabia is
financially capable of screening for these infections in the mandatory premarital
programme and of providing medical care for the discovered cases, but focusing on
the health education programmes may offset the need to mandatory testing.

Key words: Premarital, screening, HIV, HBV, HCV, Saudi Arabia

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INTRODUCTION

There are an estimated 33 million cases of human immunodeficiency virus

(HIV) worldwide with 95% of cases in developing countries.[1] Approximately 1.8
billion people have serological evidence of hepatitis B virus (HBV) infection with 350
million estimated to have chronic infection; at least 500,000 of these patients die from
liver malignancy and cirrhosis.[2] The World Health Organization (WHO) estimates
that 170 million individuals worldwide have the hepatitis C virus (HCV).[3] These
infections pose a heavy financial burden on nations; HCV infection treatment in the
United States alone is estimated to exceed $600 million per year.[3]
Disease prevalence, availability of appropriate medical care, health education and
public awareness are important factors for implementing a screening programme.
Some international associations like the Bill Clinton HIV Initiative and United
Nations Programme on HIV/AIDS suggested that HIV screening should be mandatory
in countries with a prevalence of 5% or more.[4] Cultural attitudes and individual
knowledge are important for the success of screening, and uptake is often low where
prevalence rates are high.[5-7] HIV testing has a broader impact for those planning to
marry.[6] In some communities, cultural values clash with premarital HIV testing and
confidentiality. However, mandatory HIV screening has been incorporated into
premarital screening programmes in some states in the USA and Malaysia [8, 9],
although it has since been discontinued in the USA. China implemented mandatory
premarital HBV testing due to its 10% HBsAg carrier prevalence.[10] However,
ethical and cost-effectiveness issues make mandatory HIV screening controversial.

Premarital screening in Saudi Arabia

In 2003, the Ministry of Health (MOH) of Saudi Arabia implemented free
compulsory premarital screening and counseling for sickle cell disease (SCD) and
thalaessemia.[11] To facilitate the tests, 123 healthcare centres, 70 laboratories and
20 counseling and education clinics were established throughout the country. Their
success in implementing the programme prompted the MOH to start testing for HIV,
HBV and HCV infections in January 2008.[12] Couples with negative results are
notified that they can marry without additional procedures, while positive cases must
undergo affirmative tests. The testing is mandatory but being positive does not
prevent marriage. Counseling sessions aim to provide education to prevent infection
transmission. HIV and HCV positive couples are encouraged to avoid marriage; for
HBV, the healthy partner is advised to be vaccinated.
These diseases were included in the screening programme even though there is scant
epidemiological evidence concerning their prevalence and distribution in Saudi
Arabia. The decision to include HIV, HBV and HCV in the Saudi programme was a
Royal decision. According to the regulations in Saudi Arabia this Royal decree
cancels the need for consent in such a screening programme, with the main
justification for this being public interest. In 2004, the MOH announced that there
were 11,000 HIV carriers overall, of which 2,005 were Saudis (prevalence
0.011%).[13] The male-female ratio being 3:1 and 78% of cases were between 15- 49
years.[13] According to an 18-years HIV surveillance programme, heterosexual
contact among Saudis caused 37.9% of cases, blood transfusion accounted for 25%,
6.5% was through perinatal transmission, 2.5% were from homosexual and 0.8% from
bisexual contact, 1.3% were from intravenous drug abuse and 26% from unknown

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causes.[14] Infection through blood transfusion was eradicated in 2001 due to pre-
transfusion screening [13]. A study of blood donors found that the prevalence of
HBsAg was 1.4% and anti-HCV was 0.2% among Saudis.[15]
HBV, HCV and HIV infections have no cure and scant permanent remission
possibilities, high mortality rates, lengthy infectious periods, high risks to the spouse
or offspring and costly treatments. Early diagnosis optimises treatment and
transmission prevention. This makes them ideal candidates for inclusion in a
screening programme.
Our study aims to provide prevalence data and information on the risk factors for
transmission in the specific target group of both male and female Saudis who are at
the age of marriage (between 15 and 60 years old) and are sexually active. These data
are not currently available in Saudi Arabia, so providing evidence for informed
decision-making concerning the continuing inclusion of these diseases in the national
screening programme.

MATERIALS AND METHODS

Study design
This was a cross-sectional descriptive study embedded in the existing national
premarital screening programme to estimate the prevalence of HIV, HBV and HCV
infections, with a case-control study to identify transmission risk factors. A case is
defined as any individual with a positive result for HBV, HCV or HIV from
premarital testing between January-May, 2008. Controls are individuals who
underwent the same tests during that period with negative results.

Sampling technique
No significant seasonal variation in the prevalence of these diseases was
expected. There were about 284,000 people included in the screening programme
annually. This was approximated to 300,000 individuals (the study population) in
order to simplify the sample size calculation of the prevalence study; the sample sizes
required to achieve valid prevalence results were estimated as follows: HBV, 4,600;
HCV, 9,500; HIV, 27,500. StatCalc (Epi Info software) calculated sample sizes.
However, since testing for HBV, HCV and HIV infection is mandatory, everyone
tested between January-May, 2008 was included in the prevalence estimation to get
larger and more representative sample. This resulted in 74,662 individuals being
included in the prevalence study over these four months.
After May 2008, data were gathered from MOH headquarters and peripheral centres
to generate a list of names and phone numbers. Telephone numbers were identified
for 694 positive cases and 1844 negative controls, which formed the sampling frame
that we chose the cases and controls. There were no duplicates on this list, as they
were identified by their National Identification numbers. We interviewed 540
individual cases and controls, with 270 individuals in each group. This was the
maximum number of individuals that we could interview given the limited time and
resources of the study. If the exposure (%) of control is 20% and the least odds ratio
(OR) to be detected is 2.0, the least power will be approximately 87%. Generally, all
three viruses can be transmitted during sexual intercourse, by exposure to
contaminated blood and through intravenous drug abuse, but the proportion of
transmission is different for each virus. Therefore, we assumed that all three viruses

4
are similar enough in their manner of transmission to pool them together in
calculating the sample sizes as well as in the analysis. EpiCalc (Epi Info Software)
was used to calculate the sample size. The sampling process is outlined in Figure 1.

Data collection
Data were gathered from the General Directorate for Communicable Diseases,
MOH, in Riyadh to estimate disease prevalence. A team of four researchers conducted
telephone questionnaires. Assistants underwent a training course on the questionnaire,
informed consent and how to interview participants. The interviews used a closed-
ended questionnaire about risk factors for infection transmission. The study gained
ethical and administrative approvals from the Saudi Ministry of Health prior to its
commencement.

Data processing and analysis

Data at the MOH database were reviewed to estimate the distribution of these
infections. Prevalences were calculated based on the number of positive cases divided
by the number of tests done between January-May, 2008.
After generating frequency distributions for all variables, they were grouped
according to their potential aetiological relationship to outcome: i) demographic
factors, ii) respondents’ medical condition, iii) barbershop services, and iv) sexual
intercourse Proportionally, HBV cases are more than HCV and HIV cases and
therefore the results predominantly represent HBV cases. Specific risk factors for HIV
and HCV transmission are less likely to be picked up in the analysis. It is known that
HIV is mainly transmitted by sexual intercourse, whereas HBV is transmitted by
sexual intercourse and contact with contaminated blood and HCV is transmitted by
exposure to contaminated blood and intravenous drug abuse. However, all three
viruses share the same modes and risk factors for transmission, but the proportion of
infection/transmission is different for each virus.
Bivariate analyses were performed to identify the association of each variable with
disease outcome. Multivariate logistic regression analyses observed the adjusted
effect of each variable, including demographic variables, on outcome while
controlling for all other entered variables. Partial or complete confounding effects of
all the factors were controlled but not measured. The stepwise backward Wald
method was used to identify the minimum number of predictors that were
significantly associated with outcome; variables were then removed sequentially from
the model starting with the variables showing the least association in the first step.
The stepwise process continued until all the remaining variables showed a statistically
significant adjusted odds ratio (OR) with the outcome. The probability used for a
variable to enter the model was 0.05, and 0.10 for removal. In the second phase of
multivariate analysis, all variables that exhibited statistically significant associations
in the first phase were summated in the logistic regression model using stepwise
backward Wald technique and adjusted ORs were calculated while controlling for all
other entered variables.

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 RESULTS

Prevalence
In the assigned period, 74,662 individuals were tested for HIV, HBV and
HCV were carried out across Saudi Arabia. There were 1,251 (1.67%) positive
results; the highest rate of positive tests was in Riyadh (15.8%), while the lowest rate
was in Qunfudah (0.75%). Ages of cases ranged from 15 to 63 years. Males
accounted for 73.2% HBV cases, 76% HCV and 79.2% HIV (Table 1). The average
prevalence was 0.03% for HIV, 1.31% for HBV and 0.33% for HCV.

Table 1: Positive results by gender from premarital screening of infectious

diseases in the regions of Saudi Arabia, January – May, 2008
Positive
HIV HBV HCV
results
No. of
Region
tests total males females total males females total males females
No. %
No. % No. % No. % No. % No. % No. % No. % No. % No. %

Riyadh 11771 213 1.81 8 0.07 6 25.0 2 8.3 164 1.39 99 10.1 65 6.7 41 0.35 34 13.6 7 2.8

Makkah 1577 59 3.74 0 0.00 0 0.0 0 0.0 44 2.79 32 3.3 12 1.2 15 0.95 12 4.8 3 1.2

Jeddah 3434 69 2.01 4 0.12 2 8.3 2 8.3 42 1.22 29 3.0 13 1.3 23 0.67 15 6.0 8 3.2

Madinah 8200 147 1.79 0 0.00 0 0.0 0 0.0 131 1.60 91 9.3 40 4.1 16 0.20 11 4.4 5 2.0

Qasseem 2687 23 0.85 0 0.00 0 0.0 0 0.0 20 0.74 16 1.6 4 0.4 3 0.11 3 1.2 0 0.0

Taif 4217 96 2.28 1 0.02 1 4.2 0 0.0 84 1.99 60 6.1 24 2.5 11 0.26 10 4.0 1 0.4

Hail 2893 24 0.83 2 0.07 2 8.3 0 0.0 15 0.52 13 1.3 2 0.2 7 0.24 6 2.4 1 0.4

Baha 2131 45 2.11 2 0.09 2 8.3 0 0.0 27 1.27 21 2.1 6 0.6 16 0.75 13 5.2 3 1.2

Assir 6779 143 2.11 4 0.06 3 12.5 1 4.2 109 1.61 83 8.5 26 2.7 30 0.44 19 7.6 11 4.4

Sharqyah 10585 163 1.54 1 0.01 1 4.2 0 0.0 123 1.16 88 9.0 35 3.6 39 0.37 29 11.6 10 4.0

Ahsa 4079 48 1.18 0 0.00 0 0.0 0 0.0 31 0.76 26 2.7 5 0.5 17 0.42 11 4.4 6 2.4

Qunfudah 560 24 4.29 0 0.00 0 0.0 0 0.0 20 3.57 14 1.4 6 0.6 4 0.71 3 1.2 1 0.4

Hafr Batin 1617 22 1.36 0 0.00 0 0.0 0 0.0 19 1.18 16 1.6 3 0.3 3 0.19 3 1.2 0 0.0

Jazan 4090 8 0.20 0 0.00 0 0.0 0 0.0 8 0.20 8 0.8 0 0.0 0 0.00 0 0.0 0 0.0

Najran 2331 51 2.19 0 0.00 0 0.0 0 0.0 47 2.02 40 4.1 7 0.7 4 0.17 4 1.6 0 0.0

Bisha 1592 20 1.26 1 0.06 1 4.2 0 0.0 14 0.88 10 1.0 4 0.4 5 0.31 4 1.6 1 0.4

Tabuk 2506 58 2.31 0 0.00 0 0.0 0 0.0 47 1.88 43 4.4 4 0.4 11 0.44 8 3.2 3 1.2

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Jouf 976 5 0.51 0 0.00 0 0.0 0 0.0 2 0.20 2 0.2 0 0.0 3 0.31 3 1.2 0 0.0

Arar 1739 28 1.61 1 0.06 1 4.2 0 0.0 26 1.50 21 2.1 5 0.5 1 0.06 1 0.4 0 0.0

Qurayat 898 5 0.56 0 0.00 0 0.0 0 0.0 4 0.45 3 0.3 1 0.1 1 0.11 1 0.4 0 0.0

Total 74662 1251 1.67 24 0.03 19 79.2 5 20.8 977 1.31 715 73.2 262 26.8 250 0.33 190 76.0 60 24.0

Age range 15 – 63, mean 30±10.2.

Demographic information
Age of respondents: The frequencies of cases vs. controls for each age group are
presented in Table 2-A. The minimum age for both cases and controls was 15 years,
with mean ages being 31 ± 9.5 years for cases and 27 ± 6.3 years for controls.
Respondents older than 30 years had a higher risk of infection than younger
respondents (OR=3.83) (Table 2-A).
Gender: Of the cases, 80.7% were male compared to 78.9% controls. Men were at an
insignificantly higher risk of disease than females (OR =1.12) (Table 2-B).
Educational status: Fewer cases had bachelor (30.4%) and secondary level education
(35.2%) than controls (33.3% and 45.6%, respectively). However, relatively higher
proportions existed for intermediate (18.5%), primary education (13.3%) and
illiteracy (2.6%) among cases compared to controls (Table 2-C).

Table 2: Relationship of demographic variables on the transmission of

HBV, HCV and HIV disease in the study groups

Study Groups
Cases* Controls Odds
Study parameters 95% CI
(n=270) (n=270) Ratio
Freq. % Freq. %
A: Age of respondents

< 25 years 62 23.0% 101 37.4% Ref -

25-29 years 100 37.0% 123 45.6% 1.32 0.88-2.00
30 years and above 108 40.0% 46 17.0% 3.83 2.40-6.11
B: Gender

Male 218 80.7% 213 78.9% 1.12 0.74 - 1.71

Female 52 19.3% 57 21.1% Ref -
C: Respondents’ educational status

Illiterate 7 2.6% 3 1.1% 2.56 0.64 - 10.23

Primary school 36 13.3% 16 5.9% 2.47 1.28 - 4.78
Intermediate school 50 18.5% 38 14.1% 1.44 0.86 - 2.42
Secondary school 95 35.2% 123 45.6% 0.85 0.57 - 1.27

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Bachelors degree 82 30.4% 90 33.3% Ref -
D: Respondents occupational status

Health professional (physician,

2 0.7% 7 2.6% 0.29 0.06 - 1.47
nurse, technician)
Other professional with
potential exposure to human 17 6.3% 7 2.6% 2.48 1.01 - 6.08
blood (police, fire brigade)
Professions with no obvious
contact to human blood
251 93.0% 256 94.8% Ref -
(children, housewives, retired
and unemployed)
E: Marital status before premarital screening

Married 53 19.6% 15 5.6% 4.69 2.56 - 8.59

Divorcee/Widow(er) 34 12.6% 12 4.4% 3.76 1.90 - 7.47
Never married 183 67.8% 243 90.0% Ref -
F: Respondents contacts ( family member/friends/patient) suffering from HBV, HCV and
HIV disease

Yes 109 40.4% 18 6.7% 9.48 5.54 - 16.21

No** 161 59.6% 252 93.3% Ref -
*Cases: HBV 211(39.1%), HCV 35(6.5%) and HIV 24(4.4%).
**Note: “Don’t know/Don’t remember” responses are merged into the “No” category.

Occupational status: The majority of cases and controls had no occupational contact
with human blood (93% cases; 94.8% controls). More cases (6.3%) worked with
potential exposure to human blood (police, fire brigade) compared to controls (2.6%).
Fewer cases (0.7%) were health professionals compared to controls (2.6%).
Respondents with potential exposure to blood were at a significantly higher disease
risk (OR =2.48), but health professionals had an insignificantly lower risk (OR =0.29)
(Table 2-D).
Marital status: Compared to respondents who had never married, divorcees/widow(er)s
had a significantly higher disease risk (OR=3.76); married respondents were at an
even greater risk (OR=4.69) (Table 2-E).
Infected contacts: A higher proportion of cases (40.4%) had close contacts suffering
from HBC, HCV and HIV compared to 6.7% of controls (Table 2-F). These included
close family members and friends, due to their likelihood of close physical contact.
Chronic illness: More cases (9.3%) suffered from chronic illnesses like SCD,
diabetes mellitus and renal failure compared to controls (2.6%). The respondents with
chronic illnesses had significantly higher risks for HBV, HCV and HIV (OR=3.83)
(Table 3-A).
Blood transfusion: Over 10% of cases had received a blood transfusion compared to
0.7% of controls. The respondents who had received blood transfusion were at a
higher risk of contracting disease (OR=15.5) (Table 3-B).
Injections: Only 48.9% of cases had received a prescribed injection compared to
controls (53%); 5.6% of cases received non-prescribed injections (0.7% controls).
Respondents who had prescribed injections were at an insignificantly lower disease

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 risk (OR=0.85) (Table 3-C, D). Non-prescribed injections were associated with a
higher risk of infection (OR=7.88) (Table 3-D).

Table 3: Relationship of medical condition & practices of the respondents

on the transmission of HBV, HCV and HIV

Study Groups Bivariate analysis Multivariate analysis

Risk Cases Controls
factors (n=270) (n=270) Odds Adjusted
95% CI 95% CI
ratio odds ratio
Freq. % Freq. %
A: Suffering from chronic illness

Yes 25 9.3% 7 2.6% 3.83 1.63 - 9.03 4.92 1.67 - 14.55

No* 245 90.7% 263 97.4% Ref - - -
B: Received blood transfusion

Yes 28 10.4% 2 0.7% 15.50 3.66 - 65.77 8.3 1.72 - 40.20

No* 242 89.6% 268 99.3% Ref - - -
C: Received injection prescribed by a physician

Yes 132 48.9% 143 53.0% 0.85 0.61 - 1.19 - -

No 138 51.1% 127 47.0% Ref - - -
D: Received non-prescribed injection

Yes 15 5.6% 2 0.7% 7.88 1.79 - 34.81 - -

No* 255 94.4% 268 99.3% Ref - - -
E: Received accidental needle injury or other sharp object contaminated with blood at a

health facility

Yes 18 7.2% 2 0.8% 10.25 2.35 - 44.63 7.45 1.38 - 40.22

No* 231 92.8% 263 99.2% ref - - -
F: Underwent dental work /oral surgery

Yes 166 61.5% 135 50.0% 1.60 1.13 - 2.25 1.6 1.00 - 2.54
No* 104 38.5% 135 50.0% ref - - -
G: Underwent any other surgery (other than oral)

Yes 63 23.3% 38 14.1% 1.86 1.19 - 2.90 - -

No* 207 76.7% 232 85.9% ref - - -
H: Received cutting injury in barbershop/ parlour (n=540)

Once 21 7.8% 9 3.3% 4.17 1.85 - 9.37 4.74 1.71 - 13.15

Multiple
123 45.6% 36 13.3% 6.10 3.97 - 9.39 3.88 2.27 - 6.66
times

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Never* 126 46.7% 225 83.3% ref - - -
I: Punching/puncturing of acne in a barbershop /beauty parlour (n=540)

Once 10 3.7% 10 3.7% 1.20 0.49 - 2.95 - -

Multiple
54 20.0% 12 4.4% 5.42 2.82 - 10.40 5.04 2.21 - 11.48
times
Never* 206 76.3% 248 91.9% ref - - -
J: Hijamah (n=540)

Once 23 8.5% 14 5.2% 1.74 0.88 - 3.47 - -

Multiples
15 5.6% 10 3.7% 1.59 0.70 - 3.61 - -
times
Never* 232 85.9% 246 91.1% ref - - -
K: Incarcerated for longer than 24 hrs in prison (n=535)

Yes 43 16.0% 18 6.8% 2.62 1.47 - 4.68 - -

No* 226 84.0% 248 93.2% ref - - -
L: Extramarital sexual relationships of respondent (n=526)

Yes 25 10.4% 8 3.1% 3.29 1.46 - 7.45 2.92 1.02 - 8.41

No* 240 90.6% 253 96.9% ref - - -
M: Intravenous drugs use (addictive) by the respondent (n=540)

Yes 5 1.9% 0 0.0% Fisher’s Exact Test

No 265 98.1% 270 100.0% 2-tailed p-value = 0.06
N: Sharing shaving razors with others

Share 16 5.9% 1 0.4% 16.95 2.23 - 128.70 11.13 1.23 - 101.00

Don’t
254 94.1% 269 99.6% ref - - -
share
O: Sharing tooth brush with others

Share 8 3.0% 1 0.4% 8.21 1.02 - 66.13 - -

Don’t
262 97.0% 269 99.6% ref - - -
share
P: Sharing nail cutter with others

Share 182 67.7% 126 47.0% 2.36 1.66 - 3.35 - -

Don’t
87 32.3% 142 53.0% ref - - -
share
Q: Travel abroad by respondents

Yes 89 33.0% 78 28.9% 1.21 0.84 - 1.75 - -

No 181 67.0% 192 71.1% ref - - -

*Note: “Don’t know/Don’t remember” responses are merged into “no” category.

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Accidental needle injury: A higher proportion of cases (7.2%) received a blood-
contaminated sharps injury compared to controls (0.8%). The respondents with sharps
injuries had a much higher disease risk compared to respondents without such injuries
(OR=10.25) (Table 3-E).
Dental work: Of cases, 61.5% underwent dental work or oral surgery compared to
50% of controls. Analysis showed that such cases were at a statistically significant
higher risk of viral disease (OR=1.60) (Table 3-F).
Other surgical procedures: In comparison to controls (14.1%), a higher proportion
of the cases (23.3%) had undergone surgical procedures, leaving the latter with a
significantly higher disease risk (OR=1.86) (Table 3-G).
Cutting injuries: A relatively higher proportion of the cases had received single or
multiple cuts (7.8% and 45.6%, respectively) at barber shops or beauty parlours
compared to controls (3.3% and 13.3%, respectively). Respondents with single
injuries had a significantly higher risk of disease (OR=4.17) and those who received
multiple injuries had a much greater disease risk (OR=6.10) (Table 3-H).
Acne puncturing: Over 3% of both cases and controls had undergone acne
puncturing in barbershops; a higher percentage of cases (20.0%) had multiple
treatments (4.4% of controls). Compared to respondents that had not had acne
punctured, the respondents who had one episode had an insignificantly higher disease
risk (OR =1.20), whereas respondents that had multiple puncturings had a
significantly higher risk (OR=5.42) (Table 3-I).
Hijamah (cupping-bloodletting therapy): Of cases, 8.5% had Hijamah once compared
to 5.2% controls; 5.6% of cases had multiple treatments (3.7% of controls). Both
single and multiple Hijamah experiences were at an insignificantly higher risk of
disease (OR=1.74; OR=1.59, respectively) (Table 3-J).
Incarceration: In comparison with controls (6.8%), 16% of cases were incarcerated
in prison for longer than 24 hours. These respondents were at a significantly higher
disease risk (OR=2.62) (Table 3-K).
Extramarital intercourse: Out of cases, 9.4% had extramarital intercourse compared
to 3.1% controls. A higher disease risk was observed in the respondents with
extramarital relationships (OR=3.29) (Table 3-L).
Intravenous drug users (IVDU): Only 1.9% of cases were IVDUs; no controls were
IVDUs. No significant association was found between IVDU and disease risk (p-
value =0.06) (Table 3-M).
Sharing razors: A relatively larger proportion of cases (5.9%) shared razors
compared to controls (0.4%), with a significantly higher disease risk (OR=16.95)
(Table 3-N).
Sharing toothbrushes: Only 3.0% of cases shared toothbrushes compared to 0.4% of
controls, but they had a higher risk of infection (OR=8.21) (Table 3-O).
Sharing nail-cutters: A higher proportion of cases (67.7%) shared nail-cutters
compared to controls (47%), with a significantly higher risk of disease (OR=2.36)
(Table 3-P)
Foreign travel: Although the respondents (33% cases; 28.9% controls) who travelled
abroad were at higher disease risk, this remained statistically insignificant (OR=1.21)
(Table 3-Q).

Outcomes after premarital screening

Among cases, 224 (83%) stated that their spouses-to-be are free of infections. Out of
these, 77% decided to continue with the marriage. About half of the positive cases

11
(45.9%) received education regarding hepatitis viruses and HIV from programme
staff (Table 4). There were 57 couples in total that decided not to marry after
undergoing the premarital testing programme, including 50 positively testing cases
and seven controls. The reasons for this included 18 cases (31.6%) of HBV, nine
(15.8%) cases of HCV, 23 (40.4%) cases of HIV, and 7 (12.3%) marriages were
cancelled due to other reasons.

Table 4: What happened after premarital screening testing for cases and

controls?

Study Groups
Total
Risk factors Cases Controls
Freq. % Freq. % Freq. %
A: Fiancé(e) of respondent suffering from HBV, HCV or HIV according to

premarital screening

Yes Hepatitis-B 6 2.2% 2 0.7% 8 1.5%

No 224 83.0% 247 91.5% 471 87.2%
Don't know 40 14.8% 21 7.8% 61 11.3%
Total 270 100.0% 270 100.0% 540 100.0%
B: Respondent marriage to fiancé(e) after premarital screening

Yes, already married 110 40.7% 97 35.9% 207 38.3%

Not yet, but decided to
98 36.3% 159 58.9% 257 47.6%
marry
No, decided not to
50 18.5% 7 2.6% 57 10.6%
marry
Not yet decided 12 4.4% 7 2.6% 19 3.5%
Total 270 100.0% 270 100.0% 540 100.0%
C: After premarital screening test, received health education regarding

HBV, HCV or HIV from the programme staff

Yes 143 53.0% 20 7.4% 163 30.2%

No 124 45.9% 250 92.6% 374 69.3%
not sure 3 1.1% 0 0.0% 3 0.6%
Total 270 100.0% 270 100.0% 540 100.0%
D: If yes, forms of health education imparted to respondent

Pamphlets 2 1.4% 4 20.0% 6 3.7%

Counseling session 141 98.6% 16 80.0% 157 96.3%
Total 143 100.0% 20 100.0% 163 100.0%

12
Risk factor associations after logistic regression
The study factors which had the highest associations with disease transmission
were “sharing razors” (OR=11.13) and “infected contacts” (OR=10.9). Other risk
factors in descending order of association were “blood transfusion” (OR=8.30),
“accidental needle injury” (OR=7.45), “multiple acne puncturings” (OR=5.04),
“chronic illness” (OR=4.92), “cut from barbershops” (OR=4.74), “multiple cuts”
(OR=3.88), “married” (OR=4.31), “divorce/widow(er)” (OR=4.74), “extramarital
intercourse” (OR=2.92) and “dental work/oral surgery” (OR=1.60) (Table 3).

DISCUSSION

Prevalence of HIV, HBV and HCV

From the premarital screening programme, the prevalence of HIV infection

(0.03%) in Saudi Arabia is slightly higher than the official figure (0.011%), but is still
comparatively low. The prevalences of HBC and HCV are among the lowest rates in
the world.[1,15-17] Recent study evaluated prevalence of these viruses among
marrying individuals in Sivas, Turkey showed similar demographics and HBV
prevalence in this study. [18] There were minimal variations between infections
across different regions of the Kingdom. However, HBV and HCV infection rates are
slightly higher in areas with endemic hereditary blood diseases, namely Makkah and
Qunfudah, possibly reflecting the influence of blood transfusions. HIV infections
were reported in nine regions out of 20, and 23% were in densely-populated Riyadh.
The public strongly approve of a premarital screening programme,[19-22] but social
and familial commitments make it difficult to ask partners to undergo premarital
testing. In general, the level of public health information in Saudi Arabia is poor.
Recently, the MOH launched an educational TV channel. A further advantage of
mandatory testing is to increase the public awareness of these infections, which may
in fact decrease the need for mandatory screening in the near future.
The screening programme has begun its second year. The approximate annual cost for
viral testing is estimated to be 3,750,000 Saudi Riyal (SR) (780,000 GBP). Operating
expenses triple the cost to 11,250,000 SR (2 million GBP). However, the MOH
budget for 2009 was 52 billion SR (9.3 billion GBP) [23], so the cost for the viral
screening programme is relatively insignificant. Data about care expenses of AIDS
and hepatitis patients in Saudi Arabia are not available to estimate the programme’s
cost-effectiveness.

Risk factors

Limitations
This study was limited, as although the modes of transmission of HIV, HBV
and HCV are similar, each virus has its own infectivity rate. An independent study for
each virus would yield more reliable results regarding risk factors for transmission of
infection.

13
Demographic effects
The principle aim of the programme is to prevent infections being transmitted
to healthy people. At present, there is no official data about marriages with an infected
partner. In our study, of these individuals, 77% either have married or intended to
marry. This high rate of risky marriages could be due to the social and familial
commitments among Saudis which were not investigated in this study.
The fact that older participants had more infection prevalence could be explained by
more years of exposure to the force of infection. Prevalence of these diseases almost
always grows with age. An additional hypothesis worth exploring is that older
participants may have been exposed to transfusion before widespread screening.
Males have a higher infection risk, which resembles patterns in developed countries;
males are usually more sexually active and more likely to be IVDUs.[24]
Educational levels seem to have a disproportionate association with risk of infection.
In Saudi Arabia, the protective effect of education seems to be minimal but still has an
influence.
Respondents who work in direct contact with human blood showed a significantly
higher risk of acquiring infections. This finding is logical and agrees with similar
studies worldwide.[25]
Estimates for IVDU rates are often inaccurate but generally addiction rates are
increasing in Saudi.[26] IVDUs had no statistical association with the risk of
acquiring the viruses in our study. Incarceration for more than 24 hours was twice as
common in cases compared to controls (16%: 6.8%), potentially due to the higher
number of IVDUs in this group as regionally [27] and globally documented.[28-30]

Medical history
Chronic illnesses that necessitate blood transfusions and frequent blood tests,
such as SCD, thalassaemia and renal failure, caused a significantly higher risk of
infection. A blood transfusion increases the risk of contracting HIV, HBV or HCV by
eight times.
Having non-prescribed medical injections at private pharmacists is commonplace; for
example, patients may receive analgesic or anti-malarial injections, but such
respondents in our study had a seven times higher risk of infection.
Health professionals who suffer needlestick injuries, a rare but significant mode of
HIV, HBV and HCV transmission, are seven times more likely to have viral
infections in our study. Surgical procedures, especially dentistry and oral surgeries,
are a common mode of transmitting HBV, HCV and HIV in developing countries.[30,
31] The risk of transmitting viruses through surgical procedures is lower in Saudi
Arabia than other countries in Asia and Africa.[31] Hijamah, the unique traditional
medical practice among Muslim and Chinese cultures that involves cupping and
bloodletting [32], carried no significant risk for disease transmission.

Sharing personal belongings

Sharing razors and toothbrushes is a major risk factor in transmitting
hepatitis.[25] This risky behaviour could be due to factors such as low income, poor
education and lack of health awareness. Sharing razors showed the highest significant

14
risk (11 times) associated with transmission of infections after adjusting for possible
confounders.

Sexual relationships
The commonest mode of HIV transmission (75-85%) is through sexual contact
[25], predominantly through heterosexual intercourse.[33] The modes of HBV
transmission are similar to HIV infection, but HBV is up to 100 times more infectious
as it is infectious for approximately a week outside the host [30]; HCV transmission
through sexual activity is uncommon.[34] In this study, those who have had a sexual
relationship are four times more likely to acquire a viral infection. In Saudi Arabia,
extramarital relationships are prohibited religiously and transgressors may be
penalised by capital punishment. Such affairs happen rarely and secretly.
Surprisingly, 10.4% of the respondent cases stated that they have had extramarital
relationships, compared to 3.1% of controls. This is higher than the estimated
extramarital affair rates in more liberal Muslim communities, including London (5%)
and Berlin (8%).[35] Polygyny is common among Saudis and could contribute to
infections spreading between family members. Finally, being in close contact with
any infected person is the second highest significant risk factor for virus transmission.

CONCLUSION
The prevalences of HIV, HBV and HCV in Saudi Arabia are among the lowest
worldwide. This study shows that all the important risk factors for viral transmission
are present, the most significant being sharing razors, acne puncturing and cuts at
barbershops, blood transfusions and chronic illnesses. People who were married
previously, had extramarital intercourse or were in contact with an infected person
had a higher risk of infection.
Despite the low prevalences, the lack of the effective health education and presence of
significant infection risk factors, and the affordable cost of such a screening
programme, support the inclusion of these viruses in the mandatory premarital
screening programme of Saudi Arabia. Adequately trained manpower and funds may
be provided to allow testing centres to collect confidential data voluntarily regarding
basic demographic and behavioural risk factors such as age, sex, IDUs, hijamah,
extramarital sex, contact with female sex workers, and results of previous testing for
HIV, HCV, and HBV.

15
POLICY RECOMMENDATIONS BOX

1. Saudi Arabia may continue mandatory testing and counseling for HIV, HBV and
HCV for at least four more years to raise the public awareness of these diseases.

2. The programme should be re-evaluated and revised if necessary after five years,
possibly converting the testing to be optional.

3. Further investigations are needed to identify the factors responsible for the high
rate of risky marriages due to these infections.

4. Strengthen the mandatory role of the counseling clinic in delivering educational

messages to infected individuals and couples.

5. Health education campaigns in the public media to promote public awareness of

risk factors.

6. Targeted educational campaigns to at-risk groups: patients’ contacts, barbers,

health professionals, schools and colleges students.

7. Strict enforcement of preventive measures at places at high risk of transmitting

these diseases, such as barbershops and health facilities.

WHAT THIS PAPER ADDS

What is already known on this subject?

- A compulsory premarital screening programme already exists in Saudi
Arabia for hereditary haematological diseases.

- The prevalence and distribution of HBV, HCV and HIV are not well
understood.

- Early diagnosis optimises treatment and transmission prevention.

What will this study add to the literature?

- Highlights about the Saudi mandatory premarital screening for HIV,
HBV and HCV.

- The prevalences of HIV, HBV and HCV in Saudi Arabian regions are
described based on a systematic review of a representative population
sample.

- Common risk factors for transmission of these diseases in Saudi Arabia

and their significance with regards to risk of infection are based on a
systematic survey.

16
FIGURES

Figure 1: Selection of cases and controls

Legends:
A. Total study population
B. Sampling population (based on results; positive and negative)
C. Sampling frames (based on availability of phone numbers)
D. Study sample (random selection of cases and controls)
*all available 24 HIV cases were included.

Licence Statement: "The Corresponding Author has the right to grant on behalf of all
authors and does grant on behalf of all authors, an exclusive licence (or non exclusive
for government employees) on a worldwide basis to the BMJ Publishing Group Ltd
and its Licensees to permit this article (if accepted) to be published in JECH editions
and any other BMJPGL products to exploit all subsidiary rights, as set out in our
licence (http://jech.bmj.com/ifora/licence.pdf)".

Acknowledgments: We are thankful to Dr. Ali Alwadey, Dr. Ibrahim Alzahrani and
Dr. Nasser Alhamdan from the Saudi Field Epidemiology Training Programme
(FETP) for their remarkable help in conducting the study. Also, we would like to
thank the reviewers of JECH for their valuable comments.

Contributors: All authors contributed to this manuscript. Professor S. O’Brien supervised and revised
all phases of this research.

Funding: This work was fully supported and approved by the Saudi Ministry of
Health (MOH). Field work started in Saudi Arabia after coordination between
Ministry of Higher Education and MOH.

Competing interests: None.

17
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20
 A. 74662
individuals tested in the
study period

B. 1251 positive B. 73411

results negative results

C. 694 cases (positives) C. 1844 controls

with identified phone (negatives), with
numbers identified phone
541 HBV, 129 HCV and 24 numbers
HIV

D. 211 D. 35 D. 24
HBV HCV HIV*

D. 270 D. 270
Cases Controls