DISCUSSION
In the sexual identity group, it was observed that individuals
identifying as bisexual or homosexual had a significantly higher
prevalence of HBV infection compared to those without any sexual
behavior. To account for the potential impact of gender, the data was
stratified by gender, revealing that bisexual and homosexual men had a
significantly higher prevalence of HBV infection compared to men without
any sexual behavior. However, no significant difference was observed
among women of all sexual identities. Further analysis was conducted by
grouping heterosexual individuals into heterosexual vaginal sex,
heterosexual oral sex, heterosexual anal sex, and heterosexual multiple
types. The incidence of HBV infection was found to be significantly
higher in men with heterosexual anal sex as compared to those without
sexual behavior, but no significant difference was observed in three
other groups. Bisexual men, homosexual men and men with heterosexual
anal sex may be focus populations for the elimination of HBV targets.
It is noteworthy that HBV infection has affected approximately 250
million individuals globally. HBV infection is one of the main causes of
liver cirrhosis and liver cancer, increasing the economic burden of the
people and the medical burden of the society. Despite the widespread
dissemination of HBV medical information and the existence of
professional organizations dedicated to the treatment of HBV
infection[1], there
remains a significant portion of the population who are unaware of their
HBV infection status. This lack of awareness poses challenges to
follow-up treatment, increases costs, and may even result in secondary
transmission[21].
Therefore, it is imperative to expand the dissemination of information
regarding HBV screening, transmission routes, vaccination, and the
consequences of infection, in order to raise awareness and promote
prevention efforts.
Certain studies have suggested that sexual behavior is a significant
risk factor for the transmission of
HBV[17,
22], and recent data from the United
States indicates that approximately one-third of acute HBV infections
were associated with sexual behavior during
2013-2018[23].
Despite this, limited research has been conducted on the relationship
between sexual type/identity and HBV infection.
Our findings indicate that men with heterosexual anal sex were 4.52
times more likely to contract HBV than men without sexual behavior.
However, no significant differences were observed in the risk of
contracting HBV through heterosexual vaginal sex, heterosexual oral sex,
or heterosexual multiple types of heterosexual sexual behavior. These
results suggested that
heterosexual anal sex may be a
particularly high-risk factor for HBV infection. A literature also
reported that heterosexual anal sex contributed to the transmission of
HIV[24].
Furthermore, the prevalence of HBV infection was found to be 5.23 times
higher in male homosexual sex and 1.69 times higher in bisexual sex
compared to men without sexual behavior. Homosexual and bisexual men
were identified as being at a greater risk of HCV and HIV infection,
which is consistent with the findings of a
survey[25]. A
research also revealed that the rate of HBV infection in individuals
with HIV was 6.5 times higher than in those without
HIV[26]. The
potential correlation between decreased counts and dysfunction of CD8+
and CD4+ T cells resulting from HIV infection and an increased
susceptibility to HBV infection has been suggested as a contributing
factor to the higher incidence of HBV co-infection among homosexual and
bisexual men[27,
28]. In light of this, preventative
measures such as condom use and health screenings for high-risk groups
should be prioritized to mitigate transmission.
Nonetheless, the study found no statistically significant disparities
among women, regardless of their sexual identity or sexual type. In the
study, participants with HBV infection were more likely to be men
predominant. The authors, Robin Brown et al., attributed this gender
dimorphism to variations in sex hormone levels and immune factors, which
may account for the observed differences in HBV infection rates between
men and women[29,
30]. Specifically, estrogen and its
interaction with estrogen receptors may have a suppressive impact on
HBV.
Furthermore, the prevalence of drug use was observed to be higher in the
HBV infection group compared to the non-HBV infection group, as reported
by Jaimie Z. Shing et
al[4]. The study
revealed that approximately 20% of adults with a history of drug use
were infected with HBV, which was significantly higher than the
proportion observed in the general population. Drug use was identified
as one of the common modes of HBV
transmission[5].
Additionally, previous research has demonstrated that the proportion of
smokers is higher in individuals with hepatitis B infection, which
aligns with our findings. Furthermore, smoking was correlated with an
increased risk of hepatitis B-related liver
cancer[31,
32].
To achieve the objective of the World Health Organization to eliminate
HBV by 2030, it was imperative to implement measures aimed at reducing
the transmission of HBV through sexual behavior
pathways[5].
Furthermore, vaccination and regular screening were deemed crucial.
However, our study was subject to certain limitations. The employment of
cross-sectional design in NHANES data enabled us to establish a
potential association between sexual behavior and HBV infection, but not
a causal relationship. Sexual behavior was from questionnaire, maybe
some bias existed. Furthermore, the absence of data on protective
measures, such as condom use, leading to the absence of this important
variable as covariates for the analysis.