This study showed a high prevalence (15%) of hepatitis co-infection, which is approximately one out seven HIV-infected children. The prevalence of HCV alone observed in this study was 13.8%, which is significantly higher than 7.1%, which was reported by Kitundu et al (Jesse Kitundu – Post-transfusion hepatitis C seroprevalence in Tanzanian children. 2001)  in post-transfused Tanzanian children. The difference between these studies could be due the nature of the studied populations. In the present study, all children were HIV infected and were therefore more prone to hepatitis viruses, which share modes of transmission. Secondly, the methods used were different, in this study antibodies to HCV was detected using an ELISA technique while in this study agglutination test was used which is relatively less sensitive and less specific due to potential cross reactions . However, it is important that these ELISA based results are confirmed with more sensitive technique such as HCV-RNA by PCR, since it has been shown that some positive ELISA results becomes negative when confirmed by PCR .
The seroprevalence of HBsAg alone in this study was 1.2%, which is significantly lower than 12% observed by Kitundu et al (Prevalence of Hepatitis B and C among children transfused with anti-HIV negative donor blood at the same hospital [unpublished observation]. A similar study conducted in Kenya by Rana et al  found a prevalence of hepatitis B to be 4%, among African children infected with HIV.
In this study the prevalence of HCV/HBV was not associated with age (18 months to 17 years). One limitation of this study was that children below 18 months were not investigated due to methodological limitations associated with the use of IgG based ELISA. This limitation may, at least in part, have obscured age trends.
Regarding HCV, females were more affected 17(21.5%) than males 8(9%) a finding that is consistent with a study done by Kitundu et al (Prevalence of Hepatitis B and C among children transfused with anti-HIV negative donor blood at MNH hospital in 2000) [unpublished data] in the same setting but the reason for the differences in sex is unclear.
In this study, 148 (88.6%) children had history of injection, 26 (15.6%) had Blood transfusion, 48 (28.7%) had uvulectomy and 2 (1.2%) were sexually abused. However none of these potential risk factors was associated with occurrence of the hepatitis viruses, which in another study conducted in the same hospital by Kitundu et al (Prevalence of Hepatitis B and C among children transfused with anti-HIV negative donor blood at MNH hospital [unpublished data]. This finding coupled with the young age of infection, may indicate that possibly these children acquired these viral infections vertically rather than horizontally.
We found no association between HBV and HCV, a finding that is in keeping with observations by Matee et al  and Wadell et al  among blood donors in the same hospital. Collectively these studies indicate that the epidemiology of these viruses is different in our setting .
The higher prevalence of raised ALT (20.0%) was among children co-infected with hepatitis virus compared with 7.0% without hepatitis co-infection (OR 3.99, 95% CI 1.12–14.19) (Table 3) is expected since hepatitis viruses are known to elevate liver enzyme .
We found no association between ART and elevated ALT, which is contrary to the findings of other studies [13–15]. Children recruited in this study were on first line regimen, which does not contain protease inhibitors, which are associated with more risk of elevated ALT than other antiretrovirals . There has also been reports that different genotype of hepatitis C virus differ in their ability to cause hepatotoxicity, with genotype 3 being more hepatotoxic than genotypes 1, 2, and 4. It would be interesting to perform genotyping of the HCV strains to better understand the association with liver pathology.
The high prevalence of hepatitis co-infection among HIV infected children indicates the need to revisit the current guidelines for the clinical management of HIV and AIDS. The regimen (zidovudine, lamivudine, and nevirapine for children < 3 years, with efaviranz replacing nevirapine for children > 3 years and didanosine, abacavir and ritonavir boosted lopinavir as second line) does not take care of the hepatitis co-infection. Although lamivudine works for both HBV and HIV, prolonged lamivudine therapy can result in drug-resistant HBV mutants and has been associated with hepatitis flares [16, 17].