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HIV/AIDS

AIDS is the acronym for Acquired Immune Deficiency Syndrome while HIV stands for Human Immunodeficiency Virus. HIV is the etiological agent of AIDS and infection from HIV ranges from a lack of symptoms and mild illness to debilitating disorders and fatal disease. AIDS is the last stage of HIV. There are approximately 54,000 HIV positive people in Malaysia and the figures are constantly increasing.

COMMON QUESTIONS

How do you get infected?

HIV is spread through blood, semen and the vaginal discharge of an HIV-infected person. Being in contact with these fluids via sexual intercourse, blood transfusions, needle sharing and childbirth can result in HIV infection.

How do I avoid getting infected?

How can I tell if I have been infected?

The only way to tell is by taking a blood test called the HIV Antibody Test. If you test positive, this means that you are infected with HIV and additional tests will be carried out to gauge your immune system. Some people stay healthy for a long time while others become seriously ill and develop AIDS much quicker.

Testing negative and not having any exposure to HIV for six months prior to taking the test means you do not have the infection. There are those who take longer than six months to test positive and this is known as the ‘window period’ in the HIV infection cycle.

How is HIV treated?

Currently there is no cure for the virus. New medication can slow down the damage to the immune system and doctors are able to treat the illnesses resulting from HIV infection. Many people manage HIV infection like a long-term sickness.

If I am HIV positive, what should I do?

Mother to Child Transmission

Mother-to-child transmission (MTCT) accounts for 25% of new cases, and studies show that the administration of anti-retroviral therapy for HIV-infected pregnant mothers could reduce transmission. The main aim of this treatment is to preserve the health of the mother, prevent transmission and maintain the health of the foetus.

Post-Exposure Prohylaxis (PEP)

Healthcare workers are always at a risk of exposure with the average risk of HIV transmission through percutaneous exposure at 0.3% and mucus membrane exposure at 0.09%. The risk depends on factors such as what type of body fluid is involved, type of exposure, volume of fluid, disease stage and viral load of the source.

Antiretroviral Agents Nucleoside Analogue Reverse Transcriptase Inhibitors - Nucleoside Analogues ( NRTIs)

Protease Inhibitors (PIs)

Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

Hepatitis

There are approximately 2.5 million Malaysians infected with Hepatitis, and many are unaware that they have contracted the disease. They usually only discover how ill they are when suffering from complications like liver cancer and cirrhosis.

There are several types of viral Hepatitis – A, B, C, D and E. They are all different in terms of severity, epidemic features, how it is spread, treatment and preventive measures. The main types of Hepatitis in Malaysia is A, B and C, with A and B being the most common.

Hepatitis	Transmission	Sysptoms	Carriers Worldwide	New infections per year
Hepatitis A (HAV)	Contact with food or water that has been contaminated by faeces from an infected person.	Flu-like symptoms including fatigue, stomach pain, loss of appetite, nausea, diarrhoea, dark urine and jaundice. Or, there may be no symptoms at all.	Varies - epidemics may occur every 5 - 10 years.	Estimated 1.4 million cases reported annually.
Hepatitis B (HBV)	Direct contact with infected blood or other body fluids e.g. sharing a needle or through sexual contact. May be passed from mother to child during childbirth.	Majority of sufferers have no symptoms at all. If symptoms occur, these may include jaundice, fatigue, stomach and joint pain, loss of appetite, nausea and vomiting. Can lead to liver cirrhosis and liver cancer.	More than 2 billion people infected resulting in 350 million long-term carriers.	Up to 300,000
Hepatitis C (HCV)	Direct contact with infected blood or other body fluids e.g. shared drug needles, sexual contact and blood transfusions given before screening was introduced in the early 1990's. May be passed from mother to child during childbirth.	Most sufferers do not experience any symptoms. Symptoms can include fatigue, abdominal pain, loss of appetite, jaundice, nausea and vomiting. Can cause chronic liver damage, liver cirrhosis and liver cancer.	170 million	28 - 180,000
Hepatitis D (HDV)	Direct contact with infected blood or other body fluids e.g. shared drug needles and sexual contact. May be passed from mother to baby during childbirth. HDV can only cause disease in people who are also infected with the hepatitis B virus.	Symptoms are similar to those experienced with hepatitis B. Jaundice, fatigue, abdominal and joint pain, loss of appetite, nausea and vomiting. Can cause chronic liver damage.	10 - 60% of chronic HBV carriers depending on region.	Approx. 5,000
Hepatitis E (HEV)	Contact with water that has been contaminated by faeces from an infected person.	As for hepatitis A.	Unclear	Few cases in the West.
Hepatitis G (HGV)	Transmitted by blood; transmission has been reported in patients exposed to blood or blood products during transfusion, shared drug needles, and there is some evidence of sexual transmission.	Hepatitis G virus was discovered in 1995; its role in chronic liver disease is poorly understood. Observations suggest that liver damage is absent or mild.	Unclear	Unclear

Hepatitis A

Spread by ingesting contaminated food or water. It can also occur with direct / indirect contact with an infected person’s faeces (virus is excreted two weeks before the appearance of the disease), and due to this the carrier could actually be spreading the disease without knowing.

Faecal contamination of food, water, shellfish, hands and utensils are the common ways the disease is spread. Hepatitis A is more common in areas with poor sanitation and an inadequate water supply, and poor personal and public hygiene aggravates the problem.

Treatment

There is no specific treatment for the disease although once a person recovers, they are immune for life.

Immunisation

Available and protection lasts up to 10 years. A single dose vaccine is given followed by a booster dose 6-12 months later. The single dose protects within 15 days and lasts a year. The booster dose provides protection for up to 10 years.

Immunisation is not needed for those who have already suffered an attack of Hepatitis A and a blood test is needed to detect the antibodies. It is estimated that 50% of Malaysians under the age of 30 do not have antibodies and are susceptible to the disease.

National Incidence

The national incidence rate dropped from 11.65/100,000 in 1988 to 1.23/100,000 in 1998. This was due to preventive and control measures and strategies undertaken by the government to control food and waterborne diseases by improving sanitation, encouraging personal hygiene and providing a safe water supply.

Hepatitis B

Spread via blood and certain body fluids, Hepatitis B is 100 times more infectious than the HIV. In Malaysia, there are an estimated one million carriers.

The disease spreads via contaminated needles, transfusion of contaminated blood and sexual intercourse. The virus can also be found in semen and saliva. Vertical transmission from mother to child is common and most carriers in this region have been infected this way.

In a survey of 900 patients with chronic Hepatitis B, half of them were found to be very infective and of these 30–40% had evidence of liver disease and required treatment. The majority of Hepatitis B and C sufferers seldom exhibit symptoms and do not realise they have the disease until they have blood tests.

National Incidence

The reported incidence rate has decreased from 6.78/100,000 in 1988 to 1.3/100,000 in 1997. In 1988 there were 1,151 reported cases whereas there were only 281 in 1977. In 1998 there was an alarming increase in cases due to the detection of the disease as a result of compulsory screening for foreign workers.

The Disease

Hepatitis B is a disease caused by the Hepatitis B virus (HBV) and primarily affects the liver by destroying the cells and impairing basic functions. Chronic carriers may subsequently contract the disease and death usually occurs due to liver failure.

The Virus

HBV is a Hepadnavirus where ‘hepa’ denotes that it replicates in the liver and ‘dna’ indicates its genome consists of DNA. It is transmitted through blood and bodily fluids and infects the liver. Presently the infection is incurable in most cases.

Hepatitis B is one of the most deadly diseases with an estimated 400 million chronic carriers worldwide. Many of these suffer from chronic Hepatitis, liver cancer and cirrhosis and 1-2 million people die annually from HBV-related conditions.

A COMPARISON OF HIV AND HBV

	HIV	HBV
Number of people infected worldwide in million (WHO estimation)	19.5	2000
Number of AIDS cases/HBV carriers	6 million	350 million
Minimum volume of blood required to transmit infection	01.million	0.00004 ml
Risk of infection following needle-stick injury with positive patient	0.5 %	7-30 %
Vaccine preventable	No	Yes

Hepatitis B is thought to be 100 times more infectious than HIV. Spread through contact with infected bodily fluids, its only natural host is man and it is extremely resistant to adverse conditions outside the body. Studies have shown that the virus can be detected on contaminated objects even after prolonged exposure to ambient environmental conditions. Blood is the main vehicle of transmission with semen, saliva and vaginal secretions coming after.

There are three modes of HBV transmission:

1. Vertical Transmission (during pregnancy)

HBV cannot cross the placenta, but it can be transmitted from a carrier mother to the foetus when invasive procedures like an amniocentesis is performed. This mode of vertical transmission is estimated to be responsible for less than 5% of cases in newborns.

2. Perinatal Transmission (around time of birth)

HBV is more commonly transmitted from a carrier mother to her child through contact with infected blood during delivery. It can also occur shortly after, e.g. through scratches while breastfeeding. It is estimated that about half of all chronic HBV carriers in South East Asia are infected this way.

3. Horizontal Transmission

HBV can be transmitted to anyone who comes into contact with an infected person. The mechanism of this kind of HBV transmission is not fully understood, but it is thought that small amounts of infected blood of saliva coming into contact with open wounds could be the way. Direct physical contact through sports activities or sharing personal items like toothbrushes or razors is also responsible. This sort of transmission accounts for a significant proportion of Hepatitis B infections among children, adolescents and young adults.

4. Sexual Transmission

This is the main source of infection, making Hepatitis B a sexually transmitted disease (STD) as well. Heterosexual transmission is recognised as being the leading source of infections. Studies show that people with multiple partners and those with a history of other STDs are at an increased risk of infection. Sexual transmission is a form of horizontal transmission.

5. Parenteral / Percutaneous Transmission

The most understood form of transmission where HBV-infected blood / blood products is transfused or comes into contact with damaged skin or mucous membranes. Contaminated surgical instruments and other utensils are another possible hazard. This sort of transmission can occur during surgery, intravenous drug use, body piercing, tattooing, acupuncture, circumcision or scarification. People at high risk of infection includes patients requiring frequent transfusions / haemodialysis, doctors, nurses, dentists and other healthcare workers; laboratory technicians; intravenous drug users, police and those who may come into contact with infected blood and blood products.

Acute Hepatitis B

Acute Hepatitis B develops within six weeks and six months after infection. The length of the incubation period depends on the route of transmission and on the dose of the virus. The infected person is infectious during the incubation period.

About two-thirds of infected adults experience clinical symptoms. The first to appear are similar to those of influenza and include slight fever, fatigue, loss of appetite, headache, nausea, vomiting and abdominal pain.

About half of patients will develop jaundice or icteiric Hepatitis a few days later. Jaundice lasts about two weeks and is characterised by yellow colouring of the skin and whites of the eyes, dark urine and pale stools. In a few cases, fulminant hepatitis occurs where there is a sudden onset of high fever, abdominal pain, vomiting and jaundice. This is usually fatal.

About 90% of acute Hepatitis B sufferers will fully recover and this can take up to six months, and relapses may occur.

Chronic Hepatitis B

Chronic Hepatitis B usually develops after an asymptomatic HBV infection and when the immune system is unable to eliminate the virus. It is most commonly detected in infancy or childhood and in adults who are unable to mount an effective cell-mediated immune response. The milder the initial infection, the greater the risk of developing a chronic carrier state, which is highly infectious.

There are two types of chronic Hepatitis B:

Chronic persistent Hepatitis B

The most common type which is often asymptomatic. When symptoms are present they are relatively minor and include fatigue, abdominal pain, weakness, fever and intolerance to fat or alcohol. It does not usually progress to severe liver disease but some people may develop chronic active Hepatitis B.

Chronic active Hepatitis B

This is more serious and can lead to liver cirrhosis (liver becomes enlarged and distorted) and primary heptacellular carcinoma – a form of liver cancer. Up to 80% of liver cancer cases in Asia are believed to be a consequence of Hepatitis B virus infection. The disease is more common in men than in women and its incidence increases with age.

Cirrhosis of the liver

Prevention

Vaccination:

Treatment

Alpha-Interferon:

Lamivudine:

Testing & Monitoring

Hepatitis B virus multiplying in the liver, by measuring either:

Liver damage, by measuring:

Seroconversion, by measuring:

TEST RESULTS

	Blood Test Result
Patient with long-term (chronic) Hepatitis B virus infection.	Hepatitis B antibody - Hepatitis B antigen + Hepatitis B DNA +
Patients who seroconvert	Hepatitis B antibody + Hepatitis B antigen - Hepatitis B DNA -