Blood-Borne Viruses: A Resource for Professional Interpreters and Translators This resource was developed for Professional Interpreters and Translators who work in a range of health care settings. The aim of the booklet is to give Professional Interpreters and Translators a general understanding of hepatitis B, hepatitis C and HIV. The first part of the booklet gives basic information common to all three viruses, the risks of infection and how to prevent the spread of the viruses. The second part of the booklet gives more detailed information about each virus.
Hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV) are all blood-borne viruses (BBVs). All three are major public health issues worldwide. Australia, as a whole, is rated a low risk country by global standards. But within Australia, infection rates are higher in some groups of people than in the general population. Some of these groups of people were born in countries with high rates of blood-borne virus infection and many do not have good English language skills. Interpreters and Translators play an important role in the task of helping people from a wide range of cultural and language backgrounds understand their illness and get the medical help they need.
The facts Hepatitis B, hepatitis C and HIV are different viruses that affect the body in different ways. They are all spread by blood, but hepatitis B and HIV can also be passed on in other body fluids. All these infections can be prevented. They can all be treated, but if they are not, they may lead to serious health problems. See Table 1 for ‘The Facts About Hepatitis B, Hepatitis C and HIV’.
Table 1: The Facts About Hepatitis B, Hepatitis C and HIV Hepatitis B
Hepatitis C
HIV
Prevalence of infection
An estimated 210,000 people in Australia were living with chronic hepatitis B (0.97% of the population)1 at the end of 2013.
An estimated 230,000 people in Australia were living with chronic hepatitis C (0.99% of the population)I at the end of 2013.
At the end of 2013, 26,800 people in Australia were living with HIV infection (0.1% of the population).i
Vaccination/ Immunity
HBV can be prevented by vaccination.
There is no vaccine for HCV.
There is no vaccine for HIV.
95% of adults newly infected with HBV clear the virus naturally and become immune for life.
25–45% of people infected with HCV clear the virus naturally, but do not become immune.
HIV infection cannot be cleared by the body and infection is for life.
HBV spreads through blood-toblood contact, unprotected sexual contact and from mother-to-baby during childbirth.
HCV spreads through blood-toblood contact. This means infected blood has to enter the bloodstream of another person e.g. by sharing injecting equipment.
HIV spreads through blood-to-blood contact, unprotected sexual contact and from mother-to-baby during pregnancy or childbirth.
How the infection is spread
Sexual transmission is rare.
Signs and symptoms
Some people will be unwell after infection (called acute hepatitis). However, most people have no symptoms until they have advanced liver disease.
A few people will be unwell after infection (called acute hepatitis). However, most people have no symptoms until they have advanced liver disease.
Early signs and symptoms may include: ■ flu-like illness ■ rash ■ fever After this there may be no signs or symptoms until the infection is advanced.
Treatment
Long-term antiviral treatment is available for chronic hepatitis B (CHB) to prevent liver damage. Not everyone with CHB needs treatment. Treatment rarely cures CHB but it does reduce liver damage and prevents transmission.
Antiviral treatment is available that may clear (cure) current HCV infection, prevent further liver damage and stop transmission. New treatment may cure over 90% of HCV infection.
Antiviral treatment does not cure HIV but it does stop the virus reproducing and reduces damage to the immune system and progression to AIDS. With antiretroviral treatment people can expect to live a normal lifespan.
What is the risk of getting a BBV infection? The risk of an Interpreter or Translator getting a bloodborne virus infection at work is close to zero, even if they work in a specialist clinic with high numbers of clients with blood-borne virus infections. The risk of infection depends on how the person is exposed to the virus. The risk also depends on the type of virus and how much of the virus the person with the infection (the source) has in their body. For hepatitis B, whether the exposed person has been vaccinated is also important. The following advice is general. It is important to get medical advice if contact with blood or body fluids happens.
2
You cannot get hepatitis B, hepatitis C or HIV by: ■
casual physical contact including hugging, kissing and shaking hands
■
sharing an office, public transport or gym equipment
■
coughing or sneezing (through the air)
■
contact with faeces, urine or vomit (if not contaminated with blood)
■
sharing food or drink, plates, cutlery or glasses
■
using the same shower, toilet or laundry facilities
■
eating food prepared by someone living with a BBV infection
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators
Table 2: Risk of Hepatitis B, Hepatitis C and HIV Transmission From a Known Positive Source Source status Hepatitis B+
Hepatitis C+
HIV+
moderate
low
low
■ accidentally piercing skin with a used injecting needle
very high high
extremely high moderate
very high low
Tattooing/body piercing e.g.:
very high
very high
high
moderate
moderate
moderate
Unsterile medical and other procedures (This is very rare in Australia. It may happen in some countries with lower standards of health care.)
high
high
high
Blood and saliva to unbroken skin (e.g. spitting) and skin-to-skin contact e.g. shaking hands
zero
zero
zero
very high very high high moderate
very low very low very low zero
very high high moderate very low
very low when baby is vaccinated very high if the mother is not vaccinated
very low
very low if mother is on treatment very low if mother is on treatment
Exposure type Blood contact with broken skin, mouth or eyes e.g.: ■ large blood splash, e.g. bleeding artery ■ bloody saliva contact to mouth from giving mouth-to-mouth resuscitation if no protective equipment used ■ open wounds ■ sports injuries involving transfer of blood through open cuts or wounds Needlestick and other skin-piercing injuries e.g.: ■ sharing injecting equipment among people who inject drugs
■ sharing tattooing needles, ink ■ re-using body piercing equipment without cleaning
Sharing personal hygiene products where there can be small amounts of blood e.g.: ■ toothbrushes ■ razors ■ tweezers
Sexual exposure (no condom used): ■ anal (receptive) ■ vaginal (receptive) ■ vaginal or anal (insertive) ■ oral
Mother-to-baby e.g.: ■ breastfeeding ■ pregnancy
low
©ASHM. Adapted from HIV, viral hepatitis and STIs: a guide for primary care 2014 Table 2.1 page 29
What to do if you have contact with blood or body fluid at work As in daily life, there may be a very small risk of coming into contact with someone’s blood or other body fluids when providing interpreting services: for example, a colleague cuts themselves or a patient vomits blood during an examination. You cannot tell who has a blood-borne virus by looking at someone so;
The rule is: treat all blood and body fluids as infectious. If an exposure happens, get advice from a doctor as soon as possible. You may be offered blood tests to see if
there is a risk of getting a blood-borne virus. There may be more than one blood test to do and this can take a few weeks. While waiting for test results it is important not to put other people at risk: ■ Practice safe sex, i.e. use a condom for vaginal, oral or anal intercourse. ■ Cover up any sores, cuts and scratches . ■ Clean up any blood yourself if you cut yourself. ■ Do not share personal items such as razors and toothbrushes. ■ Do not share injecting equipment and dispose of used injecting equipment safely. ■ Do not donate blood or organs. Get advice from a doctor if you are pregnant, are planning to become pregnant or are breastfeeding.
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators 3
As an Interpreter or Translator, you may be asked to interpret or translate this information for the patient. Information could be: ■
that the test and result is kept private and confidential.
■
about the possible test results and what they mean for the person.
■
about safe practices with sexual partners and household contacts while waiting for the test result.
■
about culturally appropriate support services and referrals.
■
about looking after their general health e.g. diet.
After testing: conveying a test result
Post-Exposure Prophylaxis (PEP) PEP is medication taken after a possible exposure to HIV or hepatitis B. It can lower the risk of infection. Your doctor will decide if you need PEP. PEP for HIV is usually only offered for high-risk exposures. It is not given to everyone because there can be side effects. If PEP is recommended, it must start within 72 hours, preferably within 24 hours, of the exposure. There is no PEP for hepatitis C.
Interpreter and Translator Services
Test results also need to be given in a culturally appropriate manner, promptly, in person and in private. Results are given by a doctor, nurse or other health professional. They should ask the patient if they would like an Interpreter present. It is important that all information is kept confidential despite pressure or questions from waiting friends or family. If the result is ‘positive’ it means the virus is in the client’s blood. The client will need: ■
culturally appropriate counselling.
■
follow-up appointments.
■
more tests to find out whether the virus has caused any damage.
■
a possible referral to a specialist doctor.
Interpreters or Translators may have to interpret or translate information about: ■
keeping doctors’ appointments.
■
transport support.
■
safe behaviours e.g. using condoms; not sharing drug injecting equipment etc.
Interpreters have a very important role before and after a client has a test for blood-borne viruses. This can be a very difficult time for the client. They may not accept what the doctor tells them. It is very important that information is not omitted or added to during interpreting or translation. In some states and territories there are laws about what the doctor must tell the patient and the Interpreter or Translator must comply with this.
■
who the client should tell and how the client might tell them.
■
not drinking too much alcohol, not smoking, and eating healthy food.
■
finding other people the client has been in contact with (contact tracing) e.g. sexual partners, family members or household contacts, people they may have shared injecting drug equipment with etc.
Before testing: obtaining informed consent
If the test result is ‘negative’ it usually means the virus was not found in the blood. Interpreters may need to interpret information about:
Interpreters and Translators need to be aware of specific cultural backgrounds when interpreting or translating information. It is important that all information is given impartially and accurately.
The doctor or nurse will explain to the client what they need to know and will ask the client’s permission to do the test before ordering it. This is called ‘obtaining informed consent’. Clients must understand:
■
safe behaviours.
■
difficulties the client may have in practising safe behaviours.
■
Why the test is needed.
■
How the test is done.
vaccination for hepatitis B.
■ ■
What may happen if the test is positive (the virus is in the blood) or if the result is not clear.
■
the possibility the test was done in the ‘window period’ and may need to be repeated later.
4
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators
Contact tracing/Partner notification When someone tests positive for a blood-borne virus, it is important that any ‘relevant contacts’ of that person can be found. This is so they can be told about the possible risk of infection. The contacts can then be tested themselves. This process is called ‘contact tracing’ or ‘Partner Notification’. The health professional who ordered the tests is responsible for contact tracing. They can work out when the person is most likely to have got the infection. That timeframe defines who is a ‘relevant’ contact. Relevant contacts may be: ■
all sexual partners, male and female and not just the current or long term partner.
■
household contacts or family members of people with hepatitis B.
■
people who shared needles or injecting equipment or equipment used for tattooing, body piercing or in ceremonies.
Each State and Territory has its own laws and guidelines about how to do contact tracing. There are also laws that protect people’s health information. Other laws prohibit discrimination against people with a blood-borne virus. In all areas and in all cases, client information must be kept confidential.
Stigma and discrimination People living with hepatitis B, hepatitis C and/or HIV are often made to feel embarrassed or ashamed of their conditions. Many people living with these viruses also experience discrimination. The Interpreter or Translator may need to challenge their own beliefs and attitudes towards such issues as sex and sexuality (including same sex relationships, transgender and intersex people), injecting drug use, fears of and knowledge of hepatitis B, hepatitis C and/or HIV /AIDS in order to provide the best possible services for people with blood-borne viruses. Stigma and discrimination lead to people being treated badly and without respect. Many people are scared of or, have negative attitudes about, blood-borne virus infections. This can result in people living with a BBV being insulted, rejected, gossiped about and excluded. They may also be verbally and/or physically abused. People do not always recognise their own behaviour as discriminatory. Common examples of discrimination towards people with blood-borne viruses are:
virus (e.g. not shaking hands when they usually would) ■
making assumptions about risk behaviours (e.g. sexuality, injecting drugs, unsafe sex practices) based on the patient’s blood-borne virus status
■
disclosing the person’s blood-borne virus status without their consent
Legal rights and responsibilities – Disclosure and Confidentiality “Disclosure” means telling someone you have (or someone else has) a blood-borne virus infection. There are very few situations when, by law, you must tell someone else you have a blood-borne virus (or when someone must tell you if they have a blood-borne virus). The laws are different in each State and Territory. People should get legal advice if they are unsure whether they must tell others. Each State and Territory has a Legal Aid Commission which can provide free legal advice. A person with a blood-borne virus infection has a right to confidentiality. This means if someone tells you they have a BBV, or you find out when doing your job, you cannot discuss it with anyone else, including the person’s (or your) family or carers, except in very limited situations. Both State and Federal Privacy laws, impose confidentiality on people working in healthcare services. Interpreters and Translators are also bound by their industry Code of Ethics.
■
not making eye contact (especially in a Western society)
■
speaking sharply or abruptly to them
■
physical abuse
For more information on discrimination contact the National Antidiscrimination Gateway.
■
refusing services or providing poor services, e.g. not spending enough time on the client’s needs
There is a useful list of contacts and organisations in the PDF version of this booklet at: www.ashm.org.au/resources
■
blaming the person for their blood-borne virus status
■
avoiding touching people living with a blood-borne
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators 5
Hepatitis B
Figure 1: HBV Worldwide
What is hepatitis B? Hepatitis B virus causes inflammation of the liver and liver disease. Inflammation is swelling that happens when a part of the body is injured or infected. Inflammation of the liver means the liver does not work properly. The liver helps to clean harmful chemicals from the blood, fights infection, helps to digest food and stores energy. People cannot live without a liver.
Hepatitis B around the world Worldwide, there are between 240 and 350 million people living with hepatitis B. The highest rates of hepatitis B infection are in sub-Saharan Africa and East Asia, The Amazon and the southern parts of eastern and central Europe. The Middle East and the Indian subcontinent have medium levels of chronic hepatitis B (CHB) infection. In general, Western Europe, North America and Australia have low rates of chronic hepatitis B infection. But rates can be higher among migrants born in areas with higher rates of infection (see figure 1).
6% HBsAg prevalence
HBsAg prevalence
Hepatitis B in the body Acute hepatitis B (HBV) When someone is first infected with hepatitis B, it is called acute hepatitis B. Acute hepatitis B can last up to six months. The person may feel well and have no symptoms. Most adults will clear the virus naturally without treatment. The person should be monitored by a doctor to avoid possible liver damage.
Chronic hepatitis B (CHB) If hepatitis B infection lasts for six months or more, it is called chronic hepatitis B (CHB). The change from acute hepatitis B to chronic hepatitis B infection is because the immune system fails to clear the virus. The risk of progressing from acute to chronic hepatitis B depends on when the person got the virus: ■
90% of infants with acute hepatitis B will develop chronic hepatitis B.
■
30% of children with acute hepatitis B will develop chronic hepatitis B.
■
5% of adults with acute hepatitis B will develop chronic hepatitis B.
6
38%
>8% = high * For multiple countries, estimates of prevalence of hepatitis B surface antigen (HBsAg), a marker of chronic HBV infection, 2%–7% = intermediate are based on limited data and might not reflect current prevalence in countries have implemented childhood <2%that = low hepatitis B vaccination. In addition, HBsAg prevalence might 6%vary within countries by subpopulation and locality.
Adapted from: countries, World Health Organisation, Introduction of hepatitis B vaccination into child immunization services. * For multiple estimates of prevalence of hepatitis B surface antigen (HBsAg), a marker of chronic HBV infection, WHO. 2001.on Available 01/07/2014. childhood are based limitedfrom: datahttp://whqlibdoc.who.int/hq/2001/WHO_V&B_01.31.pdf. and might not reflect current 5% prevalence in countriesAccessed that haveon:implemented
hepatitis B vaccination. In addition, HBsAg prevalence might vary within countries by subpopulation and locality.
Figure 2: Hepatitis B in Australia
9%
7%child immunization services. Adapted from: World Health Organisation, Introduction of hepatitis B vaccination into 10% WHO. 2001. Available from: http://whqlibdoc.who.int/hq/2001/WHO_V&B_01.31.pdf. Accessed on: 01/07/2014. 6% 19% 38% 6% 5% 9%
Hepatitis B in Australia In Australia in 2013, an estimated 210,000 people were living with chronic hepatitis B. The numbers have increased over the past ten years. Over 50% of people living with chronic hepatitis B were born overseas (see figure 2).
>8% = high 2%–7% = intermediate <2% = low
19%
10%
7%
■ People born in the Asia and Pacific regions (38%) ■ People born in Africa/Middle East (7%) ■ People born in Europe (10%) ■ Aboriginal and Torres Strait Islander people (9%) ■ Men who have sex with men (5%) ■ People who inject drugs (6%) ■ Other Australian-born non-Indigenous people (19%) ■ Other/not stated (6%)
MacLachlan JH, Allard N, Towell V, Cowie BC, The burdon of chronic hepatitis B virus indection in Australia, 2011. ■ People born in the Asia and Pacific regions (38%) Aus NZ J Public Health, 2012;37(5):416-22 ■ People born in Africa/Middle East (7%) ■ People born in Europe (10%) Manyandpeople first know ■ Aboriginal Torres Strait Islander peoplethey (9%) have chronic hepatitis B ■ Menwhen who have sex with men (5%) they have a blood test as an adult. ■ People who inject drugs (6%) ■ Other Australian-born non-Indigenous people (19%) People with ■ Other/not stated (6%) chronic hepatitis B need life-long monitoring
to check whether the virus is damaging their liver and if treatment is needed. Over time, the virus can cause liver damage, liver scarring (cirrhosis) and liver cancer.
How is hepatitis B diagnosed? Hepatitis B is diagnosed by blood tests. The tests will show if the person has a current infection, if the person had an infection in the past or if the person is immune (because they were vaccinated or had an infection in the past). Test results should only be given by those who are well informed about hepatitis B because the patient may need: ■
vaccination - of the client and/or other family contacts.
■
further testing (such as ultrasound or more blood tests).
■
assessment of liver health and the need for treatment.
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators
Who should be tested?
Table 3 Priority populations for testing Who should be tested for hepatitis B?
Other priority groups ■ pregnant women (to prevent passing hepatitis B to their baby) ■ adults at increased risk of infection, including:
■ People born in countries with
medium and high hepatitis B infection rates
and ■ Aboriginal and Torres Strait
Islander people
– sexual and household contacts, and family members of people with hepatitis B – men who have sex with men – people who inject drugs – people with multiple sexual partners (including sex workers) – haemodialysis patients (cleaning waste and fluid from the blood because the kidneys can’t do it) ■ people living with hepatitis C or HIV infection (because having one blood-borne virus increases
the risk of getting another [co-infection] that can change the outcomes and treatment)
■ patients about to start chemotherapy or other treatments that suppress the immune system
(because patients with past or present hepatitis B infection may develop life-threatening issues)
■ people with liver disease or abnormal liver tests ■ health professionals who may do high risk procedures or exposure-prone procedures ■ members of the armed forces.
©ASHM: B Positive: All you wanted to know about hepatitis B – A guide for primary care workers 2014 Table 3.1 pg. 32
Prevention Vaccination prevents hepatitis B infection The National Immunisation Program in Australia includes free hepatitis B vaccination of all babies at birth. Other people at risk of getting hepatitis B can also have free vaccination. This includes Aboriginal and Torres Strait Islander people, migrants from high risk countries, close family contacts of someone who has hepatitis B, sexual contacts, men-who-have-sex-with-men, people who inject drugs.
■
they may have to take this treatment every day for the rest of their life even if they feel well.
■
they will need long-term monitoring by a doctor to check if the liver is damaged.
Chronic hepatitis B and liver cancer Chronic hepatitis B infection increases the risk of developing liver cancer (hepatocellular carcinoma - HCC). People with chronic hepatitis B infection need to be monitored and screened for liver cancer.
The Australian Immunisation Handbook has a detailed list of people who are most at risk from hepatitis B and need to be vaccinated.
If diagnosed late, liver cancer has a very poor outcome; most people do not survive for 12 months. Early detection improves outcomes as treatment is possible and can result in a cure.
Treatment
Pregnancy, childbirth and breastfeeding
Acute hepatitis B (HBV)
One of the most common ways of spreading hepatitis B is from mother-to-child during pregnancy and childbirth. Without intervention, up to 90% of babies born to hepatitis B positive women will get the infection. It is important to screen all pregnant women for hepatitis B. This makes sure hepatitis B positive mothers are found and their babies vaccinated at birth. If this is done, the risk of hepatitis B spreading to the baby is reduced by 95%.
Most adults who get hepatitis B will clear the virus within six months without treatment. After clearing the virus the person will have immunity and will not get the infection again.
Treatment for chronic hepatitis B (CHB) Not all people with chronic hepatitis B need treatment. Many only need to be monitored by their doctor every six months to keep a check on their health. Treatment for chronic hepatitis B is given by specially trained doctors and is usually one tablet a day. Antiviral therapy does not usually cure the infection. The aim of treatment is to stop the virus multiplying, limit damage to the liver and reduce the risk of liver cancer. If the person does not take their medication when they should, or if they stop taking it, they may risk more serious liver damage. People who do begin treatment need to understand:
The National Immunisation Program includes free hepatitis B vaccination of all babies at birth. The first dose is given within 24 hours or at least within 7 days of birth. Three more doses are given over the next six months. There is no evidence that hepatitis B is spread during breastfeeding. Women should breastfeed if they choose to. Pregnant women need to have accurate information about the risk of passing the virus to their baby and what they can do to reduce the risk, including taking hepatitis B treatment.
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators 7
Figure 1: Global distribution of HCV
Hepatitis C
What is hepatitis C? Hepatitis C is an infectious disease that affects the liver. It is caused by the hepatitis C virus. Hepatitis C can cause inflammation of the liver and may lead to cirrhosis, liver cancer or liver failure. There are a number of different types of hepatitis C (genotypes) and some are more common in certain parts of the world. This may have an impact on treatment.
Hepatitis C around the world Hepatitis C is one of the most common infectious diseases worldwide. The World Health Organization estimates there are between 130 million and 150 million people living with hepatitis C worldwide. The most affected regions are Central and East Asia and North Africa (see figure 1).
Hepatitis C in Australia In Australia in 2013, there were an estimated 310,000 people who had been exposed to the hepatitis C virus. There were an estimated 230,000 people living with chronic hepatitis C. Over 80% of existing and almost 90% of all new hepatitis C infections are among people with a history of injecting drug use. About 11% of people who have been exposed to hepatitis C are immigrants from countries with a high rate of hepatitis C infection.
Adapted from: Center for Disease Analysis Data http://www.centerforda.com/HepC2013b/HepMap.html
Hepatitis C infection affects Aboriginal and Torres Strait Islander people at more than three times the rate of the non-Indigenous population. Newly diagnosed hepatitis C in Aboriginal and Torres Strait Islander populations increased by 29% in 2013.
Hepatitis C in the body Acute hepatitis C People with acute hepatitis C infection donâ&#x20AC;&#x2122;t usually have any symptoms and it very rarely causes life-threatening disease. About 25% of people who get hepatitis C clear the virus within six months of infection without any treatment. Hepatitis C antibodies will stay in their bloodstream but the person cannot infect others. People who have cleared the virus are not immune to hepatitis C. If they are exposed to the virus again, they can be re-infected.
Chronic hepatitis C (CHC) The other 75% of people will develop chronic hepatitis C infection (CHC). Over 20 to 40 years some people will experience liver damage and may go on to develop liver disease, liver failure or liver cancer.
Of 100 people with chronic hepatitis C and not on treatment, it is estimated that:
AFTER 20 YEARS
AFTER 40 YEARS
45 will develop liver damage
47 may develop mild to moderate liver damage
7 may develop cirrhosis of the liver
1 may develop liver failure or liver cancer
30 will develop liver damage
45 may develop mild to moderate liver damage
20 may develop cirrhosis of the liver
5 may develop liver failure or liver cancer
Adapted from G Dore/Hepatitis NSW (2012)
8
Blood-Borne Viruses â&#x20AC;&#x201C; A Resource for Profesional Interpreters and Translators
How is hepatitis C diagnosed? HCV is diagnosed through blood tests. The laboratory will look for answers to these questions: ■
Has the person ever had hepatitis C?
■
Does the person have hepatitis C now?
■
What is the current level of replication?
■
What is the hepatitis C genotype?
The test results help the patient and doctor decide whether more testing is necessary. They also help to decide if treatment is necessary.
Who should be tested? People at risk of getting hepatitis C should be tested. The following people are priority groups for hepatitis C testing: ■
People with a history of injecting drug use – Sharing injecting equipment is the most common way of spreading hepatitis C in Australia.
■
Aboriginal and Torres Strait Islander people – Aboriginal people have more than three times the risk of hepatitis C infection than the non-Indigenous population.
■
People who have ever been in prison – because of re-using needles for injecting drugs or tattooing.
■
Children born to hepatitis C positive mothers – women with hepatitis C are unlikely to pass it to their baby (about 5%), but there is a higher risk if the mother has both HIV and hepatitis C infections.
■
People who had organ or tissue transplants, blood transfusions or blood products before February 1990 in Australia, or at any time where there is no mandatory screening of donors.
■
Unsterile medical procedures in countries with high rates of hepatitis C
■
People with tattoos or skin piercings.
■
Sexual partners of people with hepatitis C – infection through sex is rare but may happen if there is blood-to-blood contact.
■
When breastfeeding, milk from cracked or bleeding nipples should be expressed and thrown away until the sores are healed.
■
Not sharing toothbrushes, razors, shavers, or barber’s haircutting equipment.
■
Not sharing or re-using tattooing or body-piercing equipment.
Treatment Many people with hepatitis C do not develop liver damage and so do not need treatment. It can take many years for some people to develop serious liver disease and they can be treated with antiviral medicines (see section: Chronic hepatitis C). The aim of hepatitis C treatment is to: ■
destroy and remove the virus,
■
prevent disease progression,
■
improve liver health,
■
improve survival.
Exactly what treatment is needed and for how long, depends on which genotype the person has.
For more information see www.testingportal.ashm.org. au/hcv/indications-for-hcv-testing
The new treatments have fewer side effects than in the past. People are more likely to complete their treatment if the side effects are easy to manage.
Prevention
Pregnancy, childbirth and breastfeeding
There is no hepatitis C vaccine. Prevention relies on people who have hepatitis C, or at risk of getting it, understanding how to lower the risk of passing it on. Prevention relies on safe behaviours such as:
The risk of passing hepatitis C from mother-to-child during pregnancy and childbirth is low (approximately 5%). There are no recommended actions to take to prevent the baby from getting hepatitis C from the mother.2 Breastfeeding is considered safe unless the nipples are cracked and bleeding. In this case, the advice is to express the milk and throw it away until the nipples have healed.
■
Always using sterile needles and syringes and new injecting equipment every time they inject. Disposing of all injecting equipment safely and washing hands immediately before and after injecting.
■
Using condoms where there is a possibility of blood contact during sex.
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators 9
HIV
Figure 1: HIV prevalence in adults
A t l a n t i c O c e a n
What is HIV? Human immunodeficiency virus (HIV) is a virus that attacks the immune system. HIV destroys important cells (T-cells and CD4 cells) that fight diseases and infections. Over time the virus destroys so many T-cells and CD4 cells the body cannot resist infections and diseases anymore. When this happens the body cannot protect you from any illness and the person becomes very sick. Once the virus is in the body it cannot be eliminated.
P a c i f i c O c e a n A t l a n OCEAN t i c ATLANTIC O c e a n
PACIFIC OCEAN
I n O
P a c i f i c Prevalence of O c e a n HIV in Adults
6%
15% – 26% Prevalence5% of – 14.9%
I n d i OCEAN a n INDIAN O c e a n
HIV in Adults 1% – 4.9% 15% – 26%
0.5% – 0.9%
5% – 14.9%
0.1% – 0.4%
1% – 4.9%
HIV vs AIDS HIV is a virus. Acquired Immunodeficiency Syndrome (AIDS) is a medical condition. Without treatment, a person’s immune system will become seriously damaged and they will develop life-threatening illnesses. If the person has one or more specific infection or a certain type of cancer, this is known as late-stage HIV infection or AIDS.3
0.5% – 0.9%
< 0.1%
0.1% – 0.4% < 0.1%
At the end of 2013, 35.3 million people were living with HIV worldwide.4 The highest rates of HIV infection are in Sub-Saharan Africa which had 21.7 million people, (nearly 1 in 20 adults), living with HIV. At the end of 2013 this accounted for 71% of people living with HIV worldwide.
HIV in Australia (see figure 2) In Australia, an estimated 26,800 people were living with diagnosed HIV infection at the end of 2013. 64% of new HIV diagnoses were in men who have sex with men (MSM). 25% of new diagnoses at the end of 2013 were in the heterosexual population. In this group, 30% were born in Sub Saharan Africa and 22% in Asia. 29% of Australian born heterosexual men and women with HIV infection had a partner from a country with high infection rates such as Sub Saharan Africa (27%), South East Asia (71%) and North Africa/Middle East (2%).
HIV in the body
When a person first gets HIV infection, they may have flu-like symptoms. In most cases, without treatment, HIV slowly causes damage to the immune system. The body becomes less able to fight infection and illness. As HIV infection advances, a person may develop AIDS.
10
25%
UNAIDS/ONUSIDA 2012. www.unaids.org
Figure 2: Newly diagnosed HIV infection in 2% Australia, end 2013 3%
64%
6%
With treatment, a person with HIV can live a normal healthy lifespan.
HIV around the world (see figure 1)
No Data
No Data
25%
64% 2% 3%
■ Men who have sex with men (64%) ■ Men who have sex with men and injecting drug use (3%) ■ Injecting drug use (2%) ■ Heteroseual contact (25%) ■ Other/undetermined (6%)
The Kirby Institute. https://kirby.unsw.edu.au/sites/default/files/hiv/resources/Figures%202014.pdf ■ Men who have sex with men (64%) ■ Men who have sex with men and injecting drug use (3%) ■ Injecting drug use (2%) ■ Heteroseual contact (25%) HIV is diagnosed(6%) by blood tests. Australia now has rapid ■ Other/undetermined
How is HIV diagnosed?
tests that take up to 20 minutes and can be done in a clinic. Other tests take a few days and are only done in a laboratory. The laboratory tests can be used alone or to confirm the result of a faster test. All the HIV blood tests detect the HIV virus and antibodies to the virus. Antibodies are proteins which the immune system makes as a defence against infections. The antibody for HIV is very specific and attaches to specific HIV protein on the surface of the HIV virus (HIV antigens). If the antibody test is ‘positive’ a second test (the Western Blot) is done to confirm the result. A second ‘positive’ test result means the person has HIV infection. Most people will have an HIV positive result six weeks after infection. A person with very early infection may test ‘negative’ meaning the virus cannot be detected. While the virus can be detected as early as three weeks after exposure, it can take up to three months. This timeframe is called the ‘window period’. Tests done in the window period are not reliable and should be repeated.
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators
Who should be tested? Anyone who asks for an HIV test should be tested. People who are at risk of HIV infection should be tested regularly. The priority groups for testing include: ■ People who have another sexually transmitted
infection (STI) or BBV (hepatitis B or hepatitis C). ■ Pregnant women. ■ Men who have sex with men (MSM). ■ People who inject drugs. ■ People whose sexual partner has HIV. ■ People who have had sex or medical procedures in
countries that have a high level of HIV in the population. ■ People with illnesses caused by low immunity such
as tuberculosis, pneumonia or skin infections.
Prevention People who know about their HIV infection are much less likely to pass it on. HIV testing is an important part of HIV prevention. Testing allows early detection of HIV. This improves health outcomes, and prevents further transmission of HIV. HIV-positive people can greatly reduce the risk of spreading HIV by having early treatment. Early treatment reduces the number of viruses in the blood, ideally to a level that is not detectable. HIV transmission is greatly reduced by: ■
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safer sex, – any sexual activity that does not allow the transfer of one person’s body fluids (blood, semen, vaginal fluid) into another, – reducing the number of sex partners and adopting safer sex practices, – using condoms and water-based lubricants for any vaginal or anal intercourse, – avoiding oral sex if there are cuts or sores on the genitals or in the mouth, – covering shared sex toys with a condom. safe injecting - using only sterile equipment (needles, syringes, swabs, spoons, filters, tourniquets and water) to inject each time or thoroughly cleaning equipment where this is not possible.
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testing for and treatment of STIs.
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interventions during pregnancy and labour, and avoiding breastfeeding.
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taking a course of post-exposure prophylaxis (PEP) within 72 hours after being exposed to HIV.
Treatment With treatment, HIV is considered a chronic disease that people live with and manage. HIV treatment is usually a combination of up to three different types of drugs. These are known as antiretroviral (ARV) medications. Each ARV type blocks different parts of the HIV virus life-cycle and stop the virus from multiplying. The aim of HIV treatment is to decrease the amount of HIV in the blood (viral load) and allow the immune system to restore itself. Once started, people must continue to take ARV treatment. If they do not take the ARVs regularly, or they stop completely, the virus will quickly multiply and cause more damage to the immune system. People can also develop resistance to the medication. That means it may not work as well (or at all) if they want to take it again in the future.
Pregnancy, childbirth and breastfeeding Routine testing of pregnant women is now standard care. Early diagnosis is very successful in preventing mother-to-child transmission. When mothers are treated for HIV during pregnancy, very few babies get infected. Without treatment, up to one in three babies will be infected through birth and breastfeeding. Using ARV therapy plus planned caesarean delivery and bottle-feeding reduces HIV transmission to less than 2%. Mother-to-child transmission of HIV has fallen dramatically in countries where antiretroviral therapy is available to pregnant women.5 It is possible to pass HIV on via breast milk. Current guidelines recommend mothers with HIV avoid breastfeeding when there is access to safe, affordable and culturally appropriate alternatives, e.g. clean water and baby formula.6
Blood-Borne Viruses – A Resource for Profesional Interpreters and Translators 11
Glossary
ASHM resources
ASHM resources are available from the ASHM website: www.ashm.org.au/publications
Profession-Based Booklets Aboriginal and Torres Strait Islander Health Workers and Blood-Borne Viruses (BBVs) ■ Aged Care Workers and HIV & Ageing ■ An Overview of Hepatitis C: Clinical management in opiate pharmacotherapy settings ■ Antenatal Testing and Blood-Borne Viruses (BBVs) ■ Correctional Officers and Blood-Borne Viruses (BBVs) ■ Dental and Orofacial Health and Hepatitis C ■ Dentists and HIV ■ Emergency Services Providers and Blood-Borne Viruses ■ General Practitioners and Hepatitis C ■ General Practitioners and HIV ■ Hepatitis B and Primary Care Providers ■ Nurses and Hepatitis C ■ Pharmacy and Hepatitis C ■ Police and Blood-Borne Viruses ■
Factsheets Decision Making in Hepatitis B Decision Making in Hepatitis C ■ Decision Making in HIV ■ Hepatitis B Factsheet: for people newly diagnosed ■ Hepatitis C in Brief – patient factsheet ■ Hepatitis C Management and Treatment for Clients of Pharmacotherapy Services ■ HIV Patient Fact Sheet ■
ARV Blood-borne Virus Cirrhosis of the liver Combination therapy Triple therapy HBV HCV HIV Intersex Liver failure MSM Negative test result PEP Positive test result Prevalence Transgender Window period
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Monographs B Positive: all you wanted to know about hepatitis B – a guide for primary care ■ Co-infection: HIV & viral hepatitis – a guide for clinical management ■ Hepatitis C: clinical management in opiate pharmacotherapy settings ■ HIV and Viral Hepatitis C: policy, discrimination, legal and ethical issues ■ HIV Management in Australasia: a guide for clinical care ■ HIV, Viral Hepatitis and STIs: a guide for primary care ■
Distance-learning Kit ■ ■
Clinical Science of HIV Medicine CD C Me, Hear Me DVD
Manuals ■
Australasian Contact Tracing Manual Available in hardcopy and online at www.ashm.org.au/ctm
Antiretroviral medications A virus passed on through contact with blood and other body fluids Scarring of the liver More than one medication taken together (usually 2-3 drugs) Three different drugs taken together Hepatitis B virus - also used to name the illness hepatitis B Hepatitis C virus - also used to name the illness hepatitis C Human immunodeficiency virus People who have different internal genitalia than on the outside of the body, e.g. having ovaries but also having a penis Life threatening condition where the liver stops working properly Men who have sex with men The virus was not detected in the blood. This is a good result. Post-exposure prophylaxis = antiretroviral medication taken within 72 hours of an accidental HIV exposure to help prevent hepatitis B or HIV infection The virus was detected in the blood test. This is not a good result. The proportion of individuals in a population that have a particular condition People who feel they are a different gender inside to how they look on the outside e.g. having the feelings, emotions and behaviours of a boy but also having female genitalia The time between being infected with HIV and being able to reliably detect the virus in the blood
References 1 The Kirby Institute (2014). The University of New South Wales, Sydney, NSW, HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report. Accessed 17 Sept 2014 at: www.kirby.unsw.edu.au/surveillance/2014-annual-surveillance-report-hiv-viral-hepatitis-stis 2 HIV,Viral Hepatitis & STIs – a guide for primary care providers, ASHM 2014 3 2010 National HIV Testing Policy v1.1, Clinical indicator diseases for adult HIV infection; available at: http://www.testingportal.ashm.org.au/resources/HIV/Indicator_table_v1.1.pdf 4 World Health Organization accessed 18 September 2014 at: http://www.who.int/hiv/en/ 5 Mother-to-child transmission of HIV, WHO; http://www.who.int/hiv/topics/mtct/en/ accessed 24 October 2014 6 Antenatal testing and Blood-Borne Viruses (BBVs), ASHM 2012
Acknowledgements Reference Group: Diana Dib Barbar, Vic Jean Burke, NSW Yuan Cui, SA Linda Finucane, NSW Dzung Gibson, NSW Dejan Grahovac, NSW Jesus Kelly, QLD Elham Khalil, WA Ceyhan Kurt, Vic Antoinette Mascari, NSW Rumiko Mori-Kerr, QLD Belinda Roberts, NSW Chevoy Sweeney, NSW Anh Ta, QLD Adriana Weissen, NSW Organisations: May Hu, The Australian Institute of Interpreters and Translators (AUSIT) Mandy Azzi, The Northern Territory Aboriginal Interpreter Service (NT AIS) ASHM Staff: Karen Seager, Senior Project Officer, NPED Images: Page 4 reprinted with the kind permission of “Meeting the Challenge, Inc.”, Colarado Springs, Co
Online resources ASHM Directory of HIV, Viral Hepatitis and Sexual Health Services ■ Guide to Australian HIV Laws and Policies for Healthcare Professionals. Available online only at www.ashm.org.au/ HIVlegal ■ Testing Policy available online https://testingportal.ashm.org.au ■ Managing Aboriginal and Torres Strait Islander patients with hepatitis B and hepatitis C ■ Aboriginal and Torres Strait Islander Health Workers and Blood-borne Viruses e-learning modules ■ Contact Tracing e-learning modules ■ Introduction to Blood-Borne Viruses ■
Print more copies of this supplement from: www.ashm.org.au/publications
ASHM LMB 5057 Darlinghurst NSW 1300 Tel +61 2 8204 0700 Fax +61 2 9212 2382 Published January 2015 ABN: 48 264 545 457 © Copyright ASHM 2015 ISBN: 978-1-920773-36-6
For additional copies of this resource please contact: ASHM T +61 2 8204 0700 F +61 2 9212 2382 ASHM offers training in HIV, viral hepatitis and blood-borne viruses for general practitioners, nurses and allied health care workers around Australia. For further information on upcoming courses visit www.ashm.org.au/courses or contact the ASHM National Policy and Education Division on education@ashm.org.au or phone 02 8204 0720 FUNDED by:
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