Blood Borne Viruses
Blood borne virus (BBV) rates are higher in homeless populations than in the general population. This fact might be partly due to the fact that intravenous drug use and sex working are more common in this group (Raoult et al, 2001; Beech et al, 2002). BBV's are spread through blood to blood contact but also by infected bodily fluids (saliva, blood, semen), especially if they have come into contact with blood.
It is worth having at least a basic knowledge of the common BBV's because screening, treatment and even vaccination are possible. In this module we will focus on Hepatitis B, C and HIV.
Hepatitis B
It is thought 1 in 350 people are infected with Hepatitis B (Health Protection Agency, 2006). It is up to 100x more infectious than HIV and is spread via blood to blood contact. This might be from other bodily fluids that have come into contact with blood or by sharing needles or other drug paraphernalia. Most people who contract the illness clear the infection but around 5% of those infected will go on to develop chronic hepatitis B, where the virus remains in the body and can damage the liver slowly. Chronic hepatitis B may require lifelong monitoring and possibly treatment with antiviral medications. A small number of people with chronic hepatitis B may develop cirrhosis of the river or liver cancer.
Hepatitis B is an important condition because it is preventable with a vaccine. The vaccine is given in 3 doses (usually at 0,1 and 6 months but accelerated schedules are possible for those at higher risk). It is entirely possible to identify vulnerable populations an target vaccinations in primary care. It is recommended that the following groups are vaccinated (Department of Health, 2009):
It is estimated that 214,000 people in the UK have chronic hepatitis C but that many are unaware (Public Health England, 2014). Over 90% of new infections are among injecting drug users. Unlike hepatitis B where there is a 4 in 5 chance of clearing the virus, there is only a 1 in 4 chance of clearing hepatitis C.
Hepatitis C is an important virus to be aware of and screen for because there is a potential cure. Treatment can last 6-12 months and be difficult to endure but early recognition and referral to a liver specialist could have major benefits for groups at risk of infection.
HIV
Human Immunodeficiency Virus attacks the body's immune system (the CD4 helper white blood cells). Left untreated this can lead to an Acquired ImmunoDeficiency Syndrome (AIDS). Thankfully progression to AIDS is rare in the developed world as effective treatments exists to halt the progression of the virus (but not yet cure it). HIV testing in primary care is becoming more common and it is important to have a clear discussion about the test and obtain informed consent before carrying one out. Discussion points for such a conversation should include:
Actions to consider if the test is negative:
Is a repeat test needed?
Look at avoiding risk in future.
Actions to consider if the test is positive:
Identify and address concerns;
Meet again soon to discuss referral to other teams and possible treatments.
For more information and educational resources about these topics you might like to go to:
It is worth having at least a basic knowledge of the common BBV's because screening, treatment and even vaccination are possible. In this module we will focus on Hepatitis B, C and HIV.
Hepatitis B
It is thought 1 in 350 people are infected with Hepatitis B (Health Protection Agency, 2006). It is up to 100x more infectious than HIV and is spread via blood to blood contact. This might be from other bodily fluids that have come into contact with blood or by sharing needles or other drug paraphernalia. Most people who contract the illness clear the infection but around 5% of those infected will go on to develop chronic hepatitis B, where the virus remains in the body and can damage the liver slowly. Chronic hepatitis B may require lifelong monitoring and possibly treatment with antiviral medications. A small number of people with chronic hepatitis B may develop cirrhosis of the river or liver cancer.
Hepatitis B is an important condition because it is preventable with a vaccine. The vaccine is given in 3 doses (usually at 0,1 and 6 months but accelerated schedules are possible for those at higher risk). It is entirely possible to identify vulnerable populations an target vaccinations in primary care. It is recommended that the following groups are vaccinated (Department of Health, 2009):
- babies born to infected mothers
- close family and friends of infected people such as partners, children and other household members
- patients who receive regular blood transfusions or blood products, patients who have renal failure, and people who care for them
- people who have a chronic liver condition
- people travelling to countries with high to medium prevalence of hepatitis B
- injecting drug users (IDUs)
- sex workers, both male and female
- people who change their sexual partners frequently or men who have sex with men
- people whose type of work places them at risk, such as nurses, doctors, prison wardens, dentists, healthcare workers and laboratory staff
- people who live and work in accommodation for people with severe learning difficulties
- prisoners
- families adopting children from countries with high to medium prevalence of hepatitis
- people who are infected with a blood borne virus (BBV), or have another form of hepatitis, such as hepatitis A, C, D, E or HIV and are at risk of co-infection.
It is estimated that 214,000 people in the UK have chronic hepatitis C but that many are unaware (Public Health England, 2014). Over 90% of new infections are among injecting drug users. Unlike hepatitis B where there is a 4 in 5 chance of clearing the virus, there is only a 1 in 4 chance of clearing hepatitis C.
Hepatitis C is an important virus to be aware of and screen for because there is a potential cure. Treatment can last 6-12 months and be difficult to endure but early recognition and referral to a liver specialist could have major benefits for groups at risk of infection.
HIV
Human Immunodeficiency Virus attacks the body's immune system (the CD4 helper white blood cells). Left untreated this can lead to an Acquired ImmunoDeficiency Syndrome (AIDS). Thankfully progression to AIDS is rare in the developed world as effective treatments exists to halt the progression of the virus (but not yet cure it). HIV testing in primary care is becoming more common and it is important to have a clear discussion about the test and obtain informed consent before carrying one out. Discussion points for such a conversation should include:
- the benefits of having a test (might allay anxiety, motivate people to reduce risky behaviours, allow early intervention if positive)
- the drawbacks (might be positive, increased anxiety, insurance issues, false reassurance from a negative test)
- assessment of risk
- understanding the test (tests for an antibody to a virus and there is a 3-month window before a test will be positive, it is a test for HIV not AIDS
- how will the result be communicated (should be in person by the requesting doctor
- will there be a need for a repeat test (if negative)?
Actions to consider if the test is negative:
Is a repeat test needed?
Look at avoiding risk in future.
Actions to consider if the test is positive:
Identify and address concerns;
Meet again soon to discuss referral to other teams and possible treatments.
For more information and educational resources about these topics you might like to go to:
- The British Liver Trust - have very clear publications on individual liver conditions including the hepatitides
- NHS Choices website - an excellent landing page for all matters and links related to HIV
References
Beech BM, Myers L, Beech DJ. 2002 Hepatitis B and C infections among homeless adolescents. Family Community Health. Jul;25(2):28-36.
Department of Health. Immunisation against infectious disease ‘The Green book’. November 2009. Chapter 18 – Hepatitis B.
Health Protection Agency. Migrant Health; infectious disease in non-UK born populations in England, Wales and Northern Ireland. A base line report. 2006.
Pubic Health England. Hepatitis C in the UK: 2014 Report. 2014 - https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/337115/HCV_in_the_UK_2014_24_July.pdf
Raoult D, C Foucault, P Brouqui. Infections in the homeless. 2001 Lancet Infect Dis, 1 pp. 77–84.