Clinical Manifestation & Treatment

Clinical Manifestation

HIV and its “Natural History”

As HIV progresses toward worsening conditions, they go through stages sometimes referred to as the disease’s “natural history.” These deteriorating stages evolve as follows:

Viral transmission → primary HIV infection → seroconversion → asymptomatic HIV infection → symptomatic HIV infection → AIDS.

In countries that are more developed where people have access to HIV medications, the progression of HIV infection can be slowed dramatically. Other countries limited access and cannot afford these expensive medications. A lack of HIV education and prevention allows the awareness of their HIV infection to be delayed until very late.

The natural history breakdown of HIV is as follows:

Viral Transmission

The point of exposure—when a person comes into contact with an HIV-infected person, either through non-protected sexual activity, needle exchange or some other risky behavior as described earlier in the course—this initial period of infection is referred to as “Viral Transmission” and starts the process of the virus beginning to circulate through the bloodstream. A newly infected person may be infectious within five days and may not necessarily have any symptoms.

HIV infection is with a person for life, however, it can become greatly controlled and create less fatal results when a person is on a medical regimen of antiretroviral drugs. The sooner the disease can be diagnosed and the sooner the medications can be started, the better outcome for the HIV-infected person.

Primary HIV infection

This period of infection, known as the primary HIV infection, consists of those first few weeks when the viral load (the amount of virus in the bloodstream) is quite high. High viral loads mean the virus can more easily pass to others. The greatest problem concerning this period is the fact that many people at this time are unaware that infection as occurred and continue risky behaviors until they do become aware.

Initial HIV symptoms will normally include fever, swollen glands in the neck, armpits and/or groin area, rash, fatigue and a sore throat. This "seroconversion syndrome" or "seroconversion sickness” is sometimes mistaken as common ailments or flu as symptoms mimicked many other types of infections. Unless there is suspicion of HIV, an incorrect diagnosis could occur, as these initial symptoms tend to go away in a few days or short weeks. The individual, however, remains infectious to others.

The key factor for healthcare providers to determine the possibility of HIV is to know if the individual has been involved in “risky” behaviors, which put him/her at risk for HIV. Symptoms after having unprotected sex or sharing needles should warn or clue an individual to seek medical care. It is important to furnish the medical provider with reasons as to why they are concerned about HIV infection.

Since an HIV antibody test may not reflect a positive result shortly after a risky behavior—because antibodies aren’t in sufficient number as of yet to be detected via testing—an HIV RNA test may be ordered as these genetic type tests can test directly for the HIV virus and can confirm or rule out recent HIV infection.

According to recent guidelines from the Department of Health and Human Services (2014), it is recommended that persons at all stages of HIV take antiviral medications, even during primary infection.

Seroconversion

The period of time from the initial exposure to the point when enough antibodies can to be detected on an HIV test is called seroconversion. How long this period is for each individual is varied. Antibodies are usually detectable within the first nine days to six months of infection, depending on the HIV test used. From this point on, HIV antibodies will remain detectable for life.

Asymptomatic HIV

Asymptomatic HIV is a term used in HIV/AIDS to describe a person who has a positive reaction to one of the several tests for HIV antibodies, but does not display any clinical symptoms of the disease. During this period, many HIV infected people do not look or feel sick, though they are contagious. It’s common for a person with HIV infection to live ten years or longer without any outward physical signs of a progressive disease. Without treatment, progression leads to AIDS. An HIV test would be necessary in order to detect the infection, so if the person is not aware, they can affect others during this vast period.

Symptomatic HIV Infection

There are no symptoms specific only to HIV, but there are common symptoms to look for if HIV is suspected. The only way to know for sure is to be tested. If HIV is possible due to any risky type behavior in the past, a person should seek medical advice and request screening for HIV.

AIDS

AIDS is an advanced stage of HIV and sometimes referred to as Stage Three of HIV infection. This more progressed stage can only be diagnosed by a licensed healthcare provider. Based on the result of HIV-specific blood tests, and/or the person's physical condition, AIDS presents itself when other “opportunistic infections” (or cancers) start combining with the HIV infection. Once diagnosed with AIDS, even if a person feels better, they do not fall back in HIV classification, as they will always be considered to have AIDS.

As stated above, other conditions begin to exist in this stage, which are called AIDS-defining illnesses, such as Kaposi’s Sarcoma and PneumocySTIIs Carinii Pneumonia (see below under Stage 3 Indicators for more AIDS defining illnesses). These specific conditions, along with changes related to white blood cell counts, are linked to making the diagnosis of AIDS.

Although the appearance of an AIDS person may look quite healthy to a casual observer, they are very infectious and can pass the virus to others if they aren’t receiving appropriate treatment and using preventive measures. Eventually, those with AIDS have a reduced white blood cell count and health grows poorer. The amount of virus present in the blood becomes elevated (high viral load).

Cofactors

Certain cofactors (conditions) can change or speed up the course of AIDS. These cofactors or conditions that can increase the rate of progression to AIDS includes:

1. A person’s age
2. Certain genetic factors
3. Possibly drug use
4. Smoking
5. Nutrition
6. Co-infection with Hepatitis C
7. Co-infection with another sexually transmitted disease (STI)

Infection to Death

Untreated HIV infection gives a person an average of 10-12 years to live, starting from the time of viral transmission to death. Since the early days of the epidemics, significant changes in a person’s lifespan has been evidenced by the use of HIV medications and treatments. Regular checkups, daily medication, routine scheduled lab monitoring, and changes in lifestyle (e.g., exercise, adequate sleep, smoking cessation) can make HIV manageable as a chronic disease. By employing appropriate treatment regimens, using preventive measures, and changing lifestyles to more positive and healthy living habits, people with AIDS can live normal or near-normal lifespans.

Stage Three HIV: AIDS

As noted previously, AIDS is an advanced form of HIV and the infected person has reached a third stage of HIV where the immune system is severely compromised. This severity is measured by CD4 cell count and/or the person becomes ill with an opportunistic infection that complicates their condition further. Without treatment, the average year span for HIV to advance into AIDS is normally between 8 to 10 years after initial HIV infection. If a person is diagnosed with HIV early on, this advancement is delayed by many years.

According to the World Health Organization (WHO), between 2000 and 2015, AIDS-related deaths fell by 28% with some 7.8 million lives saved as a result of international efforts.

Washington State, with an estimated of over 6,700 HIV/AIDS related deaths from 1981-2014, 40% happened during the ages of 35-44. Between 2009 and 2013, 33% were considered late HIV diagnosis—described as a case that was diagnosed with AIDS within 12 months of HIV diagnosis. Having a late diagnosis indicates a probable lack of being routinely tested for HIV before diagnosis occurred. 

As the CD4+ cell count is representative of diagnosing AIDS, a child less than 1 year of age, the average CD4+ (T-cell) count is found to be less than 750. From the age of one to five, the count is less than 500. Six years through adult, the count drops below 200. (See chart in Section 1 for CD4+ counts related to all stages of HIV.)

Clinical Manifestations & Opportunistic Infections

The physical results of infections, which are a part of an AIDS-defining infection, is called a “clinical manifestation.” As an example, the opportunistic infection cytomegalovirus can cause the clinical manifestation of blindness in people with AIDS.

Because the immune system of an AIDS person is more deficient, this leaves the body more vulnerable to the wide varieties of bacteria, viruses, fungi and other pathogens common almost everywhere. As the body’s defense system against disease is greatly weakened, the AIDS person becomes susceptible to many added complications. Below is a list of conditions and opportunistic infections related to AIDS.

A person is diagnosed as having AIDS when there is a positive HIV test plus one or more of the following:

• Candidiasis, of esophagus,trachea, bronchi or lungs
• Cervical cancer,invasive
• Coccidioidomycosis,extrapulmonary
• Cryptococcosis,extrapulmonary
• Cryptosporidiosiswithdiarrheagreater than onemonth
• Cytomegalovirus of anyorgan other thanliver,spleen,or lymphnodes
• Herpessimplex with mucocutaneousulcer lastinglonger thanone monthor bronchitis,pneumonitis, esophagitis
• Histoplasmosis, extrapulmonary
• HIV-associateddementia: disablingcognitive and/or motordysfunctioninterfering with activities ofdailyliving
• HIV-associatedwasting:involuntaryweightloss>10%of baselinepluschronic diarrhea(2loosestools/dayfor 30days) or chronicweaknessand documented enigmaticfever 30days
• Kaposi'ssarcoma
• Lymphoma ofbrain
• Lymphoma,non-HodgkinsofB-cell or unknownimmunologic phenotype and histologyshowingsmall, noncleavedlymphomaor immunoblasticsarcoma
• Mycobacterium avium complexor M.kansasii, disseminated
• Tuberculosis
• Nocardiosis
• PneumocySTIscarinii pneumonia
• Pneumonia,recurrent-bacterial (2episodesin 12 months)
• Progressive multifocalleukoencephalopathy
• Salmonellasepticemia (non-typhoid),recurrent
• Strongyloidiasis, extraintestinal
• Toxoplasmosis ofinternal organs

HIV Infection in the Body

HIV infection was first defined by clinical symptoms found in men. As women began to indicate conditions like invasive cervical cancer, the CDC revised the classification system for HIV infection in 1993, expanding the definition for AIDS. Since then, scientists have reported further differences in the ways HIV affects men versus women and children.

How HIV Works in the Body

With new information being discovered each year, scientists are learning more everyday about how HIV affects the body and the body’s systems. Similar to a chain reaction, HIV’s gradual damage to the immune system begins to expand into a cumulative effect for a variety of other illnesses to join in, both common and unusual.

Painful or uncomfortable conditions caused by HIV infection include:

• confusion or dementia
• diarrhea
• fatigue
• fever
• nausea or vomiting
• painful joints, muscles, or nerve pain
• difficulty with breathing
• urinary or fecal incontinence
• vision or hearing loss
• thrush (yeast infections in the mouth)
• chronic pneumonias, sinusitis, or bronchitis
• loss of muscle tissue and body weight

Children & HIV

CDC has estimated that 4,998 children (all under the age of 13) who was ever diagnosed with AIDS have died since the beginning of the epidemic. Almost all of them (91%) got HIV through perinatal transmission—from mother to baby during the period immediately before and after birth. In Washington State, the cumulative HIV/AIDS deaths reported from 1981 through 2014 numbered at 15 cases for children under the age of 13.

Of the estimated 1,999 children living with perinatal HIV at the end of 2013 in the United States, 1,298 (65%) were black/African American, 312 (16%) were Hispanic/Latino and 212 (11%) were white. In 2014 alone, most (73%) of the estimated 174 children in the United States who were diagnosed with HIV received HIV through perinatal transmission. Most (88%) of the estimated 104 children in the United States diagnosed with AIDS in 2014 got HIV through perinatal transmission as well (CDC, March 2016).

Significant differences have been noted for children concerning HIV disease and its progression. There is much dissimilarity in the virus itself as well as in immunologic responses compared to adults. Developmental delays may be revealed for children who are not treated with drug therapy. Pneumocystis carinii pneumonia, failure to thrive, recurrent bacterial infections and other conditions related to HIV may also result. One problem among antiretroviral treatments for infants and young children is that they are not always available in pediatric formulations. Side effects pertaining to the therapy drugs also differ in children than they do in adults.

Due to predominant cases of HIV being transmitted via perinatal transmission, it is vital that women know their HIV status before or during pregnancy. Women can greatly reduce their chance of transferring infection to their unborn child by taking antiretroviral drugs.

Most HIV-infected children usually became very sick by the age of seven prior to the use of antiretroviral therapy. Scientists discovered in 1994 that a short course of antiretroviral treatment medication, if given to pregnant woman, could dramatically reduce the number and rate of children who became infected via perinatal transmission. It has been found that C-sections for delivery may be preferable in certain cases in order to reduce transmission. Prenatal screening and appropriate treatment during pregnancy have greatly declined the number of HIV cases in infants in recent years. Washington State requires their providers of prenatal care to offer HIV testing to their patients.

Now that HIV diagnosis is available early for newborns, antiretroviral therapy for infants is the standard of care and should be started as soon as the child is determined by testing to be HIV-infected. It is recommended currently to treat even uninfected children born to mothers who are HIV-positive for a period of six weeks to reduce the possibility of HIV transmission.

Youth & HIV

CDC reports that youths aged 13 to 24 accounted for 22% of all new HIV diagnoses in the United States in 2014 (more than 1 in 5). Eighty percent of HIV diagnoses among youth in 2014 were young gay and bisexual males. Especially affected were young black/African American and Hispanic/Latino gay and bisexual males. Concerning AIDS, an estimated 1,716 youth aged 13 to 24 were diagnosed with AIDS by the end of 2014. This represented 8% of the total AIDS diagnoses that year.

Youth are the least likely out of any age group to be linked to HIV care. Education and preventive tools can reduce their risk and provide them a means to make healthy choices and receive treatment and care when and if needed.

Prevention Challenges for Youths include:

1. Inadequate Sex Education – a significant decline in sex education has occurred over time across the country. The percentage of US schools required to teach students about HIV prevention has decreased from 64% in 2000 to 41% in 2014.
2. High Risks for other Sexually Transmitted Diseases – youths aged 20-24, especially of color, have some of the highest STD rates. This increases a person’s likelihood of getting or transmitting HIV.
3. Stigma behind the disease – youths tend to be uncomfortable discussing their status with others and therefore don’t always agree on measures to protect themselves and their partners. This poses obstacles to HIV testing and treatment.
4. Feelings of isolation – due to a lack of support and feeling isolated from the norm, gay and bisexual high school students may engage in risky sexual behaviors and substance abuse. Fears may include bullying and other forms of violence from others who might not accept them. This can lead to mental distress and risk behaviors that are associated with contracting HIV.

Women & HIV

In Washington State, women make up only 8% of those who died of HIV or AIDS between the years starting 1981 to 2014. Total deaths of adults and adolescent females in the United States in 2013 was reported at around 4,110. More than half of these HIV cases were Black/African American women (2,527); Whites (743); Hispanic/Latino (570); multiple races (239); American Indian/Alaskan Native, Asian, and Native Hawaiian and other Pacific Islanders being at the lower end of fatality.

It has been found that most new HIV diagnoses in women are attributed to heterosexual sex. The number of new HIV diagnoses among women has been declining. Between years 2005 to 2014, the number of women with new HIV diagnosis has dropped by 40%.

The fact that receptive sex partners (bottom) have a greater risk of acquiring HIV compared to the insertive partner (top) makes women at greater risks for transmission of any sexually transmitted disease, including HIV. With this, those women who are infected with HIV are at increased risk for a number of gynecological problems, including pelvic inflammatory disease, abscesses of the fallopian tubes and ovaries, and recurrent yeast infections.

Due to women having higher prevalence of infection with the human papilloma virus (HPV) and with HIV damaging the immune system, cervical dysplasia (abnormal cell growth) becomes more aggressive. This precancerous condition of the cervix caused by certain strains of HPV can lead to invasive cervical cancer—an AIDS-defining condition. Frequent screening for cervical cancer is necessary for women who live with HIV.

One concern involving women with HIV in the United States is that studies have shown that women tend to receive less health care services and HIV medications compared to men, therefore HIV may not be diagnosed until late, and then HIV becomes more difficult to control.

Medical Care Access

The importance of receiving a diagnosis of HIV early has been stressed throughout these sections. Seeking medical advice for HIV and AIDS is encouraged and can be obtained by someone who specializes in the treatment of HIV and other infectious diseases, or a non-specialist primary health care provider with experience in treating HIV.

In Washington State, people may get help with accessing an HIV healthcare provider through the assistance of medical case manager(s) in their community. Also available and helpful are community based AIDS service organizations. 

To obtain more information about medical case management programs and other services available in Washington, visit - http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/HIVAIDS/HIVCareClientServices/CaseManagement

Information about case management programs and HIV healthcare providers in your area may be found by contacting your local health department or health district.

New Drug Therapies: Impact on Progression

New HIV Drug Therapies

Medications to treat HIV were limited before 1996. New discoveries brought new medications and researchers found that by combining some of the medications with the newer ones (such as protease inhibitors or non-nucleoside reverse transcriptase inhibitors), the amount of HIV was being dramatically reduced in the bloodstream. It was found that two or three different medications would each target a different part of the virus and its replication. Newer antiviral medications and formulations today have been able to simplify the control of HIV infection. Highly effective, these drugs are easier to take and generally reveal less side effects.

The decline in deaths from AIDS in the United States is primarily been attributed to the use of these therapy drugs called "highly active antiretroviral therapy" (HAART). “ART” is a shorter name sometimes used to refer to these HIV medications.

HIV Drug Administration

Although HAART (highly active antiviral therapy) works well for many people, it is not a cure for HIV. It will keep the amount of virus in the body at a low level, however. The viral load will increase if the medication is discontinued. Some viral replication may occur while one is on the medication. 

The key to using HAART is starting it early and using it consistently while treatment. It can only improve health outcomes when taken as directed. Not only does it lower the amount of virus in the body, it lowers the chance for transmitting the infection to others. Medication must be taken daily as recommended, else the medication becomes ineffective and the person develops a resistance to the medication. When a person doesn’t adhere to the medical regimen, their immune symptom will continue its damage and HIV-related symptoms may reappear. Different medications will be needed to control their HIV infection. Any replacement therapy may be less effective and more difficult to follow than their original one.

If a person has persistent problems with drug adherence (not taking the drugs as advised), they run the risk of running out of effective combination drug therapy. As the HIV virus develops resistance to multiple medications, fewer medications are available to the person living with HIV.

These medications are not without side effects. Even when they are working effectively, side effects may be present. When a person does not take the HIV medications as prescribed, this may also create undesirable physical symptoms. Side effects vary among individuals. A health care provider should be able to provide more information about side effects. With advanced medications, side effects from HAART has become more manageable. Most people are able to tolerate these drugs well. The benefits of HAART far outweigh the side effects that may be associated with their use.

Treatment Costs

The expense for HIV medicines per month may cost a person about $1300 per month or more. There are resources and options available for those who need assistance financially. Private insurance programs and government programs offer HIV coverage for medical visits and antiviral medications. Deductibles and co-payments, however, make it more difficult for people with low incomes concerning medical costs.

For those who don’t have insurance, or in cases where the health insurance won’t cover the care needed, there are a number of programs available that can help. Medicaid or Medicare are two options. Another option is The Ryan White HIV/AIDS Program, which provides HIV-related services like medical care and medications in the United States. This program is especially helpful to those who do not have enough health care coverage or financial resources to pay for care. A social worker or case manager should be able to help in determining if a person is eligible for these other options and can assist in applying for these programs.

To find more information about programs that can assist with the costs involved in HIV care, visit -http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/HIVAIDS/HIVCareClientServices

Other ways of finding help and resources for HIV is to contact a medical case manager and/or community-based organization that is dedicated to the fight against HIV. Those who live in other countries may have very limited access to HIV therapies due to the expense and lack of healthcare facilities in their area. There are international programs working to improve this situation, and the United States is a leading contributor to these programs.

Alternative Therapies

Other natural "alternative" therapies are being used by some people living with HIV. These are sometimes called complementary therapies that people use along with therapies from their medical provider. Such alternative means may include the use of vitamins, herbs, naturopathic remedies, massage, acupuncture, yoga and relaxation techniques, and other similar therapies. Many people report positive results from using complementary therapies. However, not enough research has been done to tell if these treatments really help people with HIV.

Some people with HIV will take herbal medicines to help them deal with side effects from anti-HIV medicines or with symptoms from the illness. These “herbal” substances come from plants, and they work like standard medicine. Some are taken from all parts of a plant, including the roots, leaves, berries, and flowers. As many of these remedies haven’t been studied scientifically, they could produce adverse effects when used with HIV medications that are not yet known.

It’s always a good idea for a person who is taking alternative therapies to tell their medical provider. The importance of this is due to possible drug reactions or other harmful side effects from combining "natural" medicine and antiretroviral medications. St. John’s Wort, for example, is a widely available herbal remedy that is sometimes taken to overcome depression, yet it has known adverse interactions with some HIV medications.

Caution should be taken with any oral intake that includes over the counter medications, prescription medications, and street drugs. Any drugs or herbal remedies being used with HIV medications should always be relayed to the health care provider.

Vaccine Availability

At this time, there is no vaccine available for HIV. The best way to avoid HIV infection is prevention. Early diagnosis and early treatment is effective not only by prolonging the life of someone living with HIV, but it helps in preventing transmission and the spread of HIV to others.

Case Management

Case managers are always available to help those seeking assistance with HIV. They will connect a person with the appropriate medical care facility, health insurance provider, and/or community support service.

Washington State has several assistant programs to help HIV and AIDS people with prescriptions and medical assistance. For case management in your community, contact your local health department or district. You can also contact the Washington State Department of Health Client Services toll-free at 1-877-376-9316.

More information about case management services can be found on their webpage at http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/HIVAIDS/HIVCareClientServices/CaseManagement

Tuberculosis, Hepatitis B, Hepatitis C, and Other Sexually Transmitted Diseases

HIV has a strong link with tuberculosis (TB), sexually transmitted diseases (STI), Hepatitis B (HBV), and Hepatitis C (HCV). This interrelationship involves numerous studies that have indicated an increased risk of both acquiring and transmitting HIV, beyond just risky behavioral patterns and lifestyles that attract and link these diseases. Any two of these diseases make a deadly combination and are far more destructive together than either of these diseases alone. In the following pages, you’ll learn more about this interconnection among these diseases and the reason why HIV often ends in death.

Tuberculosis (TB)

HIV and TB has such a close connection that it has often been described as a co-epidemic. According to the World Health Organization (WHO), tuberculosis is a leading killer of HIV-positive people and in 2015, 35% of HIV deaths were due to TB. Approximately 80 new cases of tuberculosis are diagnosed among Washington State residents each year.

In developing countries, many people infected with HIV contract TB as the first sign of AIDS. In Africa, TB is the leading cause of illness and death among people living with HIV. In some settings, TB kills up to half of all AIDS patients.

In the past 15 years, the number of new TB cases has more than doubled in countries where the number of HIV infections is also high. At least one-third of the HIV-positive people worldwide are also infected with TB and are at an increased risk of developing TB disease (the active and contagious form of TB).

Tuberculosis is a bacterial infection caused by mycobacterium tuberculosis. It is usually transmitted via airborne droplets when a person with active infection sneezes or coughs and someone susceptible breathes in the infected germ settling in the air. The disease is most common in people with immune deficiencies.

TB bacteria can live anywhere in the body, but the greatest threat to public health involves infectious pulmonary or laryngeal TB.

Cause & Epidemiology of TB

About one third of the world’s population (around 2 billion people) may be infected with TB. There are about 9 million active cases of TB each year. More people are dying of TB now than ever before, however TB can be successfully treated even if someone is HIV-positive.

The infection, when latent, is asymptomatic and not infectious. This can last for a lifetime. It does, however, remain alive in the body and can become active later. This latency is what makes TB so hard to control, as the bacteria can hide out for extended periods and later break loose in new environments.

How TB got started and where it originated is uncertain. Some theories relate that it began in Africa. What we do know for certain is that the organism causing tuberculosis—mycobacterium tuberculosis existed over 15,000 years ago (and probably much longer) as it has been found in relics from ancient Egypt, India, and China. Archeologists have detected spinal tuberculosis, known as Pott’s disease, among Egyptian mummies.

Active TB is diagnosed when there are positive test results in sputum or other bodily fluids. Confirmation of diagnosis is the identifiable presence of the tuberculosis bacterium in culture. Drug sensitivity testing of the bacteria should follow.

Transmission & Progression

Secretions from an infected person with pulmonary TB is dispersed in the air when the infected person sneezes, coughs, speaks, or sings. It may then enter another person’s lungs simply by that person inhaling residual droplets left in the air. After breathing in the bacteria, it may take several weeks for the bacteria to multiply in the body and develop some pneumonia-like symptoms.

Distributed through the bloodstream and the lymph system, the TB bacteria normally takes up residence in the lungs, though it can also affect other parts of the body, such as the brain, the kidneys, or the spine. This process called primary infection may resolve by itself. This is referred to as "delayed-type hypersensitivity." TB is measured with the tuberculin skin test and incubation for this primary infection usually lasts two to 10 weeks.

Ninety percent of people can develop latent TB and never experience subsequent disease. They will have a positive tuberculin skin test, but people with latent TB infection have no clinical, radiographic (x-ray), or laboratory evidence of TB and cannot transmit it to others.

The other ten percent of infected individuals will undergo “reactivation” at some time in their life and develop active TB. About five percent of newly infected persons will be active within the first two years after primary infection. Another five percent will present active TB at some later point in life.

You cannot get TB from clothes, drinking glass, eating utensils, from a handshake, toilet, or other surfaces.

Symptoms of Tuberculosis

When tuberculosis is active—meaning TB germs are multiplying in your body—and it has settled in your lungs, symptoms may develop two to three months after infection or years later. For those with weak or damaged immune systems (such as HIV/AIDS), symptoms of active TB may develop about 6-8 weeks after first breathing in some bacteria. The TB bacteria can multiply further and spread to other parts of the lung and body areas such as the kidneys, brain, stomach, bones/joints, heart, and spine.

Tuberculin skin testing (also called Mantoux test) can show whether a person has been in contact with TB germs at some point in life. It cannot, however, prove a person has a current active infection. Other tests should follow to confirm a diagnosis, such as a chest X-ray and phlegm (sputum) test. A blood test called the interferon gamma test can be helpful if there were unclear results from a tuberculin skin test.

The tuberculin skin test is made from part of the TB bacterium and injected just under the skin. The injection site is examined a few days later. An initial exposure to conversion of the tuberculin skin test is normally 4 to 12 weeks. During this period, the person may show no symptoms. The progression to active disease usually occurs within the first couple of years after infection, or much earlier for those whose immune system is compromised.

Without treatment of TB, symptoms usually get worse. Symptoms that settle in other parts of the body will reveal differently, depending on where the bacteria is.

Re-activated TB is more likely to occur in those with a weakened immune system. This would reflect any of the following:

• The elderly or frail
• A malnourished person
• A person with diabetes
• Someone taking steroids or immunosuppressant medication
• A person whose kidneys are failing
• Alcohol addiction and Drug abuse
• Someone who has AIDS

TB can be treated by medication. Taking the medication as directed is vital and must be finished to be effective. It can take from six months to a year to kill TB germs.

Unfortunately, there are behavioral barriers to TB management that include poor client adherence to the medication and a lack of public awareness. For the developing world, other factors play to increase the risk for contracting and spreading TB, which include:

• Poverty & poor housing or homelessness
• Lack of good nutrition
• Poor general health
• Insufficient healthcare
• AIDS
• Aging/elderly population
• Immigration or travel from areas where TB is common

Anyone managing TB disease should have adequate training in screening, diagnosis, treatment, counseling, and contact tracing for TB through continuing education programs and expert consultation. Promoting the importance for appropriate medication intake is essential. A person’s cultural and ethnic perceptions of his/her health condition should be considered. Strategies and services need to be implemented that address the multiple health problems associated with TB risks (as listed above).

Daily TB preventive therapy lasts for 12 months. This has been proven to reduce the risk for TB disease by more than 90% in persons with latent TB infection, but only for those who complete a full course of therapy. There is also evidence that the administration of Isoniazid can be an effective preventive therapy for two-thirds of persons who complete the regimen. Six months of therapy is crucial and every effort by a medical provider should be made to ensure their patients adhere to this therapy. For children, effective preventive therapy is needed for at least nine months.

Multidrug Resistant-TB

A multidrug regimen that lasts 6 to 12 months is recommended by the CDC. For more information concerning current recommendations, see the Washington State Department of Health's TB Services Manual. It can be downloaded here: http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/Tuberculosis/ProviderMaterials/TBServicesManual

A copy may also be obtained by calling the Washington State Department of Health TB Program at (360) 236-3443.

Tuberculosis & HIV Co-Infection

HIV/TB co-infected persons are at considerably greater risk of developing TB disease than those who only have TB. Studies suggest that the risk of developing TB disease is 7% to 10% each year for persons who are infected with both M. tuberculosis and HIV, whereas it is 10% over a lifetime for a person infected only with M. tuberculosis.

Two ways that an HIV-infected person can develop TB disease:

1. The person as latent TB, contracts HIV, and then TB activates due to a weakened immune system.
2. The person has HIV infection, and due to malfunctioning of the immune system, is then able to develop TB rapidly.

If a person has TB disease as well as HIV infection, this should be reported as The Centers for Disease Control and Prevention (CDC) includes pulmonary TB and extrapulmonary TB (TB occurring outside of the lungs) when collecting and analyzing their surveillance data on HIV infection and AIDS.

Other STI’S and HIV

Sexually Transmitted Infectious Disease (STI)

The World Health Organization (WHO) reports that there are more than 30 different bacteria, viruses and parasites known that has the ability to be transmitted through sexual contact. Linked to the greatest incidences of these sexually transmitted infectious diseases (STIs) are eight pathogens, four of which are currently curable: syphilis, gonorrhea, chlamydia and trichomoniasis. The other four are viral infections and are incurable: hepatitis B, herpes simplex virus (HSV or herpes), human papillomavirus (HPV), and lastly, the topic of this curriculum, HIV.

All result in dozens of clinical syndromes. These various symptoms that manifest can be reduced or modified through medication. STIs affect both men and women. Many STIs can be transferred from mother to baby during pregnancy and childbirth, such as chlamydia, gonorrhea, hepatitis B, HIV, and syphilis.

The majority of STIs are spread by sexual contact, including vaginal, anal and oral sex, though some STIs can be spread through non-sexual means such as through blood or blood products.

Bacterial, Viral, and Other Causes of STI

The variety of organisms involved in causing STIs include bacteria, viruses, mites, protozoa and fungi. Bacterial causes of STI would include chlamydia, gonorrhea and syphilis. Different viruses cause herpes, genital warts, hepatitis B and HIV. Mites are responsible for scabies. Public lice are known as “crabs.” Tiny organisms called protozoa can result in trichomoniasis. Fungi causes yeast infections.

When sexually transmitted diseases go untreated, they can cause other diseases. In women, pelvic inflammatory disease (PID) can develop as the result of STIs like gonorrhea and chlamydia. Epididymitis, a condition in men, is usually caused by gonorrhea and/or chlamydia. Gonococcal urethritis is caused by gonorrhea.

National STIs

There are more than one million sexually transmitted infections (STIs) acquired every day worldwide (WHO). In the United States, STIs have become a significant health challenge. CDC estimates that nearly 20 million new sexually transmitted infections occur every year in this country alone. More than half of these are young people ages 15–24. This poses a potential threat to an individual’s immediate and long-term health and well-being.

STIs can lead to severe reproductive health complications, such as infertility and ectopic pregnancy. As they also raise one’s risk for HIV as well, STDs have had a serious drain on the U.S. health care system, costing the nation almost $16 billion in health care costs every year.

The CDC 2015 STD Surveillance Report indicates that combined cases of chlamydia, gonorrhea, and syphilis are now at a record high. People at greatest risk for sexually transmitted disease (STD) are young people and gay/bisexual men. Men who have sex with men have the highest rates of STDs, with those 15-24 years of age accounting for the greater part of new STD infections.

Gonorrhea and chlamydia have primarily affected young people. Syphilis is the highest and rising STD in gay and bisexual men, this number rising 19% in 2015.

HIV and STI Combined

When a combination of STIs are present together, this increases the risk for HIV transmission for the following reasons:

• Syphilis and symptomatic herpes can cause breaks in the skin providing direct entry for HIV.
• Inflammation from STIs, such as chlamydia, makes it easier for HIV to enter and infect the body.
• Sores can bleed easily and come into contact with vaginal, cervical, oral, urethral and rectal tissues during sex.
• Inflammation has shown to increase HIV viral shedding and the viral load in genital secretions.
• Pus or other discharge from genital ulcers are body fluids where HIV infection have resided.

STI Symptoms & Prevention

An STI-infected person can be without obvious symptoms of disease. Though emphasis was placed on symptoms in the past, research has shown that 80% of chlamydia cases, 70% of herpes, and a great percentage of people with other STIs have no symptoms, but can still spread the infections.

Common symptoms of STIs include vaginal discharge, urethral discharge or burning in men, genital ulcers, and abdominal pain.

Testing early and receiving treatment early is important. Screening for STI infection needs to be based on behavioral risks. Health care providers are not performing routine STI testing unless inquired to do so. For women who are getting a pap test or yearly exam, this doesn’t mean they are also being tested for chlamydia or any other STI. Knowing the risk factors for STIs should prompt a person to discuss with their health care provider their potential risk for a sexually transmitted disease so that STI screening can be done, and treatment started if indicated.

Ways to prevent sexually transmitted disease:

1. Abstain from sex or be in a mutually monogamous relationship with an uninfected partner.
2. Discuss risk factors with your partners, since many STIs have no symptoms.
3. Know that birth control pills and shots do not prevent infections –condoms along with other birth control methods should be used.
4. Go with your sex partner(s) for tests if either of you have risk factors or observe any symptoms.
5. Avoid douching.
6. Learn how to use condoms correctly and do so. Talk about it with your partners and use them consistently each time you engage in sex.
7. Be sure that all sex partners are examined and treated if an STI occurs.
8. Notify your sex partners if you are diagnosed with an STI. Seek help if needed from your local public health department.

Testing for Sexually Transmitted Disease

There is no single test for every sexually transmitted disease (STD) as tests are specific to each infection. Some infections can be found using different kinds of tests. Testing normally involves a physical examination (a pelvic exam for women), a blood test, urine sample, and/or discharge, tissue, cell, or saliva sample. Urine tests for sexually transmitted infections (STIs) are widely available in medical settings. Blood tests are ordered for herpes and hybrid capture tests for genital warts may also be available. For syphilis, cultures, wet preps and blood draws are the standard testing method. Disclosing any history of STI to the medical provider should be done by both men and women.

Treating STIs

STIs (excluding viral ones like HIV and Hepatitis) are curable with the correct treatment. Based on lab work and clinical diagnosis, treatments will vary with each disease or syndrome. For help or the latest CDC treatment guidelines, visit: http://www.cdc.gov/std/treatment/2010/default.htm

Hepatitis B and HIV

Hepatitis

Hepatitis is an inflammation of the liver caused by many things, but viruses are the most common cause of hepatitis in the world. Other infections and toxic substances like alcohol and certain drugs, and autoimmune diseases can also cause hepatitis. The condition can be self-limiting or progress into the scarring of tissue (fibrosis), cirrhosis or liver cancer.

There are five main types of hepatitis—A, B, C, D, and E. Hepatitis A and E are typically the result of ingestion of contaminated food or water. Hepatitis B, C and D usually occur after parenteral contact with infected body fluids. These viruses can transmit via contaminated blood or blood products or by invasive medical procedures using contaminated equipment. Also, like HIV and STIs, transmission can occur via sexual activity. For hepatitis B, transmission can also occur from mother to baby at birth and from family member to child.

Hepatitis B

Hepatitis B (HBV) is transmitted in the same way that HIV can be transmitted—through blood and body fluids of an infected person. But unlike HIV, HBV has a vaccine that can prevent the virus. Liver effects from HBV vary and can range from mild to severe and fatal.

HBV Prevention

HBV is preventable with a vaccine that has been effective against Hepatitis B since 1981. To eliminate HBV transmission in the United States, a comprehensive strategy was recommended that incorporated four components:

1. Universal vaccination of infants beginning at birth
2. Routine HBV screening of all pregnant women and the provision of immunoprophylaxis to infants born either to infected women or to women of unknown infection status.
3. Routine vaccination of previously unvaccinated children and adolescents
4. Vaccination of adults at increased risk for infection (including health-care workers, dialysis patients, household contacts and sex partners of persons with chronic HBV infection, recipients of certain blood products, persons with a recent history of having multiple sex partners concurrently, those infected with a sexually transmitted disease, men who have sex with men [MSM], and injection drug users).

• Adult doses of the HBV vaccine is more expensive than for infants and children—about $150 per person—which may account for why more adults are not vaccinated against HBV.

Epidemiology of HBV

Due to the national strategy to eliminate HBV infection, the rate of new HBV infections in the United States has declined by approximately 82% since 1991. The decline has been greatest among children born since 1991, when routine vaccination of children was first recommended.

In 2014, a total of 2,953 cases of acute hepatitis B were reported from 48 states to the CDC. The overall incidence rate for that year was 0.9 cases per 100,000 population. After adjusting for under-ascertainment and under-reporting, an estimated 19,200 acute hepatitis B cases is said to have occurred in 2014. Concerning new HBV infections in the United States, 20% of the cases were among gay and bisexual men.

Risk Factors of HBV

Hepatitis B is an acute or short-term illness for some people, but for others it can become a long-term, chronic infection. Risk of HBV for chronic infection is related to age at infection and is greatest among young children. CDC reports that approximately 90% of infected infants become chronically infected. This is compared with 2%–6% of adults.

The best way to prevent HBV infection is to be vaccinated. CDC recommends hepatitis B vaccination for people who have or are at risk for HIV infection and who have never been infected with HBV.

HBV Vaccine is highly recommended for:

1. gay and bisexual men
2. people who inject drugs
3. sex partners of people with HBV infection;
4. people with multiple sex partners
5. people with a sexually transmitted infection
6. health care and public safety workers exposed to blood on the job

Unvaccinated people are at higher risk for getting HBV if they:

• share injection needles/syringes and equipment
• have sexual intercourse with an infected person or with more than one partner
• are a man and have sex with a man
• work where they come in contact with blood or body fluids, such as in a health care setting, prison, or home for the developmentally disabled
• use the personal care items (razors, toothbrushes) of an infected person
• are on kidney dialysis
• were born in a part of the world with a high rate of Hepatitis B (China, Southeast Asia, Africa, the Pacific Islands, the Middle East, South America and Alaska)
• receive a tattoo or body piercing with improperly sanitized equipment

How HBV is NOT Transmitted

HBV is not transmitted by breastfeeding, sneezing, hugging, coughing, sharing of eating utensils or drinking glasses, through food or water, or any kind of casual contact.

HBV Progression

As HBV causes damage to the liver and other body systems, symptoms can range in severity from asymptomatic, to mild, severe, and fatal. Acute Hepatitis B infection is a serious medical issue and can be life threatening. Disease is more severe among adults aged >60 years. The fatality rate among acute cases reported to CDC is 0.5%–1%.

Symptoms normally begin around 90 days, but may range from 60–150 days after exposure to HBV. When testing shows up as "Hepatitis B surface antigen positive"(HbsAg), the person is either newly infected or they are a chronic carrier.

The majority of HBV-infected people recover from the initial infection and do not become carriers. Carriers (about 2-6% of adults who become infected) have the virus in their body for months, years, or they can have it for life. Transmission can occur through their blood or contact with other body fluids.

HBV Symptoms

As some HBV-infected people go along with no symptoms, feel fine and look healthy, those who do experience symptoms are likely to display several or all of the following:

1. loss of appetite
2. fatigue
3. abdominal pain
4. jaundice (yellowing of the eyes and skin)
5. joint pain
6. malaise
7. dark urine
8. nausea or vomiting
9. skin rashes

More severe and long-term complications of HBV, which may incapacitate an infected person for weeks or months may include:

• Chronic Hepatitis
• Recurring Liver Disease
• Liver Failure
• Cirrhosis (chronic liver)
• Liver Cancer

Prevention of HBV

The hepatitis B virus was discovered in 1965 by Dr. Baruch Blumberg and four years later, with his help, the first hepatitis B vaccine was developed—initially a heat-treated form of the virus. It wasn’t until 1981, however, when we had an FDA approved commercial Hepatitis B Vaccine that was a more sophisticated plasma-derived hepatitis B vaccine for human use.

In 1986, a new approved vaccine was synthetically prepared and did not contain blood products, as did the other vaccine. It is impossible to get hepatitis B from the new recombinant vaccines that are currently approved in the United States.

The HBV vaccine is suitable for all ages, and those who have risk for infection should be vaccinated.

To lower the risk or to prevent HBV infection, a person can:

• abstain from sexual intercourse and/or injected drug use
• maintain a monogamous relationship with a partner who is uninfected or vaccinated against HBV
• use safer sex practices (as previously discussed in Section 2)
• never share needles/syringes or other injection equipment
• never share toothbrushes, razors, nose clippers or other personal care items that may come in contact with blood
• use Universal or Standard Precautions with all blood and body fluids

Concerning mothers and their infants, it is essential for a woman to tell their medical provider if they know they are an HBV carrier. Infants who receive an injection of hepatitis B immune globulin and hepatitis B vaccine shortly after birth (within 12 hours), their chance of becoming infected is greatly reduced, more than 90%. Two more vaccine doses should be given by age six months.

Anyone infected with HBV cannot donate blood, semen or body organs.

Treatment of HBV

Treatment for recently acquired (acute) HBV infection is supportive only. There are no medications available for new infections, though antiviral drugs may be taken for treatment of chronic HBV infection. Success of these type drugs is varied among individuals. The vaccine cannot be used to treat HBV infection once a person is infected.

Hepatitis C and HIV

Hepatitis C

2014 marked the 25th anniversary of the discovery of the Hepatitis C virus, and since the virus’ discovery in 1989, advances in research and public health have led to great progress in creating life-saving treatments. Millions of Americans, however, continue to live with this disease and a lot of them don’t know they are infected.

As stated before, the organ most affected by any form of hepatitis is the liver. Among all the types, HCV is the leading cause of chronic liver disease in the United States. It is estimated by the World Health Organization (WHO) that globally there are between 130–150 million people living with chronic hepatitis C infection. A significant number of these with chronic HCV will develop liver cirrhosis or liver cancer.

Approximately 700,000 people die each year from hepatitis C-related liver diseases (WHO). Studies have shown that antiviral medicines can cure approximately 90% of HCV infected people, which in turn reduces the risk of death from liver cancer and cirrhosis. The problem lies in the access to the diagnosis and the ability to receive treatment (which is low).

Currently, there is no vaccine for hepatitis C. Research is ongoing though.

Epidemiology of HCV

In 2014, an estimated 30,500 cases of acute hepatitis C virus infections were reported in the United States. It is calculated that 2.7-3.9 million people are living with chronic hepatitis C in the United States. Approximately 75%–85% of HCV infected people develop chronic infection, and approximately 3.75 million Americans do not know they are HCV-positive.

With about 4.1 million Americans having been infected by hepatitis C, this means that they have a current infection or a previous infection with the virus. Of the estimated 3.2 million people chronically infected with hepatitis C in the U.S., approximately 75% were born during 1945-1965 or are baby boomers. This makes them five times more likely than other adults to be infected, according to national data. It is recommended by the CDC that all persons in this age group be screened for HCV.

According recent surveillance data by the Centers for Disease Control and Prevention (CDC), deaths associated with hepatitis C reached an all-time high of 19,659 in 2014. Data shows that acute cases of hepatitis C infection have more than doubled since 2010, increasing to 2,194 reported cases in 2014. The majority of new cases were young, white individuals with a history of injection drug use living in rural and suburban areas of the Midwest and Eastern United States.

In Washington State, approximately 110,000 people are infected with HCV. In the Washington 2015 State Profile, it is recorded that between 2009 and 2013, reported rates of acute hepatitis C had increased by 200%.

HCV Transmission

Hepatitis C is a blood-borne pathogen virus, thus transmission occurs when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected. Sharing of needles or other equipment to inject drugs has shown to be the greatest risk. Although it is uncommon, Hepatitis C has occurred from blood contamination in medical settings.

A person infected with HCV will activate an immune response to the virus, but replication of the virus during infection can result in changes that dodge the immune response. This may explain how the virus establishes and maintains chronic infection.

HCV is most commonly transmitted through the injection of drug use through the sharing of injection equipment. Less common is through the reuse or inadequate sterilization of medical equipment, especially syringes and needles in healthcare settings.

Although HCV can also be transmitted sexually and can be passed from an infected mother to her baby, these modes of transmission are much less common. Having an STI or HIV, having sex with multiple partners, or having rough sex appears to increase a person’s risk for Hepatitis C.

Whenever tattoos or body piercings are given in informal settings or with non-sterile instruments, transmission of Hepatitis C and other infectious diseases is possible. Otherwise, little evidence supports that Hepatitis C is spread by getting tattoos in licensed, commercial facilities.

HCV Progression

About 20% of people are able to clear or get rid of the virus without treatment in the first 6 months, though the reasons for this is unclear. Unfortunately, a large majority of the people who are infected with the Hepatitis C virus will develop symptoms that end up turning into a chronic or lifelong struggle.

According to the Centers for Disease Control & Prevention (CDC), statistics reveal that for every 100 people who are infected with HCV:

• 15-25% will fully recover and have no liver damage
• 75-85% will develop long-term chronic infection
• 60-70% will develop chronic liver disease
• 5-20% will develop cirrhosis over a period of 20-30 years
• 1-5% will die from chronic liver disease

HCV Symptoms

There is an incubation period of two weeks to six months for acute hepatitis C. People infected with HCV may not present with any symptoms initially and can be asymptomatic for decades. This accounts for about 80% of HCV-infected persons. Many people do not realize they are infected. The HCV virus of a person who is asymptomatic can still be detected in the blood.

When someone is acutely symptomatic, they may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal discomfort, dark-colored urine, grey-colored feces, joint pain and muscle pain, and jaundice (yellowing of skin and the whites of the eyes).

When symptoms appear with chronic Hepatitis C, this is often a sign of advanced liver disease and may develop liver failure and even liver cancer.

Prevention of HCV

As no vaccine exists at this time to prevent HCV infection, prevention is the best way to protect against HCV infection.

Steps in preventing HCV:

1. Avoid contact with blood or accidental needle sticks by following standard and universal precautions.
2. When acquiring tattoos or skin piercings, be sure the business is legitimate and practices universal precautions.
3. If using non-prescription drug via injection use, do not share syringes or any drug equipment.
4. Do not share toothbrushes, razors, nail clippers or other personal care items.
5. Always cover skin cuts and sores.
6. Use latex condoms and practice safer sex.
7. For any child planning, discuss choices beforehand with a medical specialist if HCV infection is present or there is risk for infection.
8. If HCV infected, know that you cannot donate blood, semen or body organs.

Testing & Treating HCV

In order for a person to know they have Hepatitis C, they must get tested. Testing involves a blood test called a Hepatitis C Antibody Test, which looks for antibodies against the Hepatitis C virus. Antibodies remain in the bloodstream even if the person clears the virus. When a positive or reactive Hepatitis C Antibody Test results, this means that a person has been infected with the Hepatitis C virus at some point in their life. A positive antibody test does not necessarily mean a person still has Hepatitis C. An RNA test may be needed to determine if a person is currently infected with Hepatitis C.

Since many people infected with HCV are unaware they have the infection, they should consider testing.

Risk factors that indicate a need for HCV testing:

• A person who has certain medical conditions, such as HIV or AIDS
• People born between 1945 and 1965
• A current or former injection drug user, even if it was just once or many years ago
• A person who has abnormal liver tests or liver disease
• A person who received blood transfusions or an organ transplant prior to 1992
• A hemophiliac who received clotting factor concentrates produced before 1987
• A person who has received chronic hemodialysis
• A child/person born to a mother with Hepatitis C (HCV)
• Healthcare workers who have been occupationally exposed to blood or who have had accidental needle sticks
• Persons who are sex partners of people with HCV
• A person who has been exposed to blood from a person who has Hepatitis C

Treatment for HCV

Treatment depends on many different factors and requires a medical doctor or provider to evaluate what treatment is best for the Hepatitis issue at hand. New and improved treatments have become available that can cure Hepatitis C for many people.

The treatment for acute hepatitis C is similar to treatment for chronic hepatitis C. The difference lies in the response rate to treatment, which is much higher among persons with acute HCV than with chronic HCV infection. An optimal treatment regimen, and when it should be initiated, remains uncertain.

HCV-positive persons should be evaluated by referral or consultation, if appropriate, for the presence of chronic liver disease. An assessment of liver function tests, evaluation for severity of liver disease and possible treatment, and determination of the need for Hepatitis A and Hepatitis B vaccination needs to be considered.

New approved treatments for Hepatitis C have emerged in recent years and with positive results. Research is ongoing.

HIV & HCV Coinfection

HIV coinfection more than triples the risk for liver disease, liver failure, and liver-related death from HCV. About one quarter of HIV-infected persons in the United States are also infected with Hepatitis C virus (HCV). About 80% of people with HIV who inject drugs also have hepatitis C virus (HCV). Most new HCV infections in the U.S. are among injecting drug users. The majority of hemophiliacs who received blood products contaminated with HIV also are infected with HCV.

A person infected with both viruses (with an impaired immune system) can speed up the disease process much faster and lead to serious, chronic or fatal liver damage.

Treatment can be complicated when dealing with both HIV and HCV as many medicines that are used to treat HIV may damage the liver. Treatment, however, is possible for some cases of coinfection with close physician supervision.

Comparison Chart of HIV, HBV, and HCV

Transmission By…	HIV	HBV	HCV
Blood	Yes	Yes	Yes
Semen	Yes	Yes	Rarely, More likely if blood present
Vaginal Fluid	Yes	Yes	Rarely, More likely if blood present
Breast Milk	Yes	No, unless blood is present	No, unless blood is present
Saliva	No	No	No
Target in the body	Immune System	Liver	Liver
Risk of Infection After Needle Stick exposure to blood	0.5%	1-31%	2-3%
Vaccine Availability	No	Yes	No
Curable?	No	Yes	Yes