Chronic illness and co-morbidities for African Australians living with HIV

HIV Australia | Vol. 11 No. 2 | July 2013

Chris Lemoh looks at health challenges experienced by African Australians

HIV is now a chronic illness, rather than a death sentence. The long-term complications of HIV infection, like those of diabetes mellitus, are preventable with constant monitoring, adherence to treatment management of co-existing health conditions and attention to general health.

People diagnosed with HIV may now look forward to many years of good health and a life expectancy comparable to that of people without HIV, although the benefits of combination antiretroviral therapy are diminished by late diagnosis, older age at diagnosis and imperfect adherence to treatment.

For members of Australia’s African communities, viewing HIV as a manageable chronic illness with a good long-term prognosis represents a major shift away from previous conceptions of HIV as equivalent to AIDS: a deadly, untreatable illness that has devastated many communities in their countries of origin.

The relative invisibility of HIV in Australia and the overall public health focus on gay men and other men who have sex with men have left a paucity of information that addresses the needs of the various African and other culturally and linguistically diverse communities.

HIV-related stigma still impedes African community access to appropriate information about HIV in Australia and is a barrier to timely diagnosis, treatment and support for African Australian people living with HIV.

African community awareness of HIV is growing, due partly to the efforts of health promotion agencies such as the Multicultural Health and Support Service (MHSS) in Victoria, the Multicultural HIV and Hepatitis Service (MHHS) in New South Wales and African community discussion forums such as those organised in 2011 and 2012 by the Australian Federation of AIDS Organisations (AFAO).

However, much work remains to be done to provide African communities with accurate, relevant, appropriate information about the diagnosis and management of HIV, as well as important co-morbidities and health issues that influence long-term prognosis and quality of life for African Australians living with HIV.

Some health issues, such as smoking and obesity, are important for all people living with HIV, regardless of their origins. Others, such as tuberculosis (TB), chronic viral hepatitis and vitamin D deficiency, are of special importance to African Australian people living with HIV; both those affected and their treating doctors and other health professionals need to be aware of the rapidly evolving state of scientific knowledge and its application to individual situations.

Tuberculosis

Tuberculosis (TB) is a common opportunistic infection among people living with HIV in Sub-Saharan Africa and other regions where TB incidence is high.

In addition to cases of active TB, it is estimated that up to one third of the world’s population has latent TB infection, with the risk of reactivation at some time in the future.

Latent TB is of particular importance to people living with HIV, whose risk of active TB is 10% per year, compared to 10% over a lifetime for those without HIV.

Latent TB is diagnosed by means of a tuberculin skin test (TST, or ‘Mantoux test’) or by a blood test such as the QuantifERON Gold®.

Both TST and QuantiFERON Gold® assess the risk of active TB, rather diagnosing active TB, so a positive test does not mean the person is contagious to others; latent TB is, by definition asymptomatic.

TB has been a focus of both traditional and modern medicine for millennia, but new challenges continue to arise and new advances are made in diagnosis and prevention.

These developments have been invigorated by the Global Fund against TB, Malaria and HIV, which redressed decades of relative under-investment in TB research.

One challenge is the rise of multidrug- resistant TB (MDR-TB) and extensively drug-resistant TB (XDRTB) in Central Asia, Eastern Europe, Papua New Guinea – and southern Africa (particularly the Republic of South Africa).

Multi-drug resistance renders standard first-line combination therapy ineffective; the treatment of MDR-TB and XDR-TB is even longer, more complex and toxic than that of sensitive TB, with correspondingly poorer outcomes.

People with HIV travelling to regions where MDR-TB and XDR-TB are prevalent need to discuss with their doctors strategies to avoid exposure.

New developments in TB research include the development of more rapid diagnostic tests for infection and drug resistance, and trials of new, shorter treatments for both active and latent TB and exploration of the role of vitamin D deficiency in TB reactivation, prevention and treatment.

The importance of these developments for African Australian people living with HIV will become evident over time.

In the meantime, it is recommended that all people with HIV – particularly those from Africa and other regions of high TB prevalence – should be tested for TB and those with latent TB may need treatment with anti-TB drugs to prevent future reactivation, with the attendant symptoms and risk of mortality, both from the illness and its treatment.

Chronic viral hepatitis

Chronic viral hepatitis is caused by hepatitis B and hepatitis C viruses (HBV and HCV). HBV is transmitted through contact with bodily fluids (genital secretions, saliva, blood, breast milk) and from mother to child during pregnancy or delivery.

HCV is less contagious, being transmitted primarily through blood-to-blood contact (although a small risk of sexual transmission also exists). Unlike hepatitis A and E, which are acute, short-lived illnesses acquired from contaminated drinking water, HBV and HCV infections often persist long-term.

People who acquire hepatitis B early in life are less likely than those exposed as adults to become unwell at the time of infection; however, infection in early childhood is more likely to become chronic.

Exposure to hepatitis B is common in people from Sub-Saharan Africa. Chronic HBV infection is also very common, due to acquisition of the virus in early childhood (through mother-to-child transmission or by household contact).

About 8% of the general population in many Sub- Saharan African countries have chronic hepatitis B, with similar prevalence in African diaspora populations living in other countries such as Australia.

The number of African Australians with chronic HBV far outnumbers the number with HIV, but the true prevalence is unknown, since immigration health assessments may miss some HBV infections and routine screening after migration usually occurs only amongst pregnant women, newly-arrived refugees, health workers and people diagnosed with HIV.

HBV infection is preventable with highly effective vaccines, which are universally administered to babies born in Australia; those born abroad may have missed the opportunity for routine immunisation, but screening for immunity to HBV is not routine except among health workers and recently arrived refugees.

Hepatitis C is also quite common in Africa, but its risk factors and transmission are less predictable than hepatitis B.

Since hepatitis C is mainly transmitted via blood, the risk of infection arises from exposure to the blood of another person, either directly through blood transfusion or organs transplantation, or indirectly through the use of surgical instruments that have been re-used without sterilisation, or through the inappropriate re-use of needles intended for single use.

No effective vaccine for HCV is available. In industrialised countries and North Africa, most hepatitis C transmission occurs through sharing of injecting equipment among people using illicit drugs, but in Sub-Saharan Africa, health care facilities and traditional initiation or healing procedures also pose risks of exposure.

Exposure to HCV after migration most commonly occurs amongst people who inject drugs. Whilst the number of African Australian people injecting drugs is still very small, they are often extremely marginalised (even within the social networks of people injecting drugs); they experience intense stigma, contend with multiple mental health and social issues and encounter layered cultural and linguistic barriers to accessing appropriate services.

Chronic viral hepatitis may not produce any symptoms for many years, because the liver is able to compensate for the ongoing damage caused by the viral infection.

However, the silent inflammation and fibrosis caused by these viruses reduces the ability of the liver to cope with additional strains such as infections, or some new medications. Symptoms of decompensated liver disease include jaundice (yellow discolouration of the eyes and skin), decreased appetite, drowsiness, confusion, swelling of the limbs and abdomen.

Bruising or bleeding may occur spontaneously or following minor trauma. Lifethreatening bleeding from dilated veins in the oesophagus (gullet) may occur. All of these symptoms and signs usually occur only after the liver has suffered extensive damage from long-standing, chronic inflammation.

However, the liver damage can be halted or partially reversed by treatment with antiviral drugs and immunotherapy. HBV can be controlled with lifelong antiviral drugs, some of which are also active against HIV. Another complication of chronic viral hepatitis is liver cancer, which is curable if diagnosed early, but has a very poor prognosis when it reaches the advanced stages of disease.

Early recognition of HBV or HCV infection is thus very important for African Australians and other people living with HIV. Both infections can be diagnosed with simple blood tests, but additional testing such as an abdominal ultrasound is necessary to assess the severity of liver disease and to screen for liver cancer.

Diagnosis of chronic viral hepatitis not only enables assessment and treatment of the hepatitis, but also enables treating doctors to select appropriate medications and doses for the treatment of HIV.

Screening for viral hepatitis is routine for people living with HIV, so few infections should be missed. Those without evidence of HBV exposure or chronic infection are susceptible and require immunisation.

New advances have occurred in the field of chronic viral hepatitis. HCV infection can now often be cured with antiviral medications that are much safer and better-tolerated than those previously used.

Assessment of chronic HBV and HCV is now less likely to involve the invasive procedure of liver biopsy, thanks to the availability of sophisticated ultrasound technology to check for liver fibrosis (scarring).

Early liver cancers can frequently be cured without major surgery. Newer antiviral drugs for treatment of HBV are less likely to induce resistance in the virus, reducing the need to switch therapy that is well-tolerated; however, much work needs to be done to improve understanding of the viral and human factors that influence the risk of liver damage from chronic HBV and HCV infection, the risk of cancer, as well as the social and psychological implications of a diagnosis of chronic viral hepatitis for members of Australia’s African communities.

Vitamin D deficiency

Vitamin D deficiency is very common among African Australians and other people with dark skins or little exposure to the sun.

The skin synthesises vitamin D when exposed to ultraviolet radiation. Since few people eat much of the foods containing vitamin D (oily fish), exposure to UV radiation in the form of sunlight is the major source of vitamin D.

People with dark skins need much longer exposure to UV light to synthesise vitamin D, since the dark pigment (melanin) absorbs much of the UV radiation. This, together with the Australian lifestyle and climate, means that few African Australians will spend long enough in the sun to maintain adequate stores of vitamin D throughout the year.

Vitamin D is necessary for bone health as well as a properly functioning immune system. Vitamin D deficiency has long been associated with demineralised bones and increased fracture risk, but is also associated with increased risk of active TB.

Many other potential associations with vitamin D deficiency are being investigated, including depression, schizophrenia, diabetes mellitus and some forms of chronic arthritis.

Vitamin D deficiency can be diagnosed with a simple blood test. Increased exposure to sunlight may be enough to correct mild deficiency, but if levels are very low, oral supplements are needed.

Many different formulations are available, most of which do not need a doctor’s prescription. Overdose or toxicity from supplements is extremely rare, since the form of vitamin D in the supplements needs an extra processing step in the body before it becomes active.

However, it is wise to consult with a doctor and have regular tests to make sure that the supplements are having the desired effect to increase vitamin D levels.

People with kidney disease need to have a special, active form of supplement that is only available by prescription, since their kidneys may not be able to activate the usual form of vitamin D found in overthe- counter supplements.

Challenges

African Australian people living with HIV and their treating clinicians thus face several challenges in the maintenance of health and wellbeing after diagnosis, in addition to those relevant to other people living with HIV.

Providers of health and social support, along with people living with HIV, need to actively seek and discuss information about these conditions and issues, addressing them in the wider context of living with HIV in Australia after migration from Africa.

Further information is available from the following sources:

Chris Lemoh is a physician practising in the areas of general internal medicine and infectious diseases. He is currently undertaking research on HIV in Victoria’s African communities. He is also a former Board Member of AFAO.