Hepatitis and HIV
The worlds of HIV and viral Hepatitis are similar, but different.
In Australia, HIV largely impacts gay men. Viral hepatitis, on the other hand, disproportionately and largely impacts Aboriginal and Torres Strait Islander people, people who are imprisoned, ethnicised communities where hepatitis B is endemic in countries of origin, and young people.
In other words, the people who are impacted by viral hepatitis in Australia are, on aggregate, less politically enfranchised than the single group most affected by HIV, gay men.
Another way of framing this, in an Australian context, is that viral hepatitis largely impacts on poor people and disenfranchised people.
Why, on aggregate, are the communities who are affected by HIV so different from those affected by hepatitis?
In Australia, HIV is largely transmitted through unprotected anal intercourse between casual partners of unknown status. At the same time HIV was identified about a half a decade sooner than hepatitis C (which was once known as “non-A, non-B” hepatitis).
Also, there is a “neatness” to HIV and the way it is understood which is not so true for hepatitis.
For example, you either have HIV or you don’t. You are either HIV positive or you are HIV negative. If you have it, you will not clear it, either on your own or with treatment. There is no vaccine.
On the other hand, there are 5 known types of viral hepatitis, known as hep A, hep B, hep C, hep D, and hep E. Each of them has different window periods, differing forms of transmission, different courses of treatment, and different possibilities for clearance as well as reinfection. Some of them can be vaccinated against (hep A & B, which can impact also on D), and others you cannot (hep C and E).
Further examples: Hepatitis B is easily cleared by most people (95%) if it is contracted when you are an adult. However, if you got it when you were a child from your mother, you are more likely to have it for the rest of your life (chronic hep B). Hep B is treatable with antiviral medication, but, like HIV, you have to take the medication for the rest of your life.
Hep C, on the other hand, has a lower rate of clearance when contracted as an adult. Unlike hep B or HIV, treatment for hep C can effectively cure you of the virus (i.e. you can become hep C negative after having been hep C positive). Still, you can also get it again.
In terms of transmission, hep B in Australia is largely transmitted from mother-to-child during childbirth, and is sexually transmissible as well from having penetrative sex (vaginal/anal) without a condom, and is also moderately transmissible through unprotected oral sex. Hep C, on the other hand, is not classified as sexually transmissible unless there is direct blood-to-blood contact in the context of sex play. The highest rates of transmission of hep C in Australia is through sharing injecting equipment.
There is so much more to learn.
While HIV theoretically has two forms (HIV-1 and HIV-2), worldwide when one says “HIV”, we are most likely to refer to HIV-1, because HIV-2 is mostly isolated to West African regions.
Yet: All the various viruses that are collectively known as viral hepatitis are also quite different from one another in their structure. For example, hep B is DNA, whereas hep C is RNA.
Hepatitis viruses are also found in diverse prevalence around the world. For example, hep A, which is transmitted through oral contact with contaminated fecal matter, is primarily found in countries with low standards of food hygiene. It is quickly cleared by most people (i.e. there is no chronic hep A), and once cleared, offers immunity, and thus tends to occur more sporadically and epidemically (ubiquitously in a time-limited way) in populations.
One the other hand, hep B is more likely to be found endemically (ubiquitously and indefinitely) in certain countries. At the same time, unlike hep C, both hep A and hep B can be vaccinated against, which means that they are largely preventable without having to engage in any significant behavioural change. Indeed, in Australia, at this point children born in Australia are vaccinated against both hep A and hep B. This means that hep A has been largely eradicated in Australia (given that it has been vaccinated against and is quickly cleared without treatment, even when contracted), while hep B will be largely seen in communities that trace themselves to hep-B endemic migrant communities (e.g. the two largest groups with hep B in Victoria are Chinese and Vietnamese communities).
As there is no vaccine for hep C, and it is blood-to-blood transmitted, we largely see it in significant proportion among people who inject drugs who share injecting equipment, plus a significant minority of people who get hep C from contaminated tattoo equipment (e.g. home-done tattoos with poor infection control).
Whereas the introduction of needle and syringe programs (NSPs) in Australia led to rapidly lower rates of HIV among people who inject drugs, the same outcome has unfortunately not been true for hep C. The reasons are complex. They are related to how the use of NSPs were encouraged, and the sorts of health promotion messages that were encouraged.
“Don’t share fits” (i.e. don’t share needles) is a fantastic message for preventing the transmission of HIV through injecting drug use. However, this does not work quite as well for preventing hep C transmission. My understanding of this includes that HIV does not live very long outside of the body compared to hep C. In other words, if there was a bit of HIV-infected blood left on the tourniquet or the communal water used to rinse needles, etc., this would be less likely to lead to seroconversion. However, if there was a bit of hep C-infected blood left on the tourniquet or the communal water used to rinse needles, etc., this would be enough to lead to the spread of hep C among people who inject drugs, even if the needles themselves were not being shared.
Health promotion and hep C prevention messages, therefore, had to expand to become about not sharing any injecting equipment whatsoever, thus moving away from a focus on needles and needle-stick injuries, and into more information about standard infection control procedures for all people who might come into contact with any blood of this nature.
In a sense, the coalition of workers around HIV makes a particular sort of strategic sense; in Australia, the AIDS Councils have evolved over time to include many aspects of broader gay men’s health. The NSW-based one (the AIDS Council of NSW), where I used to work, has evolved in its brief to include a broader commitment to the health of all gay, lesbian, bisexual and transgender people, who have a visible enough commonality to one another (in our non-normative diversity of gender and sexual practice/expression) that this coalition makes a particular type of political sense.
However, it is more difficult to see what this means in doing hepatitis work.
Because of the huge differences culturally between communities who are impacted by hepatitis, it seems difficult to imagine what sort of coalitionary practice would make the most sort of strategic sense in moving forward in this field. Viral hepatitis seems infinitely more intellectually challenging and politically fraught when compared to HIV.
It is striking that, by numbers alone, hepatitis impacts on 9 times more people than HIV, and is the cause of the fastest preventable form of cancer in Australia (liver cancer).
In considering the relative political strength and resource-density of HIV work in Australia that I have been involved in (at the AIDS Council of NSW), I want to propose a number of strategic decisions and political commitments that we could make in the field of hepatitis that might be of similar weighty import. I admit that my bias, given my professional background in health promotion, is in the social justice aspects of health. I believe any work in health promotion is necessarily incomplete without a proper consideration of the many broad justice issues which impact on access to testing, prevention, and treatment of disease.
There are a few positions I believe are worth exploring, therefore…
Just as in HIV, we know that people who are living with viral hepatitis experience stigma around their experience. People with HIV have historically borne the brunt of stigma for being too sexually promiscuous, or for homosexual deviance. Similarly, people with hepatitis (C, especially) are stigmatised for their association with injecting drug use.
We need to speak out against the pathologisation of all drug use.
We need to be more mindful about the ways in which skin penetration is associated with a particular intensity of illegality.
i.e. We need to support the decriminalization of ALL drugs, with a strong evidence base to indicate how this will lead not only to better health outcomes for people who currently use drugs (who will be less afraid to seek support), but may well actually reduce the frequency of drug use (just as the decriminalization of homosexuality is highly correlated, internationally, with the proper controlling and managing the rates of HIV seroconversion).
We need to speak out against the injustice that is the existence of colonially-brought prisons on Aboriginal land, which have led to the disproportionate incarceration of Aboriginal people in this country, and the introduction of this institution which is an independent risk factor for the spread of disease. Correlated issues include speaking out about Aboriginal deaths in custody from correctional neglect and abuse, the privatization of prisons which turns the detention of racialised people into a product for profit, and the strategic targeting of prison guard unions to educate on the evidence for introducing NSPs into prisons all across Australia as a way to minimize the spread of all blood-borne viruses within prisons.
Furthering this, it is important for us to become more cognizant and participatory in all immigrant justice work, including looking into the exploitative conditions that students and skilled migrants are brought into Australia, who may well become entrenched in systems which rely on employer-driven visas (like 457 visas) for international recruitment, driving down wages in Australia, impacting on Australian employment conditions, subjecting these visa holders to an overattribution of blame for these diminishing conditions, as well as problematic routes (or lack thereof) to permanent residency status, thus compromising on the health of all Australians due to the relative lack of health entitlements of these workers.
Another form of immigrant justice would be to take a less paternalistic stance on the health of culturally diverse communities, particularly the highly racialised communities who bear the disproportionate brunt of hepatitis B in Australia (Asians, Arabs and Africans). This is not about “blaming” Anglo-Australians nor our existing health system for the failure to address this inequity (for indeed, many communities with hep B have had hep B prior to contact with Australia), but rather about imagining what sort of country we want to be and to be serious about the accountability for the health and wellbeing of all human beings who find ourselves present on this land.
This means increasing our commitment to overt anti-racist work, and, from a bureaucrat’s perspective, the support of community-driven responses to health inequity, health literacy and political empowerment.
On aggregate, we also see that viral hepatitis, compared to HIV, affects people who are on the lower socioeconomic end of the population. As a determinant of health then, we must also speak out about the widening gap between the rich and the poor in this country, which is, in itself, a sort of spiritual tax on the “liver” of society, the seat of vitality and strength. By disenfranchising a relatively larger and larger number of people within our society, we are complicit in maintaining the economic conditions which propel people to risky behaviours. There is evidence to show that it is not only poverty alleviation, but the narrowing of the wealth-poverty gap within societies, which is highly correlated with better health outcomes for ALL people across the board, both the rich AND the poor.