GVASex
| The ABCs of Hepatitis
for Gay Asian Men |
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Actually, A could just as easily stand for anyone. A glance at the Centers for Disease Control (CDC) website on global hepatitis shows bright red smears across Asia, the Pacific, South America, and Africa. The triad of hepatitis A, B, and C are ubiquitous, and indeed, the diseases have taken advantage of our need to be communal, sharing, and intimate. To understand how these viruses affect various populations differently, we need to take a look at how each is transmitted. Hepatitis A, for example, is dependent on oral-fecal spread because the virus is only shed in the gut. It’s much more prevalent in developing countries where up to 15% of people get it every year, and so traveling to endemic areas puts you at greater risk as well. Overwhelmingly, the spread of hep A is through personal contact, which accounts for 25% of all cases in this country. ‘Personal contact’ is the CDC’s polite euphemism for rimming and other things we love to do that puts us in contact with feces. This is why most of the sporadic epidemics of hep A that we see in this country are through food or sex, especially among men who have sex with men (MSM) and people with multiple sex partners. A lot of clinical information is useless so let’s indulge in a scenario. You’re at a sex club and see a hot guy who you decide to go down on. Unbeknownst to you, he had sex 15 minutes earlier with someone who carried the virus, and he didn’t bother to clean himself afterwards. On the other hand, personal contact can also just mean sharing cups or utensils with someone who has hep A and didn’t wash his or her hands after going number two. Voilà, oral-fecal contact. Hepatitis C is transmitted through blood and can be spread by sharing needles during injection drug use or by receiving contaminated blood transfusions. It is therefore relatively less common in the gay community. There is a substantial subset of injection drug users (IDU) among gay men as a whole and also among guys who have sex with other men for subsistence. In Asia, hep C is fairly common and in countries such as Viet Nam and the Philippines, some estimates of hep C prevalence put it at nearly 100% among IDUs. It’s also spread sexually, although gay men and Asian Pacific Americans are no more likely to be infected than anyone else. The U.S. has 40,000 new cases per year and 2.7 million people are chronically infected. The spread of hepatitis B is much more interesting by comparison. About one-third of the earth’s population has been exposed to it at some point. It’s similar to HIV in its transmission and is spread through blood contact. Many are chronic carriers of hep B and are therefore potent sources of new infections. As a result, vertical transmission from mother to unborn child occurs frequently. Close household contact may also pass the virus on, probably from accidental vampirism—getting blood into one’s system from an infected household member’s blood. Sharing toothbrushes or razors might do the trick because unlike HIV, hep B is a rather hardy virus that can survive the elements for long periods of time. Kissing does not transmit the virus. The human race would have gone the way of the dinosaur and feathered hair long ago if this were the case. Other modes of infection include blood transfusion, sharing needles, and using contaminated instruments in tattoo parlors, medical and dental clinics. The other major vehicle for transmission is unsafe sexual contact with someone who is infected. Oral sex is relatively safe and not known to transmit hep B. In Asia and the Pacific, hep B is considered endemic with 8-20% of the population infected. We’re talking about 275 million of people, many of whom acquired their infection in childhood. The prevalence is about 15% of all people in China and Vietnam; 4% of those in Singapore, Taiwan, Tonga, and Samoa; and 2% of Hawaiians are chronically infected. By comparison, 0.1% of Caucasian Americans are infected. How much of a problem is hep B for gay Asians and Pacific Islanders living in the U.S.? No one really knows. However, poking around a few departments of public health, including Seattle, New York, and San Francisco, this was the best I could come up with: MSM constitute 32% of new hep B infections in San Francisco and API make up 18% of chronic cases. And still the question remains: what about those who are MSM and Asian? Theoretically, we have a dual risk due to potential sexual as well as vertical transmission before we are born. This has been confirmed in a recent unpublished study of gay API men (GAM) in San Francisco’s clubs that showed a whopping 28% were chronically infected with hep B. To quote a Chinese friend of mine, “Ai-yah!” What proportion of this is due to vertical transmission from our parents versus sexual partners is unclear. To our credit, gay API-Americans are the most likely to talk about STDs and HIV status before having sex, so it may be that vertical transmission is mostly, but not entirely, to blame. B is Because They Can Kill Hepatitis A can be debilitating for a month or so. But for those who rest and abstain from alcohol for six months, it goes away with nary a thought or complication, and they get immunity, to boot. In contrast, hepatitis C is more deadly than A. Between 75% and 85% of people who get a new infection will go on to develop chronic disease. Up to 20% will develop cirrhosis and 5% will die from chronic hep C. So why all the hullabaloo about hep B, which just makes you a bit jaundiced, nauseated, and fatigued? The acute infection in children and adults can go relatively unnoticed, with 30% of people showing no outward signs. However, one percent of people may die from the acute disease. Among newborns that do get exposed at birth in endemic areas or who are born to parents with the disease, 90% will develop chronic disease. Kids who make it out of childbirth unscathed but are unfortunate enough to be exposed up to the age of five are less likely to be chronic carriers, but 30-60% of kids will still have chronic disease. And those who get it as adults become chronic 6-10% of the time. People whose bodies are able to clear the infection generally become immune. But for those who are chronically infected, up to a quarter of them will die from liver failure or cancer, the most serious complications of Hep B. In the U.S. about 5,000 people die each year as a result of hep B. One of the most devastating consequences of hep B is that it can lead to liver cancer. In addition, hep B can also cause death through cirrhosis and liver failure. Worldwide, hep B claims more than a million lives each year. As the accompanying piece by Joel Engardio poignantly shows, liver cancer tends to strike when people are young, between 30 and 65 years of age. This is because the virus has had several decades to do its damage to liver cells, transforming them into malignant lesions. Once diagnosed, it’s often incurable because it advances silently at first and only causes detectable problems when it’s too late. It’s insidious and deadly, but can nothing be done about it? Early detection via blood tests and ultrasonography has been proved to save lives. Clinicians routinely screen those who are chronically infected. So once again, this goes back to the issue of screening, because we first need to identify those who are chronic carriers in order to prevent cancer in API adults. For API men born abroad, the incidence of liver cancer in the U.S. is lower than it is back in the motherland, but is much higher than it is for API born here. Vietnamese have the highest risk at 13 times the rate of Caucasian Americans. Filipinos, Japanese and Chinese men are three, five and nine times more likely, respectively, to get liver cancer than their white counterparts. Koreans are about on par with Chinese at eight times the risk. For some API, we are more likely to die from liver cancer than from lung cancer. As for gay API, no data exist whatsoever. C is for Caring and Cure. Unfortunately, no vaccine exists for hep C. A vaccine for hepatitis B has been available since the early 1980s, but it’s not 100% effective. As many as 15% of recipients who receive all three shots at 0, 1, and 6 months acquire no immunity. They usually require additional booster shots to get their immune systems primed. As vaccination is required for health care professionals, I went for my vaccine in medical school and required a total of six shots before antibodies developed. While this degree of stubbornness is rare, it shows that testing for antibodies after vaccination can be crucial. Currently, the CDC does not require routine antibody tests after vaccination due to prohibitive costs, but your doctor will do it if you ask. National campaigns to vaccinate gay men against hep A & B have been underway for years by organizations such as the Gay and Lesbian Medical Association (GLMA) and local health departments. San Francisco started offering vaccination at a gym in the Castro recently. As a board member of GLMA, I was dismayed to find that only 22-32% of gay men polled at pride events around the country had been vaccinated against hep B. We are currently developing public policy to push for more active and targeted national vaccination in the gay community and would like to see 100% coverage. More drastically, in 1991 the CDC recommended vaccinating all newborns. The vaccine has been 95% effective at stopping vertical transmission. But even with widespread vaccination programs in the U.S., not everyone who’s sexually active in 15 or 20 years will be immune to hep B in the future. Immunity wanes. There is constant migration from endemic areas. Access to health care can be prohibitive in this market-driven country, and indeed, only 14-67% of API children in this country have actually received all doses of the hep B vaccine. When the CDC developed its statement on which populations are at risk and should be screened or vaccinated, they egregiously failed to mention the need to test Americans of API descent. Now, we’ll grant that these recommendations were released 11 years ago, just before cultural awareness became trendy, but even at that time, API’s made up three percent of the population and half of all chronic cases of hep B. The recommendations do make mention of the need to vaccinate adoptees from endemic areas such as Asia. Since 1991, the CDC’s recommendations have expanded to include infants born to immigrants from endemic areas but still fail to target the actual source of new infections in infants: immigrants themselves. It seems the world often forgets that children become adults, and when it comes to disease prevention, adulthood is really when we begin to see the horrific effects of long-term infection. Why hasn’t the U.S. implemented a more aggressive strategy aimed at API’s in general? Sadly, even countries in Asia and the Pacific have yet to implement widespread testing programs in adults. Some self-loathing types may wonder why the U.S. should even bother with screening API’s on a large scale level at all. In total, Asian Pacific Americans make up 11.3 million or 4.1% of the U.S. population, of whom 6.6 million or 58.4% are foreign-born. In short, there are a lot of people who are carrying the virus and not getting tested or vaccinated. An even more frightening prospect is that if Ward Connerly's drive to eliminate the government’s collection of information race and ethnicity information is successful, we’ll have no way to know whether or not trends among API’s in liver cancer and hep B infection are improving in the future. One study of Vietnamese adults in the bay area found that 48% had never even heard of hep B. And while individual accountability and community efforts are ideal, we’re all taxpayers and have a right to proper care. Our government has the capacity to carry out such a targeted testing and vaccination campaign. In the 1980s, programs implemented in Alaskan natives and Native Americans have virtually wiped out the epidemic from their communities. A safer, more globally-correct, and intuitive approach was undertaken by the World Health Organization early on in 1991, when they called upon all nations to vaccinate newborns and adolescents 11-18 years old. Whereas 8-15% of kids in many Asian countries were formerly found to be chronically infected, that number is now reduced to 1% where vaccination programs have been successfully implemented. Therefore demonstrating that good public health intervention works. However, some low-income countries still cannot afford to implement large-scale, country-wide vaccination programs. Why the targeting of a specific age group when the reality is that so many adults are also at risk? First, new disease in adults is less likely to progress to liver failure or cancer than it is in kids. There are also many logistical issues that policy makers and public health officials need to address such as cost. Newborns are an easily accessible group, being born in hospitals. The CDC also expanded its recommendations in 1996 to include adolescents because they can prevent a kid from going to school if they’re not vaccinated. For the parents, at least, this is a strong motivation to get the shots. So screening for hep B among all API’s regardless of age to figure out who’s chronic makes perfect sense. But is it enough? The blood tests used to discriminate between those with immunity due to past exposure and those with chronic disease are not accurate. Among API’s in particular, many people may harbor active disease without appearing to be chronically infected. A full 2% of people with chronic liver disease have so-called occult hep B, which has nothing to do with the supernatural and more to do with the hidden nature of the infection. It can even progress to cirrhosis, liver failure, and cancer. Looking for the DNA of virus itself can spot occult cases, and perhaps this is something we should consider for those who have been previously infected. The real tragedy is that treatments like lamivudine and interferon exist for hepatitis B that, in combination, are up to 50% effective at achieving a cure. Some studies show that they may be somewhat less effective in API, possibly due to the fact that chronic hep B may be more severe in us. Presumably, treating and curing it will prevent progression to cirrhosis and liver failure, as long as it’s caught early enough. Whether or not these medications prevent progression to liver cancer in Hep B remains to be seen, but there’s little reason to believe that they will not. Similarly, for hepatitis C, interferon has been shown to stop progression to cirrhosis. Unlike hep B, this treatment has been shown to prevent liver cancer. Now I generally regard myself as a pretty enlightened person, applying medical developments to my own personal life and allowing private experience to inform my public health work. But it only dawned on me while writing this article to encourage testing to my boyfriend, who is of Japanese descent, and to my family. And now that you know you have a one in four chance of having hep B, wouldn’t it be worth it to find out for yourself? I would strongly encourage you get yourself tested, and if you’re refused, tell ‘em you’re savvier than that and they should know better. Better yet, hit them with the facts and tell them that your life is worth the trouble. |
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