What YOU Need To Know About Hepatitis C

What is Hepatitis C?

“Hepatitis” means liver inflammation. Hepatitis C is a liver disease caused by the hepatitis C virus, a highly infectious, bloodborne virus. It can cause both acute (short term) and chronic (long term, persistent) liver inflammation which can range from very mild with no symptoms to severe and life/organ threatening. 
The World Health Organisation (WHO) estimates that 71 million people worldwide have chronic hepatitis C. In Singapore, the prevalence of hepatitis C is about 0.2% of the population. 50% of individuals with hepatitis C are unaware that they are infected because they have no symptoms. 
Most infected individuals (more than 70%) end up with chronic hepatitis C. Hepatitis C can result in chronic liver inflammation and eventual liver failure and is also a major risk factor for liver cancer (hepatocellular carcinoma). 
Thankfully, anti-viral medications are very effective in curing hepatitis C (a more than 95% cure rate). Early diagnosis and treatment of hepatitis C is crucial to avoid the potentially liver and life-threatening complications that can result from chronic hepatitis C. 

What is the difference between Hepatitis A, B and C?

Hepatitis A, B and C are all viruses which cause liver inflammation. However, they differ in terms of their modes of transmission and impact on the liver. 
Hepatitis A is transmitted through ingestion of contaminated food, water products or oro-fecally from an infected individual. Symptoms of hepatitis A tend to surface 2-4 weeks after initial infection and include fever, nausea/vomiting and diarrhoea, jaundice (yellowing of the skin) and tea coloured urine. Hepatitis A does NOT cause chronic liver inflammation – while there is a rare risk of fulminant acute hepatitis (severe, potentially life-threatening liver inflammation), most individuals recover completely from hepatitis A and have lifelong immunity. 
Hepatitis B is a bloodborne virus which is transmitted through sexual intercourse, blood transfusions, needle sharing, or through vertical transmission i.e. from mother to child during childbirth. Like hepatitis C, it causes both acute and chronic liver inflammation. Chronic hepatitis B infection can also result in liver damage (liver cirrhosis), failure and liver cancer. 

How is Hepatitis C transmitted?

Hepatitis C is a bloodborne virus and can be transmitted through:

  • Sharing of contaminated needles, syringes or related equipment 
  • Blood transfusions
  • Tattoos or body piercings in parlours that do not observe proper sanitation protocols 
  • Sexual intercourse with an infected individual – the risk of transmission through sexual contact is considered low but increases if one has multiple sexual partners
  • Sharing of personal care items that come into contact with infected blood e.g. razors 
  • Vertical transmission from mother to child during childbirth

The hepatitis C virus can survive and remain infectious outside the body for up to 6 weeks, which implies transmission through contaminated equipment is a real risk. 

What are the different stages of hepatitis C infection and their associated symptoms?

Acute hepatitis C

  • Symptoms may begin 2 weeks to several months after initial infection
  • Most individuals may not have any symptoms whatsoever but if a liver function test is done, it may show evidence of liver inflammation (elevated liver enzymes) 
  • Individuals who do develop symptoms may experience fever, fatigue, jaundice (yellowing of the skin and eyes), tea-coloured urine, nausea, right sided abdominal pain, joint pains 

Chronic hepatitis C

  • In 75-85% of infected individuals, the hepatitis C infection persists long term
  • Most individuals with chronic hepatitis C do not have symptoms but liver function blood tests may show evidence of ongoing liver inflammation
  • About 10-20% of individuals with chronic hepatitis C will develop liver cirrhosis (scarring of the liver with possible impaired liver function)
  • Individuals with cirrhosis may not show any symptoms until advanced stages of cirrhosis 
  • Individuals with hepatitis C and cirrhosis are at increased risk of liver failure and liver cancer

It is important to note that a lot of infected individuals have NO SYMPTOMS during both the acute infection and chronic phase. 

How is a hepatitis C infection diagnosed?

Hepatitis C infection is diagnosed through blood tests – the initial test done is usually a screening test for antibodies against hepatitis C. Further confirmatory tests like hepatitis C RNA testing will be done if you test positive for hepatitis C antibodies.
The hepatitis C antibody test can detect hepatitis C infection from 4 weeks after initial infection. 
Other blood tests like the liver function test and possibly imaging studies like an ultrasound scan of the liver will also be useful in determining the severity and possible complications of hepatitis C. 

What is the treatment for hepatitis C? 

Treatment of hepatitis C is only offered for chronic hepatitis C. The good news is that the current anti-viral treatment options for hepatitis C have a high cure rate of >90%. 
Infected individuals will also need regular follow-ups to monitor for liver inflammation and complications like liver cirrhosis and cancer. They should also abstain from alcohol or anything that may worsen liver inflammation and damage. 

Is there any vaccine against hepatitis C?

There is unfortunately no vaccine available for hepatitis C. The only hepatitis virus vaccines available are against hepatitis A and B. 

Who is at increased risk of hepatitis C?

Certain groups of people may be at increased risk of hepatitis C. These include:

  • Individuals who abuse drugs (inject/snort etc)
  • Individuals who engage in sexual activity that poses an increased risk of exposure to blood e.g. anal intercourse 
  • Individuals with partners who have hepatitis C 
  • Individuals with HIV 
  • Individuals who are or were previously incarcerated 
  • Children of mothers with hepatitis C 

What do I need to know about Hepatitis C and HIV coinfection?

All individuals diagnosed with hepatitis C should also be screened for HIV (and vice versa). Individuals with both hepatitis C and HIV (known as co-infection) are at increased (3x) risk of liver-related complications and overall mortality. This is even with aggressive anti-retroviral treatment to control HIV.
Overall, the outcomes for individuals with HIV and hepatitis C co-infection are poorer than individuals with either hepatitis C or HIV alone.  Treatment of individuals with HIV/hepatitis C co-infection can be complex and challenging as there are also special considerations when it comes to the choice of medications for treatment in individuals with co-infection, because of concerns about drug interactions. 

In conclusion, Hepatitis C is a SILENT and often overlooked infection. Regular screening for hepatitis C (be it as part of your routine health screening or sexual health screening) is crucial for early detection and treatment. The complications of untreated hepatitis C are potentially severe and life threatening but can easily be avoided with appropriate treatment.


Learn More about Other STDs & Other STD Symptoms

Also on DTAP: hiv screening, hiv screening singapore

16 Frequently Asked Questions About Hepatitis B

Hepatitis B virus (HBV) is the most common human hepatitis virus in Singapore. 
Hepatitis B is an infection of the liver caused by a virus called Hepatitis B virus. It can cause an acute infection which sometimes results in the person becoming a carrier (ie. Persistent infection).  Locally, 6% of the Singapore population are hepatitis B carriers. Those who test positive for hepatitis B for more than 6 months after the first test, are diagnosed as chronic. Having chronic hepatitis B increases your risk of developing liver failure, liver cancer or cirrhosis — a condition that permanently scars of the liver.
A vaccine can prevent hepatitis B, but there’s no cure if you have the condition. If you’re infected, taking certain precautions can help prevent spreading the virus to others.

1. Factors that have led Hepatitis B to become one of the biggest health threats in the Asia-Pacific region?

There are approximately 300 million chronic HBV carriers in the world, of whom 75% are found in the Asia Pacific region. Up to 50% of people who are newly infected have no symptoms. As the infection can lead to a chronic infection where majority of them have no symptoms, they are unaware that they are carriers and there can easily pass it to their partners and from mothers to their unborn child.

2. How does one get infected with Hepatitis B?

  • Sex with an infected partner
  • Injection drug use that involves sharing needles, syringes, or drug-preparation equipment
  • Birth from an infected mother
  • Contact with blood or open sores of an infected person
  • Needle sticks or sharp instrument exposures
  • Sharing items such as razors or toothbrushes with an infected person

Hepatitis B (HBV) does not spread through the sharing of food, water, utensils, breastfeeding, hugging, kissing, hand holding, coughing, or sneezing.

3. What are the symptoms of a Hepatitis B infection?

Newly acquired (acute) Hepatitis B (HBV) infections symptoms arise occasionally. The presence of signs and symptoms varies by age. Most children under age 5 years and newly infected immunosuppressed adults are generally asymptomatic, whereas 30%–50% of persons aged ≥5 years have signs and symptoms.
Symptoms include:

  • Fever
  • Fatigue
  • Loss of appetite
  • Nausea
  • Vomiting
  • Abdominal pain
  • Dark urine
  • Clay-colored bowel movements
  • Joint pain
  • Jaundice

Some acute HBV infections will resolve on their own, but some will develop into a chronic infection. Most people with a chronic HBV infection are asymptomatic and have no evidence of liver disease.
Approximately 90% of infants and 25%–50% of children aged 1–5 years will remain chronically infected with HBV. By contrast, approximately 95% of adults recover completely from HBV infection and do not become chronically infected.

4. How long does it take for the symptoms of Hepatitis B to show?

The symptoms appear an average of 90 days (range: 60–150 days) after exposure to HBV. If they develop yellowing of the whites of the eye, yellowing of the skin with vomiting, abdominal pain and drowsiness, they should seek medical attention as soon as possible.

5. If the symptoms are not obvious, how then would an infected person know?

Given the prevalence of chronic Hepatitis B carriers in our region, the best advice would be to go for a blood test to screen for Hepatitis B.

6. What are the dangers that one could face, if his or her Hepatitis B condition becomes chronic?

It may result in liver cirrhosis (hardening of the liver) or liver cancer.

7. How long before an infected person is deemed to have chronic Hepatitis B?

We will diagnose the person as a chronic Hepatitis carrier if the Hepatitis B surface antigen remains positive in their blood test result for 6 months or more.

8. How will a person be diagnosed, if he or she is suspected of being infected with Hepatitis B?

Through a blood test looking at the Hepatitis B surface antigen and Hepatitis B surface Antibodies;  a Hepatitis B core antigen is used to distinguish active from past infection.

9. What is the difference between Hepatitis B surface antigen and Hepatitis B surface antibody?

A Hepatitis B antigen detects the actual part of the virus and the antibody detects the body’s immune response to that same part of the virus.
HBsAg will be detected in an infected person’s blood an average of 4 weeks (range: 1–9 weeks) after exposure to the virus. About 1 of 2 patients will no longer be infectious by 7 weeks after onset of symptoms, and all patients who do not remain chronically infected will be HBsAg-negative by 15 weeks after onset of symptoms.

10. What are some of the ways in which Hepatitis B is treated?

There is no specific treatment; only supportive care.
In many cases, chronic Hepatitis B carriers do not need treatment but they will require 6 month follow up with blood tests and/ or ultrasound liver for the rest of their lives. In cases where Hepatitis B carriers require treatment, the treatment may involve immune molecules or antiviral medications.

11. Can Hepatitis B be transmitted from an infected mother to her newborn? How can this be avoided?

Yes, mothers can transmit Hepatitis B to their newborn. The best way to avoid passing the infection to their newborn is to get tested for Hepatitis B when they are pregnant or prior to starting a family. If they are not being infected with Hepatitis B and are not immune to Hepatitis B, they should consider getting a vaccination.

12. If your child gets infected with Hepatitis B and is not treated, what are some of the problems that he or she could face for the rest of his or her life?

The risk of developing chronic HBV infection after acute exposure is about 90% in newborns of HBeAg-positive mothers and 25% of they may go on to develop liver cirrhosis and liver cancers in the future.

13. Prevention of Hepatitis B?

Hepatitis B is a vaccine-preventable disease. All sexual partners, family and close household members living with a chronically infected person should be tested and vaccinated.

14. Who should get the Hepatitis B vaccine?

  • All infants
  • Non-vaccinated children aged <19 years
  • People at risk for infection by sexual exposure
    • Sex partners of hepatitis B surface antigen (HBsAg)–positive persons
    • Sexually active people who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months)
    • People seeking evaluation or treatment for a sexually transmitted infection
    • Men who have sex with men
  • People at risk for infection by percutaneous or mucosal exposure to blood
    • Current or recent injection-drug users
    • Household contacts of people who are HBsAg-positive
    • Residents and staff of facilities for developmentally disabled people
    • Health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids
    • Hemodialysis patients and predialysis, peritoneal dialysis, and home dialysis patients
    • People with diabetes aged 19–59 years; persons with diabetes aged ≥60 years at the discretion of the treating clinician
  • International travelers to countries with high or intermediate levels of endemic hepatitis B virus (HBV) infection (HBsAg prevalence of ≥2%)
  • People with hepatitis C virus infection
  • People with chronic liver disease (including, but not limited to, persons with cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
  • People with HIV infection
  • People who are incarcerated

15. For people who have Hepatitis B, how does it impact their day to day activities and what are the best ways to cope?

For chronic Hepatitis B carriers, there are no major impacts on their day to day activities. They have to follow up with their doctors on a 6 month basis. They should, however, avoid alcohol because it can cause additional liver damage.

16. What are the signs showing that an infected person no longer has Hepatitis B?

For those who have acute Hepatitis B infection, if the HbsAg becomes negative after 6 months and they develop an immunity which will show on their HBsAb test, then it means they are cleared from the infection and are immune to the virus.

If you would like to find out more about Hepatitis B or C, come down to any of our clinics for a consultation.


Learn More about Other STDs & Other STD Symptoms

Also on DTAP: hiv screening, hiv screening singapore

Descovy As New HIV Medication For HIV PrEP

What is HIV Pre-Exposure Prophylaxis (PrEP)?

HIV Pre-Exposure Prophylaxis (PrEP) is the use of medications to effectively prevent the transmission of HIV. Individuals who are taking PrEP can reduce their risk of contracting HIV infection by up to 99% if taken regularly. This type of medication must be taken before exposure to be effective. It is different from Post-Exposure Prophylaxis (PEP), which is taken immediately after possible exposure and uses additional medications.

PrEP is usually taken as a once-daily combination tablet of tenofovir disoproxil fumarate (TDF) + emtricitabine (brand name: Truvada), although other types of dosing regimens are available as well depending on the unique lifestyle of the individual. Studies have shown that PrEP is generally safe for long term use, but some may experience side effects such as a reduction in kidney function and bone density.

FDA Approved

The FDA recently approved a new drug combination of tenofovir alafenamide (TAF) + emtricitabine (brand name: Descovy) for use as PrEP, which has shown to be equally effective in preventing HIV infection whilst touting an improved safety profile for renal and bone toxicity.

The main difference between Descovy and Truvada is the form of tenofovir drug present – the newer Descovy uses TAF, which enters cells more efficiently than Truvada’s TDF, and means that a much lower dose of tenofovir is needed. This means that other tissues such as the kidney and bone are exposed to a much lower dose of the drug and there is less risk of drug toxicity.

The DISCOVER trial for Descovy as PrEP showed that the new drug is as effective as Truvada in preventing HIV transmission in men or transgender women who have sex with men, when taken as a once-daily tablet. They have not yet performed specific studies to evaluate protection in vaginal sex, or with other PrEP dosing schedules (such as Event-Based Dosing, T’s and S’s, etc.).

However, given that Descovy is essentially just a new and improved Truvada (which has been extensively studied in these situations), it is likely just a matter of time before further studies are done and show similar efficacy.

Descovy also includes a warning in usage as PrEP for patients with known hepatitis B infection, stating a potential risk of hepatitis B exacerbation after stopping the drug. While it can still be used as PrEP in patients with a history of hepatitis B infection, close monitoring of liver function and hepatitis B viral load for up to 6 months following discontinuation of Descovy is recommended (same as Truvada).

Speak To Our Doctors Today!

Descovy is currently available in all Dr Tan & Partners (DTAP clinics) in Singapore. It is a prescription-only medication and must be prescribed by a doctor. Speak to our doctors for more information about Descovy and find out if a HIV-1 treatment that contains Descovy is right for you. Dr Jonathan Ti, MB, BCh, BAO (Ireland), MRCP (UK), Cert. Men’s Health, is a member of the Singapore HIV PrEP Taskforce and is a co-author of the Singapore HIV PrEP Guidelines and is currently practising at our Robertson Walk Clinic.

HIV PrEP does not protect the user against other STDs. Therefore, even if you are on HIV PrEP, it is important to still to use a condom regularly, as well as get your regular STD screening & HIV Testing.

If you are interested to find out more about HIV PrEPplease call our any of our clinics or drop us an email at hello@dtapclinic.com.sg for an appointment with our doctors.

Lymphogranuloma Venereum (LGV )

 

What is Lymphogranuloma venereum (LGV)?

Lymphogranuloma venereum (LGV) is an uncommon sexually transmitted disease (STD) caused by Chlamydia trachomatis.  It is rare in industrialized countries. LGV is more commonly seen in third-world countries, including certain areas of Africa, Southeast Asia, India, the Caribbean, and South America.

However, in recent times, more cases of LGV have been noted in first-world countries.

What is Chlamydia VS Lymphogranuloma venereum (LGV)?

Chlamydia trachomatis is the name of the bacteria that causes Lymphogranuloma venereum (LGV).  LGV refers to clinical disease.

Not all subtypes of Chlamydia cause LGV. Of the 15 known clinical serotypes, only the L1, L2, and L3 serotypes cause LGV.

These serotypes are more virulent and invasive compared to other chlamydial serotypes.

What are the signs and symptoms of LGV?

Lymphogranuloma venereum (LGV) occurs in 3 stages:

First Stage of LGV

In the first stage, LGV presents with self-limited genital ulcers which may appear anywhere from 3 days to 1 month after exposure. This may be small and/or painless and may be missed by the patient. It may even look like a herpes infection.

Also See: Syphilis Symptoms – Painless Sore & Rashes

The Second stage of LGV

In the second stage, the patient usually presents with painful lymph node swelling in the inguinal and/or femoral groups of lymph nodes, usually appearing 2-6 weeks after exposure.

Other groups of lymph nodes may be involved as well, such as the armpit or neck lymph nodes. Painful, swollen lymph nodes may coalesce (join together) to form buboes, which may rupture in as many as one-third of patients.

Those that do not rupture harden, then slowly resolve. The second stage may be associated with back pain, joint pain, inflamed eyes, cardiac inflammation, lung inflammation or liver inflammation if the bacteria disseminate from the local area of infection.

Last Stage of LGV

In the last stage, patients with LGV may present with rectal ulcerations and symptoms of inflammation of the rectum which include bloody purulent anal discharge, rectal pain and the feeling of incomplete evacuation after passing stools.

This is more common in patients participating in receptive anal intercourse.

This may occur many months or even years after the initial infection. This can cause lasting damage to infected tissue and general health.

Scarring, swelling and deformity in infected areas have also been reported. It may affect your gut as well, resulting in significant morbidity.

Having genital sores, cold sores or cauliflower-like warts around your genital area?
These are signs and symptoms caused by the Herpes Simplex Virus and Human papillomavirus (HPV).
Not all STDs will display signs and symptoms. Other typical signs & STD symptoms of Sexually Transmitted Infections (STIs) are as followed.
Read: STD Symptoms of Different STDs

Is LGV Associated with Other Subtypes of Genital Ulcer Diseases such as Herpes Simplex Virus 2 (HSV-2), Syphilis, and Chancroid?

Lymphogranuloma venereum (LGV) is one of the causes of genital ulcer diseases that includes other STDs, such as Herpes Simplex Virus 2, Syphilis, and Chancroid. Any other form of STDs increases your risk of contracting another STD, including LGV.

How is Lymphogranuloma venereum (LGV) Transmitted?

LGV is almost exclusively transmitted through sexual contact.

Infection occurs after direct contact with the skin or mucous membranes of an infected partner. The organism does not penetrate intact skin.

The organism then travels by lymphatics to nearby lymph nodes, where it replicates within a type of white blood cell known as macrophages and causes systemic disease.

Can Sharing of Sex Toys Transmit Lymphogranuloma venereum (LGV)?

As long as the Chlamydia bacteria is present on the surface of the sex toy, and was introduced to the anogenital mucous membranes on the anus, vagina or penis, the infection can be spread.

It is thus important to make sure that sex toys are clean. It is also important to keep your sex toys clean.

How about Rectal Douching or Vaginal Douching?

Rectal and vaginal douching does not cause LGV, as if the surfaces of the douching tool is clean, there will not be the Chlamydia bacteria.

Having said that, most doctors do not recommend vaginal douching for ladies, as it may affect the normal flora of the vaginal cavity.

How Do I Test for Lymphogranuloma venereum (LGV)?

Laboratory diagnosis ultimately depends on detecting Chlamydia in the lesions/ulcers.

We can do a swab test of any lesions and do a urine test to see if Chlamydia is present or not.

What are the treatments for Lymphogranuloma venereum (LGV)?

LGV can be treated with antibiotics. However, a longer course has to be given (3 weeks). Your doctor will choose the appropriate antibiotic for you.

Sex partners who have had contact with the patient within the past 60 days should be evaluated and treated if symptomatic. If no symptoms are present, they should be treated for exposure, usually with shorter courses of antibiotics.

It is possible to be re-infected with LGV again after being successfully treated. Make sure all of your sexual partners have also been treated.

Is LGV more prevalent in MSM? How about other groups (Heterosexual & WSW)?

LGV has been postulated to probably affect both sexes equally, although it is more commonly reported in men. This could be because early signs and symptoms of LGV are more apparent in men and are therefore might be diagnosed more readily. Men typically present with the acute form of the disease, whereas women often present later.

Most cases in Europe and North America have been identified among white, frequently HIV-positive Men-Who-Have-Sex-with-Men (MSM) patients presenting with proctitis.

What are other STDs prevalent in Men Who Have Sex with Men?

Receptive anal sex carries the highest risk of contraction of all forms of STDs. STDs, in general, can affect everyone regardless of gender, age or sexual preference. If you are involved in sexual activity and have been exposed to an STD, you can contract it.


It is therefore important for you to get regularly tested for all STDs as long as there has been a new sexual encounter.

The best way to reduce the contraction of an STD from a sexual exposure is to use a condom. The proper usage of a condom (right size and fit) is equally important.

If you have experienced the above symptoms and wish to speak to a doctor, please visit us at our clinics. Alternately,  call us or email us for an appointment.


Learn More about Other STDs & Other STD Symptoms


Also on DTAP: hiv screening, hiv screening singapore

Chlamydia Symptoms & Treatment

What is Chlamydia?

Chlamydia is one of the most common bacterial sexually transmitted infections worldwide. It is caused by a bacterium called Chlamydia trachomatis. According to the US Centers for Diseases Control (CDC), Chlamydia is the most frequently reported bacterial STD in the US, with 2.86 million infections reported every year.

Who is at risk of getting Chlamydia?

Chlamydia can affect anyone who is sexually active, both males and females alike, regardless of sexual preference or orientation.
Young people may be at higher risk for various reasons, including practices like inconsistent condom usage. Young women may have a benign condition called cervical ectopy, which makes them more susceptible to getting Chlamydia.

How is Chlamydia transmitted?

Chlamydia is transmitted through sexual contact with the genitalia, anal canal or oral cavity of an infected individual – this includes through vaginal sexual intercourse, anal sexual intercourse and oral intercourse. Sexual activities involving the sharing of sex toys and contact with body fluids can also spread Chlamydia.
During childbirth, an infected mother can also transmit Chlamydia to her unborn infant, resulting in complications which are detailed below.

What are the Symptoms of Chlamydia?

Most individuals with Chlamydia DO NOT HAVE ANY SYMPTOMS. Less than 50% of both men and women with Chlamydia develop symptoms. This is also why Chlamydia is such a common bacterial STD – because asymptomatic individuals are unaware that they are infected and continue to spread it to their sexual partners.
IF symptoms do develop, they may occur anytime from days to weeks after the initial infection.

Symptoms of Chlamydia in men include:

  • Dysuria (painful urination)
  • Urgency and frequency of urination
  • Discomfort along the urethra/urine tract
  • Penile discharge which is usually clear or watery
  • Pain or swelling of the testicles may occur in a less common but serious infection called epididymoorchitis
  • Pain or discomfort in the pelvis due to prostatitis (inflammation of the prostate gland)

Chlamydia in males can result in urethritis (inflammation of the urine tract) and epididymoorchitis (inflammation of the testicles or epididymis).

Symptoms of Chlamydia in women include:

  • Abnormal vaginal discharge which may be different in colour, odour, quantity and consistency
  • Bleeding after intercouse (post coital bleeding)
  • Abnormal spotting/bleeding in between menstrual periods
  • Painful intercourse (dyspareunia)
  • Abdominal pain or fever can possibly occur during pelvic inflammatory disease (PID), where the infection spreads upwards to affect the uterus and Fallopian tubes, but the bulk of Chlamydia related PID is actually ASYMPTOMATIC

Chlamydia in females can result in vaginitis, cervicitis and pelvic inflammatory disease (involving the uterus and fallopian tubes).

Symptoms of Chlamydia infection not specific to males or females:

  • Chlamydia conjunctivitis – red, irritated eyes can occur after contact with infected fluids
  • Proctitis (inflammation of the rectum) – can give rise to rectal discomfort, discharge or pain, but most cases of rectal Chlamydia are again ASYMPTOMATIC
  • Throat chlamydia tends to be asymptomatic

What are the possible complications of a Chlamydia infection?

Women Chlamydia Complication

In untreated women, Chlamydia can lead to pelvic inflammatory disease, where the infection spreads to the uterus and fallopian tubes, resulting in chronic inflammation, scarring, potential infertility, increased risk of ectopic pregnancies (pregnancies outside of the uterus) and possible chronic pelvic pain.
Unfortunately, Chlamydia tends to cause “silent” PID without any symptoms at all.

Men Chlamydia Complication

In men, uncommon but more serious infections affecting the testicles and epididymis can occur.
Chlamydia infection increases the risk of pre-term delivery in pregnant women. Transmission of Chlamydia to the infant during childbirth can also result in severe eye infections (known as opthalmia neonatorum), or lung infections (pneumonia).

A condition called “reactive arthritis” (joint pain and swelling) can occur in both males and females.
Chlamydial infections in both males and females increases the risk of acquiring HIV.

How is a Chlamydia infection diagnosed?

The diagnosis of Chlamydia is best done using nucleic acid amplification testing (NAAT), which detects the presence of Chlamydia trachomatis DNA in a sample:

  • In men: a urine sample
  • In women: an endocervical swab
  • A throat swab or rectal swab can be used to diagnose throat or rectal Chlamydia respectively

See: Rapid Chlamydia & Gonorrhea PCR Screening (Next Day Results) is available in all our clinics in Singapore.

How is Chlamydia treated?

Chlamydia is treated with antibiotics, however, there is an increasing concern of resistance to certain antibiotics in various parts of the world.
Testing and treatment of sexual partners is also crucial and infected individuals should abstain from sexual intercourse or activity during treatment. After completion of treatment, a repeat test should also be done to confirm that the Chlamydia infection has truly been cleared.
Your doctor will be able to advise you on the specifics of treatment.

How do I minimise my risk of getting Chlamydia?

You can reduce your risk of Chlamydia through observing safe sexual practices – including consistent and correct use of barrier protection (condoms), reducing the number of sexual partners or being in a mutually monogamous relationship where you know your partner’s infection status.
Regular sexual health screening is also important, since most Chlamydia infections are asymptomatic. In fact, the US CDC recommends yearly Chlamydia screening for sexually active women under the age of 25.

If you would like to find out more about Chlamydia Testing and Treatment, come down to any of our clinics for a consultation.
Rapid Chlamydia & Gonorrhea PCR Screening (Next Day Results) is available in all our clinics in Singapore.

Stay safe, stay healthy.


Learn More about Other STDs & Other STD Symptoms


Trichomoniasis in Men and Women – Sexually Transmitted Infection

What is Trichomoniasis?

Trichomoniasis (also known as “trich”)  is a very common sexually transmitted infection caused by a parasite (a single-celled protozoan organism) called Trichomonas vaginalis. The US Centers for Diseases Control (CDC) estimates that about 3.7million people in the US have this infection.
Both men and women can be infected with trichomoniasis, although it is more common amongst women.

Only 1/3 of infected individuals actually develop symptoms and asymptomatic individuals can still transmit the infection to their sexual partners.

How is Trichomoniasis Transmitted?

Trichomoniasis is transmitted through sexual intercourse. The parasite commonly resides in the urethra in men (the urine tract), and the lower genital tract (including the urethra, vaginal canal and cervix) in women. Transmission occurs with genital to genital sexual contact. Sex toys may potentially be a mode of transmission if shared. The transmission does not occur through oral intercourse.
DidYouKnow:
Chlamydia, Gonorrhea, and Trichomoniasis are all common sexually transmitted diseases (STDs) that can cause infections in the genitals, rectum and throat. These diseases are easily spread by having vaginal, anal, or oral sex with someone who is infected with the disease. See: Gonorrhea Symptoms 

What are the Symptoms of Trichomoniasis?

In men, the symptoms of trichomoniasis may include:

  • Discomfort, itching or an irritation along the urine tract
  • Dysuria (pain) or discomfort when passing urine
  • Penile discharge
  • Discomfort or pain during or after ejaculation

In women, the symptoms of trichomoniasis may include:

Again, it is crucial to remember that less than half of infected individuals develop symptoms. As with many other STDs, feeling well does not rule out the possibility of trichomoniasis.


Learn More about Other STDs & Other STD Symptoms


What are the Possible Complications of Trichomoniasis?

Trichomoniasis infection in women has been shown to increase the risk of acquiring as well as transmitting HIV to partners.
In pregnancy, trichomoniasis increases the risk of preterm labour in pregnancy (going into early labour before the baby is due) and of the infant being of low birth weight.

How is Trichomoniasis Diagnosed?

In women, trichomoniasis can be diagnosed with a vaginal swab test or a urine test. In men, testing can be done with a urine sample, semen sample or urethral swab. Trichomoniasis is more easily diagnosed in women than in men. See: STD Screening
Test methods that involve nucleic acid amplification testing (NAAT) are highly accurate, while other methods like a culture (waiting for the parasite to grow on a culture medium) may potentially yield false negatives.

How is Trichomoniasis Treated?

Trichomoniasis is treated with oral antibiotics – either metronidazole or tinidazole. Both sexual partners should be treated so as to minimise the risk of the infection recurring.

How Can I Reduce My Risk of Getting Trichomoniasis?

Observing safe sexual practices can help reduce your risk of trichomoniasis – this includes the proper and regular use of condoms, reducing your number of sexual partners as well as ensuring both you and your partner get tested regularly for STDs, regardless of whether you have symptoms or not.
If you would like to find out more about Trichomoniasis Testing and Treatment, come down to any of our clinics for a consultation.
Also see: std test singapore

Is HPV Vaccine Necessary for Males?

HPV is a virus that can infect both males and females of all ages. HPV infections may lead to diseases such as skin warts, genital warts, vaginal/vulvar cancers, cervical cancer, penile cancer and anal cancer. There are hundreds of subtypes of HPVs, with about 40 known to affect the genital area. Of these, there are high-risk types known to cause cancer and low-risk types which may cause genital warts. Vaccines against some of these high and low-risk types are available today.

 

Most HPV infections clear naturally, but there is no way to predict who can clear the virus on their own, or who will carry the virus and potentially spread it. The virus itself cannot be treated. However, some of the diseases it causes can be managed. For example, if a person infected with HPV presents with a wart, we can use medications to treat it or use various techniques to remove it, but the virus itself is not eradicated from the body. That is why vaccination is so important for everyone so that the virus will not take root in the body.

 

HPV vaccinations have been available since 2006, and the vaccination has seen high uptake in many countries as they have been introduced into their national immunization schedule. HPV vaccination, along with pap smears and HPV testing, has been the cornerstone in reducing the burden of cervical cancer in women. In fact, we are already starting to see the benefits of this vaccine in reduced precancerous lesions of the cervix among countries with high uptake of this vaccine.

Read: Counterfeit HPV Vaccines (Gardasil 9) In Hong Kong

The vaccination in its early introduction largely left out males. The U.S. Food and Drug Administration has recently approved the use of Gardasil 9 for both males and females ages 9 to 45. The HPV vaccination is also now recommended by the U.S Center for Disease Control for men through age 21, for men who have sex with men, transgendered people, or those who have a compromised immune system (including HIV) who are ages 26 and younger. In the UK, from September this year, boys aged 12 and 13 would be offered the shots as part of a government health programme.

Read: HPV Vaccination for Men-Who-Have-Sex-With-Men

HPV has been linked to more than 99 per cent of cervical cancers, as well as 90 per cent of anal cancers, about 70 per cent of vaginal and vulvar cancers and more than 60 per cent of penile cancers. The protection against female cancers has already been proven. It also appears that vaccinated boys will receive some protection against anal and penile cancers as well.

 READ: Perianal Warts (Peri-Anal Warts) & Anal Warts Removal

 

There are 3 different types of HPV vaccines available in Singapore. Cervarix, which protects against 2 high-risk HPV types – 16 and 18. Gardasil 4, which protects against the high risk 16 and 18 and 2 more low-risk types 6 and 11. And Gardasil 9, the only vaccine used in the United States now which protects against 9 subtypes (6, 11, 16, 18, 31, 33, 45, 52, and 58). The vaccination schedule is 3 doses; one on your first visit, one 2 months later and the last one 6 months after the first dose (0,2,6) Other dosing schedules may be suitable depending on your age.

So should you as a male get vaccinated? Speak to your doctor about it to discuss the pros and cons. As for myself as a male – I’m already vaccinated.

HPV Vaccination is available in all our clinics in Singapore & Malaysia


Other Reads:

  1. Do I Have HIV Rash? Or Are They Other STD-Related Rashes?
  2. Weak Erection? Erectile Dysfunction? How to Improve Erection with Pills
  3. 11 Causes of Penile Itching & Pubic Itch
  4. HPV Infection & HPV Vaccination for Men who have sex with Men
  5. STD Risk for Receptive Unprotected Anal Sex in Men
  6. Low HIV Risk Doesn’t Mean No HIV Risk
  7. HIV PrEP for Travel – How You Need to Know
  8. An Overview on STD from an STD Doctor
  9. Everything You Need to Know About Herpes Simplex Virus
  10. How Do I Treat Oral Herpes (Cold Sores)
  11. Syphilis Symptoms – Painless Sore & Ulcers
  12. HIV Symptoms – What You Need to Know
  13. Sex During Period (Sex & Menstruation) What To Know
  14. 10 Common HIV Related to Opportunistic Infections

 

Apakah Simtom HIV Dan STD?

Hai, Saya Dr. Taufiq dari Dr. Tan dan Partners, dan hari ini saya ingin bercakap mengenai simtom penyakit kelamin atau STD, dan HIV.

Doktor yang boleh berbahasa melayu


Apakah simtom HIV dan STD?

Penyakit kelamin atau STD berpunca dari beberapa jenis virus, bakteria atau kuman yang boleh menjangkiti seseorang melalui hubungan seks dengan pasangan yang sudah pun mempunyai jangkitan tersebut. Penyakit HIV pula berpunca dari virus yang dikenali sebagai Human Immunodeficiency Virus, dan ia juga tersebar melalui hubungan seks.


Simtom-simtom STD

Simtom-simtom STD boleh dibahagikan kepada tiga jenis – simtom semasa kencing, simtom pada kulit dan simtom umum. Simtom-simtom STD boleh mengambil masa yang berbeza untuk muncul – ada yang mungkin seawal 3 hari selepas hubungan seks, ada juga yang mengambil masa beberapa minggu atau bulan untuk menjadi jelas. Ada pula sesetengah orang yang dijangkiti STD, tetapi mereka tidak mengalami apa-apa simtom yang nyata.


Jangkitan Chlamydia dan gonorrhea (CGP)

Jangkitan Chlamydia dan gonorrhea (CGP) adalah penyakit STD yang paling kerap dijangkiti. Antara simtom 2 termasuk pengeluaran cecair dari kemaluan.

Ada juga yang dijangkiti tapi tidak menunjukkan apa2 simtom. Jangkitan ini juga boleh membawa kepada kemandulan.

Anda boleh mendapat keputusan dalam masa 24 jam. Pengesanan awal dapat membolehkan rawatan awal.

Simtom-simtom HIV pula mungkin berbeza bergantung pada individu dan peringkat penyakit.


Simtom-simtom HIV

Bagi seseorang yang mengalami jangkitan HIV peringkat awal, mereka mungkin dapat melihat simtom-simtom tertentu dalam masa 2 hingga 4 minggu pertama.

Simtom yang paling ketara pada peringkat awal ialah selsema yang serius, yang selalu disifatkan sebagai “selsema yang paling buruk yang pernah dialami”.

Keadaan ini dikenali sebagai sindrom retroviral akut, atau ARS. Sindrom jangka pendek ini disifatkan dengan sakit tekak, ruam, keletihan, sakit-sakit badan dan sakit kepala. Simtom-simtom HIV boleh berlarutan dari beberapa hari hingga ke
beberapa minggu.

Selepas jangkitan HIV peringkat awal, simtom-simtom penyakit ini mungkin hilang. Tapi awas, jangkitan HIV mungkin sudah mara ke peringkat kedua yang dipanggil peringkat latensi. Pada peringkat ini, virus HIV membiak di dalam tubuh badan, tanpa menunjukkan apa-apa kesan yang jelas seperti simtom- simtom yang telah saya katakan tadi.

Peringkat terakhir jangkitan HIV dikenali sebagai penyakit AIDS. Pada peringkat ini, fungsi perlindungan dalaman atau sistem imun badan akan mula merosot.

Seseorang yang mempunyai penyakit AIDS akan lebih senang jatuh sakit, dan mungkin juga mati kerana sebab-sebab yang pada asasnya, tidak serius.


HIV Rapid Test

Untuk mengesan jangkitan HIV, ujian pantas HIV (HIV Rapid Test) hanya boleh diambil sekurang-kurangnya 14 hari selepas anda terdedah pada aktiviti berisiko tinggi.Ini adalah ujian generasi ke 4 dimana ia boleh mengesan HIV
seawall 14 hari.

Ujian generasi ke 3 pula memakan masa 90 hari selepas pendedahan sebelum boleh mengesan HIV.


PrEP dan PEP

PrEP (Pre-Exposure Prophylaxis) adalah ubat yang diambil untuk mengelak daripada menjangktii virus HIV. PEP (Post exposure Prophylaxis) pula adalah ubat yang diambil setelah terdedah pada virus HIV.

PrEP biasanya digalakkan bagi mereka yang berisiko tinggi untuk mendapat HIV seperti golongan yang mempunyai pasangan yang berbeza, lelaki yang berhubungan sesama lelaki lain.

PEP pula di galakkan bagi golongan yang terdedah pada HIV. Contohnya kondom yang pecah sewaktu bersetubuh, berhubungan dengan pekerja seks tanpa kondom dan pendedahan pada HIV melalui suntikan jarum. (needlestick injury).


Apa itu HPV

HPV atau Human Papilloma Virus adalah sejenis virus yang merebak melalui sentuhun kulit. Ia boleh menyebabkan ketuat (warts) serta kanser pangkal rahim (cervix).

Kini ada vaksin yang bleh melindungi anda daripada 9 jenis virus HPV. Ia dinamakan Human Papillomavirus 9-valent Vaccine. Human Papillomavirus 9-valent Vaccine adalah satu-satunya vaksin yang boleh mengelak daripada kanser. Ia digalakkan bagi lelaki dan perempuan berumur 12 tahun ke atas.

Saya telah pun memberikan penerangan ringkas tentang penyakit STD, HIV dan AIDS.

Sebelum saya akhiri, saya ingin memberi beberapa pesanan.


Kesimpulannya

  • Pertama, saya ingin menegaskan bahawa simtom-simtom seperti selsema, sakit tekak, sakit badan dan sebagainya, sama seperti simtom-simtom untuk penyakit biasa. Jadi, janganlah tergopoh-gapah untuk menganggap bahawa awak telah dijangkiti penyakit HIV hanya kerana awak ada simtom-simtom tersebut. Pada masa yang sama, saya juga ingin mengingatkan bahawa ramai orang yang dijangkiti penyakit HIV tidak menunjukkan apa-apa simtom yang jelas dan nyata.

Jika awak berasa ragu tentang kesihatan awak, adalah wajar untuk berjumpa dengan doktor yang bertauliah untuk mendapatkan pemeriksaan dan kepastian.

  • Kedua, mujurnya, kini kita sudah boleh merawat dan mengawal penyakit HIV dengan lebih berkesan. Sekiranya anda mendapatkan rawatan untuk jangkitan HIV, anda mempunyai peluang untuk hidup dengan sihat, dan bebas dari simtom-simtom ini untuk masa yang lama.
  • Ketiga, anda hanya akan dapat mengesahkan penyakit HIV dan kesihatan anda melalui ujian khas, tiada jalan lain untuk mendapatkan kepastian ini.

Sekiranya anda bimbang tentang kemungkinan pendedahan, atau anda mengalami simtom-simtom STD dan HIV, sila lawati klinik kami untuk penilaian dan ujian yang betul. Kami sedia membantu untuk memberi nasihat dan rawatan yang diperlukan. Bicaralah dengan dokter Anda hari ini!


Tag: hiv test

Common Causes of Penile Itching and Pubic Itching

A myriad of conditions can cause a man to have penile itching or pubic itching. The excruciating urge to scratch and relieve that itch at such an inconvenient part of the body can be a major source of embarrassment to some. When severe, it can result in extreme discomfort in the day, and disrupt one’s sleep at night.

 

Here are some of the causes of Penile Itching and Pubic Itching:

 

6 Common Causes of Penile Itch:

 

1. Balanitis

Balanitis is a common infection of the foreskin and head of the penis. It is caused by bacteria or fungus, or a combination of both.

Symptoms include redness, swelling, discomfort, penile itching, and sometimes pain when passing urine.
(See: Penile Infection, Infection of the Penis)

When fungal infection (candidiasis) is present, a whitish cottage cheese-like discharge can be found under the foreskin. Balanitis is often hygiene related, but can also be caused by STDs. It is more likely to occur in uncircumcised males.  Watch: What are the causes of Foreskin Infection (Balanitis)

2. Genital Herpes

Genital herpes is caused by the Herpes Simplex Virus (HSV). Itching of the penis (penile itching) is usually the first symptom and can occur in other areas such as the scrotum, groin, buttocks and anus.

Shortly after, tiny clusters of fluid-filled blisters or ulcers can develop and these are usually painful. Other symptoms include painful urination, enlarged groin lymph nodes, fever and body aches. The virus can lie dormant in the body for years without causing any symptoms, therefore some people may not even be aware that they are infected.

Read: Genital Blister, Genital Ulcers & Genital Warts & Causes of Oral Herpes (Cold Sore)

 

3. Genital Warts

Genital warts are caused by the Human Papillomavirus (HPV), a sexually transmitted disease. They appear as flesh-coloured growths that can cluster and resemble a cauliflower. Most of the time they do not have any symptoms but can sometimes itch. Bleeding can also occur during sexual intercourse.

Read: Genital Warts Treatment

 

4. Contact Dermatitis

Contact dermatitis is a skin reaction to contact with an irritant. This can happen anywhere on the body, including the penis. When this happens, it is usually caused by latex condom usage. The skin of the penis can turn red and itchy.

Sometimes the skin can break causing serious discharge, and bacterial infection can occur. Mild cases can be treated with a corticosteroid cream. Non-latex condoms can be used if you have a latex allergy.

 

5. Urethritis

One of the causes of penile itching is Urethritis. Urethritis refers to inflammation of the urethra, the tube that carries urine from the bladder to outside the body. This condition most often causes pain or itching in the penis, which worsens when passing urine.

Other symptoms include urethral discharge, urinary frequency or urgency, difficulty urinating, and blood in the semen. Urethritis is most commonly caused by a bacterial infection and can be sexually transmitted. See other STD Symptoms 

 

6. Psoriasis

Psoriasis on elbows.

Genital psoriasis often occurs alongside psoriasis of the skin. Skin cells develop at an extremely fast rate, resulting in the accumulation of skin cells on the skin surface, building up into itchy, red plaques of scaly skin. See Psoriasis Treatment

5 Common Causes of Pubic Itch

 

1. Jock Itch

Also known as tinea cruris, jock itch is a fungal infection of the skin in the genital area, groin and buttocks. The rash is usually itchy, red, scaly and ring-shaped. It tends to occur in people who sweat a lot and/or are overweight.

 

2. Pubic Lice

More commonly known as crabs, these are tiny parasitic insects that attach to the hair and skin in the pubic region. Pubic lice can be easily spread via sexual contact or other forms of close contact, and can spread to other body areas with coarse hair such as beards, armpits and chest hair. It is also possible for pubic lice to spread by using an infected person’s clothes, towels, or bed.

 

3. Folliculitis

This is a condition in which hair follicles become inflamed and is usually caused by bacterial or fungal infection, or inflammation from ingrown hair. Initially, the affected hair follicles may have small red bumps or white-headed pimples, but can swell and become painful and subsequently develop into crusty sores.

 

4. Contact Dermatitis

As mentioned earlier, this condition can also occur in the pubic area.

 

5. Molluscum Contagiosum (mo-LUS-kum kun-tay-jee-OH-sum)

Molluscum Contagiousum is a benign viral infection of the skin and is caused by the molluscum contagiosum virus, resulting in painless, small, shiny pearl-shaped lesions. They can happen anywhere on the body as a result of contact, but when they occur in the genital area, it is usually as a result of sexual contact. They can appear alone or in clusters. They usually do not cause any symptoms, but can sometimes itch.

If you need to speak to our doctors, please visit our clinics.  Alternatively, you can email us hello@dtapclinic.com.sg or call us for an appointment.
Take Care.


Other Read:

HIV Elite Controllers and Long-term Non-progressors

Elite controllers are defined as those individuals who have been infected with HIV but is able to achieve undetectable levels of virus (<50 copies/ml) without any medication. While long-term controllers are those who have been able to achieve low but detectable levels of HIV (<2000 copies/ml) without treatment.

There are many theories as to how these individuals are able to control the virus:

  • These individuals CD4 cells are less susceptible to infection by the HIV virus
  • Infected with defective strains of the HIV virus that makes the virus less able to produce copies of itself.
  • Individuals’ whose immune system is able to mount an effective response to the virus
  • Individuals’ immune system causes less inflammation when the HIV virus is encountered and thus limiting the exposure of the virus to CD4 cells.

There is a fair amount of evidence to suggest that perhaps the main mechanism that allows for control of the HIV virus is that an effective and potent immune response by an individual. Studies have shown that when only CD4 cells of elite controllers were isolated without CD8 cells, and then infected with HIV virus, the CD4 was just as easily infected as non-elite controllers thus giving evidence that the elite controllers CD4 cells were just as susceptible to HIV infection as non-elite individuals.
In recent months, researchers in Sydney, Australia has reported a case of a known HIV person who has spontaneously cleared HIV infection with no treatment. This patient was infected due to a blood transfusion back in 1981. The patient was able to suppress the HIV virus in his body through his own immune system and have undetectable levels of the virus since 1997. Most recently, they tried to look for traces of the HIV virus in his blood, intestines and lymph nodes but did not detect any traces of the virus, thus the researchers believe this is the first case of spontaneous clearance of HIV infection in humans.

So what factors may have contributed to this patient being able to clear the virus from his body?

  • The virus that originally infected that patient was lacking in a gene called nef. In HIV virus deficient in this gene, the virus replicates more slowly and thus is associated with lower viral loads.
  • The patient was born with 1 copy of a gene called CCR5. The gene is required for HIV to attach to human immune cells. Thus persons with only one copy of the gene would make it more difficult for the HIV virus to attach on to the immune cells. (See: CCR5 HIV Test)
  • It was also found that the patient’s immune cells were naturally more able to recognise a protein called gag made by the HIV virus. This protein is found on the surface of infected human cells. Thus allowing his immune system to better recognise cells that have been infected with HIV virus and aid in their destruction.
  • In addition, the patient was born with 2 specific immune-cell genes called HLA-B57 and HLA-DR13 and in combination allows his immune system to be more effective in responding to HIV infection.
  • As a result of his strong response by his CD4 cells as a result of the presence of the HLA-B57, he is able to mount a bigger immune response by his CD8 cells. CD8 cells are required to activate cytotoxic T cells which as the name suggests are immune cells that kills defective or infected human cells.

In essence, the combined effects of each of the above factors contributed to the clearance of the HIV virus from this particular patient. To replicate this combined effect artificially at this point in time is not possible. However, perhaps in the future with further development of gene therapy, we may be able to achieve this unique set of host factors to achieve clearance of HIV virus.


Other Interesting Reads:

  1. Weak Erection? Erectile Dysfunction? How to Improve Erection with Pills
  2. Do I Have HIV Rash? Or Are They Other STD-Related Rashes?
  3. What are the Causes of Abnormal Penile Discharge?
  4. An Overview of STD – From an STD Doctor
  5. What You Need To Know about HPV, Cervical Cancer, Pap Smear & HPV Vaccination
  6. Anonymous HIV Testing – What You Need to Know
  7. Low HIV Risk Doesn’t Mean No HIV Risk
  8. What is HPV Vaccination (Gardasil 9)
  9. 10 Causes of abnormal Vaginal Lumps and Bumps
  10. An Overview of Gonorrhoea
  11. What is the Treatment for Cold Sores? What causes Cold Sores?
  12. Genital Warts: The Cauliflower-Like Lumps on the Genitals
  13. Syphilis Symptoms (Painless STD Sores & STD Rashes)

Tag: hiv test