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HCV/HIV
Coinfection Reports from the 2004 Retrovirus Conference
Liz Highleyman
Hepatitis C coinfection was a major
focus of the 11th Conference on Retroviruses and Opportunistic
Infections, held February 8-11, 2004, in San Francisco, with
more than 50 abstracts devoted to the topic.
A Patient Guide to Finding an HCV Support Group
Alan Franciscus, Editor-in-Chief
Many people with HCV feel isolated
and find it difficult to cope with the effects of living with
a chronic illness. Family and friends can be a great source
of comfort and support, but support from people who have faced
some of the same fears and challenges can be crucial in helping
people understand, manage and live successfully with hepatitis
C.
HealthWise: Hepatitis C and Aging
Lucinda K. Porter, RN, CCRC
The aging process has an impact on every body system.
Our bodies are somewhat like automobiles. The better you take
care of your car, the longer it is more likely to last. However,
sooner or later various parts start to break down.
Questions to Ask Your Healthcare Professional
Kara Wright, PA-C
The diagnosis of hepatitis C can be overwhelming. Many
people are shocked at the time of diagnosis and have difficulty
understanding all of the implications at first. To help you
get started, here are some important questions you may want
to ask.
Occupational Exposure to Hepatitis C
Alan Franciscus, Editor-in-Chief
It has been well-documented that transmission of hepatitis
C in a healthcare situation can occur. Healthcare workers
are at risk because of needlestick accidents and unavoidable
situations that may result in direct contact with blood from
an HCV infected individual.
Review: Winning the Hepatitis C Battle
by Dr. Schalla
Alan Franciscus, Editor-in-Chief
Stay informed on the latest news
..click here to register for email alerts
HCV/HIV
Coinfection Reports from the 2004 Retrovirus Conference
Liz Highleyman
Hepatitis C coinfection was a major focus of the 11th Conference
on Retroviruses and Opportunistic Infections, held February
8-11, 2004, in San Francisco, with more than 50 abstracts
devoted to the topic.
Pegylated Interferon plus Ribavirin: APRICOT, ACTG
5071, RIBAVIC
Among the major news: data from three studies of hepatitis
C treatment in HIV/HCV coinfected patients. Past studies have
shown that while about half of people with hepatitis C alone
achieve a sustained response to combination therapy with pegylated
interferon plus ribavirin, response rates are lower in coinfected
patients?about 40-60% in those with genotypes 2 or 3, and
less than 25% in those with genotype 1.
Douglas Dieterich presented long-awaited 72-week results from
the Roche APRICOT study, the largest such trial to date (abstract
112). In this study, 860 subjects were randomly assigned to
one of three arms: 3 million IU standard interferon three
times weekly plus 800 mg ribavirin daily, 180 mcg pegylated
interferon (Pegasys) once weekly plus placebo, or the same
doses of pegylated interferon plus ribavirin, all for 48 weeks.
The participants in the three arms were similar: about 81%
male, about 79% Caucasian, mean age of 40, about 60% with
HCV genotype 1, and about 16% with bridging fibrosis or cirrhosis.
The participants had well-controlled HIV disease and 85% were
on antiretroviral therapy.
Overall, 40% of patients treated with Pegasys/ribavirin achieved
a sustained virological response (SVR; undetectable HCV RNA
at the end of a 24-week post-treatment follow-up period),
compared with 20% of those receiving Pegasys monotherapy and
12% of those receiving standard interferon/ribavirin. Among
subjects with genotypes 2 or 3, the respective SVR rates were
62%, 36%, and 20%, while in genotype 1 patients the corresponding
rates were 29%, 14%, and 7%. The higher SVR rates in the Pegasys/ribavirin
arm compared with the Pegasys monotherapy arm suggest that
ribavirin plays an important role in preventing HCV relapse.
Adverse side effects or laboratory abnormalities were seen
in about 15% in all three arms.
Raymond Chung presented final results from ACTG A5071 (abstract
110). This was the first randomized study looking at pegylated
interferon/ribavirin in coinfected patients. Interim (48-week)
data was presented at the Retrovirus conference two years
ago. A total of 133 participants were randomized to receive
either standard interferon three times weekly or 180 mcg Pegasys
once weekly, both for 48 weeks. Subjects in both arms also
received daily ribavirin in escalating doses from 600 mg to
1000 mg. About 80% of the participants were men, about half
were African-American, 75% had genotype 1, the median fibrosis
score was 2.0, and the median HAI score was 5.0. Participants
in this study also had well-controlled HIV.
As previously reported, after 48 weeks,
an end-of-treatment response (ETR) was seen in 41% of patients
in the Pegasys arm, compared with 12% in the standard interferon
arm. Within the Pegasys arm, 80% with non-1 genotypes achieved
an ETR, compared with 29% of genotype 1 patients. By 72 weeks,
overall SVR rates were 27% in the Pegasys arm and 12% in the
standard interferon arm. In the Pegasys arm, the SVR rates
were 73% for non-1 patients, compared with just 14% for genotype
1 patients; in the standard interferon arm, the corresponding
rates were 33% and 6%. Notably, while the overall ETR and
SVR rates were the same in the standard interferon arm, the
response rate declined dramatically from week 48 to week 72
in the Pegasys arm. Dr. Chung suggested that the lower initial
dose of ribavirin (reduced to improve tolerability) may have
led to higher relapse rates, indicating that timing of ribavirin
is important. Histological response was seen in about half
of virological responders and about one-third of nonresponders
who had repeated biopsies. The incidence of side effects was
similar in both arms, and 12% in both prematurely discontinued
therapy. HCV treatment had no adverse effect on HIV disease
progression.
Finally, Christian Perronne presented 72-week results from
the French RIBAVIC (ANRS HC02) study (abstract 117LB). This
412-person trial also compared standard and pegylated interferon,
but used Peg-Intron instead of Pegasys. Participants were
randomly assigned to receive 3 million IU standard interferon
three times weekly plus 800 mg ribavirin daily, or 1.5 mcg/kg
Peg-Intron once weekly plus 800 mg ribavirin daily. In this
study, 74% of participants were male, the mean age was 40,
79% had a history of injection drug use, 58% had HCV genotypes
1 or 4, and 40% had stage F3 or F4 fibrosis. Here, too, the
subjects had well-controlled HIV disease and 82% were receiving
antiretroviral therapy.
Overall, at 72 weeks, 19% of participants receiving standard
interferon achieved SVR, compared with 27% of those on Peg-Intron,
using an intent-to-treat analysis. Among patients with genotype
1, SVR was seen in 5% of the standard interferon arm and 15%
of the pegylated interferon arm; among non-1 patients, the
corresponding rates were 40% and 45%. Liver histology improvement
was seen in the responders. In terms of tolerability, about
40% discontinued therapy in both arms and about 30% experienced
severe adverse events.
It is unclear why the sustained response
rate was so much higher in the APRICOT study compared with
the other two trials, but there were some important differences
in the patient populations. ACTG 5071 included more African-Americans
than APRICOT, a group that appears to respond less well to
treatment. The RIBAVIC study included patients with more advanced
liver damage, and drop-out rates and rates of severe adverse
events were considerably higher. Also, RIBAVIC used Peg-Intron
while the other two studies used Pegasys.
How Long to Treat?
In patients with HCV alone, response to pegylated interferon/ribavirin
after 12 weeks of therapy predicts the likelihood of achieving
SVR. Data have been conflicting as to whether the same cut-off
applies for coinfected patients. In an analysis of medical
records, Vincent Soriano and colleagues (abstract 819) found
that while no coinfected patients who failed to achieve an
HCV RNA decrease of at least 2 logs after 12 weeks of treatment
went on to achieve SVR, about 40% of those who did achieve
ETR later relapsed, regardless of genotype. This relapse rate
was surprisingly high, especially in patients with genotypes
2 or 3 (relapse is uncommon in HCV monoinfected people with
these genotypes), suggesting that coinfected patients may
respond more slowly than those with HCV alone and thus may
benefit from a longer course of treatment (12 months for genotypes
2 or 3; 18 months for genotypes 1 or 4). N. Shire and colleagues
(abstract 823) reported that in a population of hemophiliacs,
even a decrease in HCV RNA after 48 hours of therapy predicts
ultimate SVR. However, HCV viral load decreased less in coinfected
patients, and the difference between coinfected and monoinfected
patients was more pronounced in those with genotypes 2 or
3. The researchers suggested that coinfection may alter how
the immune system responds to interferon.
Fibrosis Progression and Improvement
Maribel Rodriguez-Torres and colleagues
(abstract 813) presented data confirming that HIV appears
to accelerate hepatitis C progression. The researchers detected
fibrosis progression even in some younger coinfected patients
with shorter durations of HCV infection, and suggested that
“Therapeutic interventions should be a priority in this
population.” Dr. Rodriguez-Torres (abstract 821) also
reported that retreatment with Pegasys was associated with
improved liver histology in coinfected patients who did not
respond previously to standard interferon alone. The researchers
found that both Pegasys monotherapy and Pegasys/ribavirin
led to decreased fibrosis grade and progression rate in patients
who received at least 24 weeks of therapy—even if they
did not achieve SVR. In another fibrosis study, C. Uberti-Foppa
and colleagues (abstract 814) reported on a retrospective
analysis of 354 consecutive liver biopsies from coinfected
individuals. Twenty-six patients (about 7%) had persistently
normal ALT; among people with HCV alone, studies have shown
than 20-30% maintain normal ALT. The researchers found that
75% of the patients with persistently normal ALT had minimal
or no evidence of fibrosis (stage 0-1) compared with 43% of
patients with elevated ALT, and that those with abnormal ALT
were twice as likely to have advanced fibrosis. Persistently
normal ALT is also associated with reduced risk for fibrosis
in individuals with HCV alone. However, because liver disease
progression does occur in some patients with normal ALT, treatment
decisions should not be based on this marker alone.
HAART and the Liver
HIV therapy in coinfected patients is a
concern because studies have shown that antiretroviral therapy
is associated with increased HCV viral load, and HIV protease
inhibitors may cause liver toxicity. Looking at a subset of
57 coinfected subjects from the Abbott 863 study, K. Sherman
and colleagues (abstract 811) found that using a combination
HIV regimen that included either nelfinavir (Viracept) or
lopinavir/ ritonavir (Kaletra) was associated with significantly
increased HCV viral load at 24 weeks. Increases were generally
similar, except that among patients with low CD4 cell counts
(below 100), HCV viral load rose more in the nelfinavir group.
By 48 weeks, however, HCV viral load levels improved. At 24
weeks, ALT increased more in the nelfinavir arm than in the
lopinavir/ ritonavir arm, but levels fell with continued therapy,
and were not significantly different from baseline in either
arm at 48 weeks. No patients in either arm discontinued therapy
due to liver toxicity. The researchers concluded that, “Patients
treated with lopinavir/[ritonavir]-based therapy are less
likely to have grade 3+ toxicity (ALT flares) associated with
HCV RNA increases than those treated with nelfinavir-based
therapy.” However, on the whole, both protease inhibitors
appeared safe in coinfected patients. In related research
on the adverse effects of HIV therapy, J. Moya and colleagues
(abstract 747) reported that drug-related liver toxicity is
correlated with histological stage. Among coinfected patients
with mild or moderate fibrosis (stage 1-2), the liver toxicity
rate was 5% in patients receiving nevirapine and 7% in those
taking efavirenz. Among patients with more severe fibrosis
or cirrhosis (stage 3-4), the corresponding rates were 25%
and 18%. Conversely, J. Macias and colleagues (abstract 810)
reported that fibrosis progressed faster in coinfected patients
taking nevirapine, while those taking protease inhibitors
showed less liver fibrosis.
Neuropathology in HIV/HCV Coinfected Individuals
Both HIV and HCV can cause neurological complications and
cognitive impairment, but the interaction between the two
viruses is not well understood. David Clifford (abstract 26)
presented results from a substudy of ACTG 5095 looking at
neuropsychological function in treatment-naive individuals.
Dr. Clifford looked at 25 HIV/HCV coinfected patients and
210 with HIV alone. The two groups were generally similar,
but the coinfected group had less education and were more
likely to have a history of injection drug use. The researchers
conducted various neuropsychological assessments including
the trailmaking and WAIS digit symbol tests—used to
measure attention, mental flexibility, and information processing
speed—and the Center for Epidemiologic Studies-Depression
Scale (CES-D). Coinfected participants had significantly lower
neuropsychological performance scores overall; in particular,
they did less well on the digit symbol task. About half (52%)
of the coinfected subjects had clinical depression, compared
with 33% of patients with HIV alone. Notably, the coinfected
subjects had significantly higher “somatic complaint”
scores, reflecting physical symptoms. Depression is known
to be associated with impaired cognitive function, but a statistical
analysis suggested that in this study, HCV infection was associated
with reduced performance even after controlling for depression,
education, alcohol use, and other factors. The investigators
concluded that HIV/HCV coinfection adversely affects neuropsychological
performance and may also be associated with depressed mood—even
in the absence of interferon therapy.
Coinfection and Mortality
L. Backus and colleagues (abstract 800)
found that HCV coinfection was associated with an increased
risk of death in a large cohort of patients from more than
100 U.S. Veterans Affairs facilities. This research confirms
previous studies showing that as HAART has reduced the rate
of death due to AIDS, liver disease related to HCV has become
a major cause of mortality in people with HIV. In another
study, D. Salmon and colleagues (abstract 798) reported that
HIV positive patients coinfected with both HCV and HBV are
at greater risk of death due to end-stage liver disease than
those coinfected with either HCV or HBV alone. In triple-infected
patients, 44% of all deaths in 2000 were due to liver disease,
compared with 31% of all deaths in HIV/HCV coinfected patients
and 22% of all deaths in people with HIV/HBV coinfection.
Liver disease was the primary cause of death in both triple-infected
and HIV/HCV coinfected patients, and the second leading cause
of death in HIV/HBV coinfected individuals. The researchers
also reported that liver cancer (hepatocellular carcinoma)
appeared to occur more often in patients coinfected with HBV
compared with HCV, and that heavy alcohol use is an important
factor contributing to death from liver disease. Finally,
M. Puoti and colleagues (abstract 829) reported that liver
cancer has a more severe clinical presentation, progresses
more rapidly, and is associated with reduced survival in HIV/HCV
coinfected patients, compared to those with HCV alone.
HCV/HIV in Women
T. Shahidyazdani and colleagues (abstract
807) presented one of the first studies of HIV/HCV coinfection
in women, studying more than 300 coinfected women in the Women’s
Interagency HIV Study (WIHS) cohort. In a statistical analysis,
women with HIV viral loads above 55,000 copies were nearly
three times more likely to have detectable HCV RNA. Unfortunately,
this first look at coinfection among the WIHS women was largely
based on older data, when few women were taking effective
HAART. Hopefully this cohort will continue to be followed,
shedding more light on the natural history of coinfection
in women and whether it manifests differently in women and
men.
Renewed Hope
While HCV coinfection remains a significant
cause of death in people with HIV, and while inconsistent
results from different studies are perplexing, the news about
HIV/HCV coinfection presented at the Retrovirus conference
was generally encouraging. The APRICOT study produced the
highest SVR rate ever seen in a coinfected population—
approaching rates achieved in patients with HCV alone—and
its large number of participants gives added weight to the
findings. In addition, research continues to show that interferon
can reduce liver damage even in patients who do not achieve
complete HCV clearance. Together, these results provide renewed
hope for people with HIV/HCV coinfection.
For the 2004 Retrovirus conference program
and abstracts, see www.retroconference.org/2004/home.htm.
HCV and HBV coinfection abstracts are available on our site
on our conference reports page. Click here
to view them.
Back to top
A
Patient Guide to Finding
an HCV Support Group
Alan Franciscus, Editor-in-Chief
Many people with HCV feel isolated and find it difficult to
cope with the effects of living with a chronic illness. Family
and friends can be a great source of comfort and support,
but support from people who have faced some of the same fears
and challenges can be crucial in helping people understand,
manage and live successfully with hepatitis C.
A support group can offer a safe space
to discuss the emotional and practical issues of living with
hepatitis C. In addition, the information shared by peer members
can be helpful in making decisions about a wide variety of
issues from disease stigma, disclosure, disease management
and treatment options. Family members may also need help when
they learn that a loved one has a potentially life-threatening
disease, and in coping with a loved one undergoing treatment.
Many HCV peer-led support groups have begun to emerge to address
the need for support and education in the hepatitis C population.
In addition, people who have come together in support groups
have been the same individuals who have emerged as HCV advocates/activists.
Support groups can be divided into two basic types: information
(or educational) and emotional, although most support groups
provide aspects of both, but may focus on one area or the
other. Informational support group meetings typically have
a lecture format that includes a guest speaker.
A wide variety of people seek out and attend support group
meetings. People who have been recently diagnosed with HCV
are usually interested in educating themselves about the disease
and talking to other people living with chronic hepatitis
C. Hepatitis C is a highly stigmatized disease and for some
people a group is a "safe" place where they can
talk and seek advice from people. People considering HCV therapy
can receive help with their decision-making process and talk
with others about what to expect and how to prepare for treatment.
People currently undergoing HCV therapy can receive emotional
support and learn coping strategies to help them deal with
the physical and psychological side effects of treatment.
Finally, people with symptomatic HCV can benefit from the
emotional support and the chance to discuss the various issues
that surround living with a chronic illness.
Support groups are usually led by hepatitis positive people
who have not been professionally trained as therapists or
counselors. It is very important that people seeking a support
group explore different support groups to find well informed
facilitators and to make sure that they are a "good fit"
with the group.
The first step is finding a support group. HCV positive friends
and acquaintances, healthcare providers, agencies that work
with people and the internet are all good sources.
Unfortunately, some people may not have access to a support
group in their area. These people may find internet resources,
online HCV email lists or discussion groups beneficial. You
can also check the local paper or call one of the organizations
listed at the end of this article for referrals to support
groups. If possible interview the support group leader. This
will help you with deciding if an initial visit is warranted.
Some questions to ask:
• Is the support group facilitator knowledgeable about
hepatitis C?
• What is the typical size of the support group?
• Is the support group leader a healthcare provider
or is the group linked to a healthcare advisor?
• What is the focus of the group?
• What populations frequent the group? Is the group
geared to one particular aspect such as treatment or primarily
focused on one population?
• When does the support group meet?
• How often and at what time does the group meet?
• Is this a strictly emotionally focused group or are
there informational meetings?
• Does the support group feature speakers? If so, how
frequently?
• Are there membership fees or dues?
• Is the support group held in an area that is considered
safe?
• Are family members/friends allowed to attend the group?
• How is confidentiality dealt with?
If you are able to talk with someone
"live" before sitting in on a support group you
should also use your gut reaction. Is the person warm and
fuzzy? Is the person too warm and fuzzy? It is pretty easy
to tell after a couple of minutes if the support group leader
is conducting a group that you would like to attend, or if
you will just sit in on one session.
Once you have a chance to sit in on a group, ask yourself
the following questions:
• Is the information and emotional support unbiased?
• How is the tone of the group—is it positive
and upbeat?
• Is the group leader able to "leave" his
or her ego at the door?
• Is the information just about treatment or does it
include a broader range of topics?
• Is the time divided up evenly among the members?
• Is this a group in which you would feel comfortable
talking about personal issues?
• Does the facilitator keep the group discussion moving?
• Does the facilitator allow time for all group members
to talk?
• Are the group's members open-minded and not judgmental?
• Is the group a safe haven?
• Did you feel supported by the other group members?
This list of questions is by no means exhaustive, and once
you get started you will probably think of more specific questions
to ask.
Write down notes and questions that came up for you during
the group session. Talk briefly with the support group facilitator
or other members after the meeting about any concerns that
may have been raised during the meeting.
If you do not find that the group is a good fit for you, try
another support group, or, even better yet, start your own
support group.
Support Groups
For referrals to support groups, please contact one of the
following organizations:
Hepatitis C Support Project
www.hcvadvocate.org
American Liver Foundation
800-223-0179
www.liverfoundation.org
Hepatitis Foundation International
800-891-0707
www.hepfi.org
Hep C Connection
800-522-4372
www.hepc-connection.org
L.O.L.A.
888-367-5652
www.lola-national.org
HepCBC
www.hepcbc.ca
Back to top
HealthWise:
Hepatitis C and Aging
Lucinda K. Porter, RN, CCRC
"To me, old age is always 15 years older than I am."
- Bernard M. Baruch
According to the most recent census, there
are more than 35 million adults age 65 and over in the United
States. By the next census in 2011, Baby Boomers will push
this growth to notable numbers as this group reaches the age
of 65. The National Institutes of Health (NIH) Consensus Conference
on the Management of Hepatitis C (HCV) reported that the highest
prevalence of HCV occurred in persons age 40 to 59. This means
that by the 2011 census, the U.S. population will have record
numbers of aging adults living with HCV. This group includes
a high prevalence of African Americans and Veterans, groups
that already have unique health problems without the extra
burden of an HCV diagnosis.
The aging process has an impact on every body system. Older
adults experience eye, skin, and gastrointestinal problems.
Immune and cardiovascular systems become affected. Bladder,
bowel, and brain functions can become impaired. Arthritis,
insomnia, depression and sexual dysfunction are reported more
frequently in older adults. Our bodies are somewhat like automobiles.
The better you take care of your car, the longer it is more
likely to last. However, sooner or later various parts start
to break down. In Reader's Digest, Gloria Pitzer
sums up the process well when she said, "About the only
thing that comes to us without effort is old age."
People living with HCV may report various symptoms that accompany
this viral infection. There are some similarities between
the medical problems incurred by aging and those of chronic
HCV infection. An area worth exploring is the relationship
between aging and HCV.
At the American Association for the Study of Liver Diseases
(AASLD) 2003 conference, Dominique Thabut and colleagues from
Groupe Hospitalier Pitie-Salpetriere, Paris, France reported
that in patients 65 years or older, chronic hepatitis C is
more severe and presents with lower ALT levels than in younger
patients. This report was based on data collected from 2,410
people living in France. The report also stated in the conclusion
that treatment is effective and well-tolerated. Additionally,
the use of biochemical markers may be useful as a non-invasive
alternative to liver biopsy in this population.
The age at which HCV was acquired may have an impact on prognosis.
A number of studies have reported that individuals who become
infected with HCV at older ages tend to have a worse prognosis
than those who acquire HCV while young. The NIH HCV Consensus
report lists people over age 40 among those who are more likely
to develop HCV-related liver cancer. Age can also have a negative
impact on liver transplantation survival. In a study from
Spain, Ignacio Herreroa and colleagues reported in the November
issue of the American Journal of Transplantation
that older liver transplant recipients have a significantly
lower survival rate than younger patients.
Treatment for older adults living with HCV has dimensions
that occur less frequently in younger adults. Some physicians
are reluctant to treat elderly HCV patients. The current standard
treatment of pegylated alpha interferon and ribavirin carries
some risks. Couple the list of treatment side effects with
the list of changes that occur during aging and the overall
picture becomes more complicated. The NIH HCV Consensus report
states that patients over the age of 60 years old should be
managed on an individual basis.
Another consideration of HCV treatment for older adults is
life expectancy. Just like certain models of cars, some individuals
can expect to live longer. Further, a report in the medical
press preliminarily suggests that life expectancy may be increased
in chronic hepatitis C patients undergoing interferon therapy
by preventing liver-related deaths.
Regardless of age, treatment decisions are always between
the medical team and the patient. These decisions are individualized,
based on multiple factors. The impact of age is a component
of the decision-making process. Hopefully as new treatments
develop, there will be more and easier to tolerate options
available to aging persons living with HCV. Until that time,
take good care of yourself. We all know that life is short.
In the words of Maurice Chevalier, "Old age is not so
bad when you consider the alternatives."
Back to top
Questions to Ask
Your
Healthcare Professional
Kara Wright, PA-C
The diagnosis of hepatitis C can be overwhelming. Many people
are shocked at the time of diagnosis and have difficulty understanding
all of the implications at first. After adequate time to process
the information, patients should do a little research to learn
more about the disease. After this research, it is important
to sit down with your healthcare provider to learn more about
this diagnosis. To help you get started, here are some important
questions you may want to ask.
General Hepatitis C Questions
• How does my diet affect the hepatitis C virus?
• May I be referred to a dietitian or nutritionist for
help with my dietary needs?
• How do my social habits (drinking alcohol, using drugs,
and smoking) affect my liver or the hepatitis C virus?
• Do I need to stop drinking alcohol completely?
• If I want to stop using alcohol and/or other drugs,
can you refer me to an alcohol and drug counselor?
• If I want to stop smoking, can you refer me to someone
to help me quit?
• Do I have to change my sexual practices?
• Should my partner(s) be tested?
• What kinds of symptoms/signs can I expect now that
I have been diagnosed with hepatitis C?
• What if I feel fine? Does that mean my liver is not
damaged?
• Is there a support group in the area that I can attend?
Other Infections
• Do I need to be tested to see if I am immune to hepatitis
A and/or hepatitis B?
• Am I immune to hepatitis A and/or hepatitis B? If
not, do you recommend I be vaccinated for either or both the
hepatitis A and B viruses?
• Should I be tested for HIV or other infections?
Questions about Labs
• What is my hepatitis C viral load?
• How often should I have my viral load checked?
• What is my hepatitis C genotype? (This is a one-time
liver test.)
• How does my genotype affect my illness and possible
treatment?
• What are my liver function test levels? (Liver function
tests are ALT/AST, ALP, and SGTP, bilirubin, albumin, and
prothrombin time.)
• How often should I have liver function tests done?
Questions about a Liver Biopsy
• Do you recommend I have a liver biopsy?
• If yes, why?
• If no, why not?
• What is involved in getting a biopsy?
• What are the risks?
• How is the procedure performed?
• How long does the procedure take?
• What experience do you have, or does the doctor performing
the procedure have in doing liver biopsies? (The more experience
they have, the better.)
• If a liver biopsy shows that I have fibrosis or cirrhosis
(scarring), how does that affect my treatment options?
• (If you have already gotten a biopsy) What are the
results of my liver biopsy and what does it mean? Will the
result affect my treatment?
• May I have a copy of the biopsy report for my records?
Questions about Treatment
• Do you feel I am a good candidate for interferon and
ribavirin combination therapy? What about pegylated (peg-a-lated)
interferon therapy?
• If so, why?
• If not, why?
• What are the pros and cons of beginning treatment?
• What are the potential side effects of interferon
and ribavirin, or of pegylated interferon?
• How long do you think I will have to be on therapy?
• How is the treatment taken?
• How may the treatment affect my life and my lifestyle?
• What is the likelihood that the treatment will be
successful?
• Should my partner or I practice birth control while
on the medications?
• Can my partner (or I) get pregnant safely while I
am on the medications?
• Do you exclude patients from interferon/ribavirin
or pegylated interferon treatment if they have advanced liver
scarring?
• If I have a history of mental health issues (depression/anxiety),
will I be a candidate for hepatitis C treatment?
• How will my mental health be managed?
• What will be done if my mental health gets worse?
• If I am on methadone, how will this affect my eligibility
for hepatitis C treatment?
• How do you feel about treatment for hepatitis C while
a person is on methadone?
• Will you work together with my dispensing/treatment
agency to coordinate my care?
• Are there new therapies that will soon be available,
and do you think I should wait for them?
• While on treatment, how often will I need to return
for follow-up?
• What should I do if my health gets worse between now
and the next time I see you?
• Are you available by phone?
• What should I do if I have side effects? Is there
anything I can take to help the side effects go away?
• Is there anything I can do on my own to help—such
as changes to my diet, etc?
Questions about Emotional Issues
• Where can I find emotional support for my family and
for me?
• How can I expect this to affect my marriage or other
intimate relationships?
• How do I explain my diagnosis to friends and family?
• Are there any clinical trials I could participate
in?
• Who from your office can I speak with if I have questions
or concerns about my treatment?
Questions about a HealthCare
Provider’s Experience with Hepatitis C:
• Do you have many other patients with hepatitis C?
• Do you feel up-to-date on all the latest changes and
advancements in hepatitis C treatment?
Now that you are armed with some questions to ask, you may
wonder how to ask these questions. Providers can sometime
appear intimidating and may make you feel they are rushed.
Be confident. Providers are usually more than happy to take
the time to answer any questions or schedule time to answer
questions later, perhaps by email or phone.
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Occupational
Exposure to Hepatitis C
Alan Franciscus, Editor-in-Chief
Hepatitis C virus (HCV) is transmitted through blood-to-blood
exposure. The most common transmission routes include sharing
HCV infected needles and drug preparation tools, and receiving
blood products/ transfusions before 1992. Sexual transmission
is less common but has been documented in studies. Tattooing,
body-piercing and sharing personal items such as toothbrushes
and razors are also possible transmission routes, but are
not well-documented. Health-care workers are at risk because
of needlestick accidents and unavoidable situations that may
result in direct contact with blood from an HCV infected individual.
HealthCare Workers
Healthcare workers or healthcare personnel are defined as
people whose occupational activities involve contact with
patients or with blood or other body fluids from patients
in healthcare, laboratory, or public-safety settings.
Occupational Exposure
It has been well-documented that transmission of hepatitis
C in a healthcare situation can occur. However, the general
rate of transmission is considered low—about 1.8%. The
risk is primarily with needlestick accidents involving hollow-bore
needles. Transmission from exposure to fluids or tissues other
than HCV-infected blood can occur but it is uncommon. If exposure
does occur, testing should be initiated and an occupational
exposure report should be filed.
Prevention
All healthcare workers should always follow standard universal
precautions including the use of gloves and face and eye protection
if appropriate. Properly dispose of or sterilize used equipment.
Safely dispose of used bandages, and clean and disinfect spilled
blood and body fluids. Unlike hepatitis B, there is no pre-
or post-exposure vaccine or immunoglobulin (IG) to protect
against HCV transmission.
Exposure
If exposure does occur the U.S. Public Health Service Guidelines
for the management of HCV exposure include:
For the source of infection:
• Perform testing for anti-HCV (antibody)
For the person exposed to an HCV positive
source:
• Perform baseline testing for anti-HCV and ALT activity;
and
• Perform follow-up testing at 4-6 months for anti-HCV
and ALT activity—if earlier diagnosis of HCV infection
is desired, testing for HCV RNA (viral load) may be performed
at 4-6 weeks.
• All anti-HCV results should be confirmed by enzyme
immunoassay using supplemental anti-HCV testing (RIBA).
• Information on counseling, testing and medical follow-up
should be given to individuals exposed to hepatitis C.
Antiviral Therapy for Post
Exposure
There are currently no treatment recommendations for patients
with acute hepatitis C, but recent data has shown that up
to 98% of people treated with interferon monotherapy were
able to rid their bodies of the hepatitis C virus. However,
the best time to start antiviral therapy and who should be
treated remain unknown.
Back to top
Review: Winning
the Hepatitis C Battle
by Dr. Schalla
Alan Franciscus, Editor-in-Chief
The book Winning the Hepatitis C Battle and its companion
CD cover every topic related to hepatitis C in an easy to
understand format sprinkled with patient anecdotes that help
guide the reader though the difficult process of understanding
the complexities of hepatitis C—the importance of your
liver, maintaining a healthy lifestyle, making treatment decisions,
preparing for treatment and getting through treatment. There
is a section devoted to helping a patient's loved ones understand
hepatitis C, learn to accept and be supportive as well as
assist and cope during treatment. The CD is jam-packed with
information presented by a variety of speakers, and there
are plenty of colorful graphics that make watching it a pleasurable
and rewarding learning experience.
It is very apparent that the book and CD are a labor of love
by someone who has a passion for hepatitis C and cares deeply
for his patients. I highly recommend the book and its companion
CD to anyone with hepatitis C. It is also an excellent educational
tool for helping hepatitis C affected families, medical providers,
health service organizations as well as the general public
learn more about hepatitis C.
To learn more about the book and
companion CD please visit: http://www.hepcbattle.com
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