back to 2005 Newsletters
Alan Franciscus, Editor-in-Chief
HealthWise: "Train with Slogans"
Lucinda K. Porter, RN, CCRC
Acetominophen and Your Liver
How to Start a
Support Group: Part 4
Alan Franciscus, Editor-in-Chief
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Alan Franciscus, Editor-in-Chief
of TreatmentThe current standard of care for treating hepatitis C is the combination of pegylated interferon and ribavirin, which results in an overall sustained virological response (SVR, continued undetectable HCV viral load six months after the completion of therapy) of up to 50% in genotype 1 and up to 90% in genotype 2 and 3 patients. Standard treatment protocol is to treat genotype 1 patients for 48 weeks and genotype 2 and 3 patients for 24 weeks. However, more and more research is indicating that there are other important factors to consider when treating hepatitis C, such as viral load, liver histology, gender, body mass index and steatosis. In hepatitis C genotype 1 patients there is a high relapse rate in patients treated with pegylated interferon and ribavirin when patients are treated for 48 weeks. The reasons for the relapse are unknown, but one speculation is that these difficult to treat patients may require an even longer course of therapy.
Thomas Berg and colleagues reported on a German multicentre study of 456 patients with hepatitis C genotype 1 infection treated with 180 ug peginterferon alfa-2a (Pegasys) plus 800 mg ribavirin for either 48 weeks (231 patients) or 72 weeks (225 patients).
The results of this study reported that the relapse rate for all patients who responded to the course of therapy was 23%. There was a slight difference in the relapse rate in patients treated for 48 weeks (26% relapse) vs. 72 weeks (19% relapse). However, a significant difference in relapse rates was found in patients with a late virological response, defined as HCV RNA greater than 1000 U/L at week 4 or 12, and negative at week 24. In the group that was treated for 48 weeks with a late virological response the relapse rate was 46% or 82% compared to 29% or 44% in patients who were treated for 72 weeks.
The authors concluded that a small but significant number of genotype 1 patients with detectable HCV RNA at week 4 or 12, but who became HCV RNA negative by week 24, would benefit from a longer duration of therapy. There is a larger prospective study underway to confirm these findings.
Durability of SVR
Sustained virological response is defined as becoming HCV RNA (viral load) negative during treatment with continued negative HCV RNA following 6 months after the completion of HCV therapy. SVR is considered by some experts to be a “cure” even though some reports have shown that a minority of patients (approximately 2-3 %) of patients become HCV RNA detectible after achieving an SVR. The reason for the return of detectable viral load has not been well studied, but some unknown variables such as re-infection of HCV, sensitivity of HCV RNA tests or lab error may exist. Because pegylated interferon plus ribavirin therapy has been studied for a shorter period of time, the durability of sustained virological response for pegylated interferon plus ribavirin therapy is unknown. The interim results of a study of peginterferon alfa-2a (Pegasys) plus ribavirin (Copegus) SVR durability were reported.
Mark Swain and colleagues reported on the interim results of 845 patients who achieved an SVR and on those of more than 40 patients have been followed for 5 years or longer. Of the total number of patients enrolled in this follow-up trial, 174 patients received peginterferon alfa-2a (Pegasys) monotherapy and 671 received various doses of peginterferon alfa-2a (Pegasys) plus ribavirin (Copegus). Overall, 838 of the 845 patients (99.2%) remained HCV RNA negative during the long term follow-up period. The authors concluded that “An SVR achieved with peginterferon alfa-2a (40KD) (Pegasys), alone or in combination with ribavirin (Copegus) is durable for up to 5 years after completion of therapy.” The authors also reported that there were no obvious common risk or treatment factors associated with detection of HCV RNA during follow-up, but that further investigation is underway to determine the reason for the reemergence of the hepatitis C virus.
Pegylated Interferon Long Term Maintenance
There is much research to determine the benefits of long term peginterferon maintenance therapy to delay or reverse HCV disease progression. Two ongoing trials are of interest: the HALT-C trial using Pegasys, and the COPILOT study using Colchicine (COLC) vs. Peg-Intron (PEG).
Colchicine vs. Peg-Intron
The interim analysis of clinical outcomes at Year 2 of the COPILOT study was reported at AASLD. Colchicine (KOL-chi-seen) is used to prevent or treat attacks of gout (also called gouty arthritis). Colchicine does not cure gout or take the place of other medicines that lower the amount of uric acid in the body. It prevents or relieves gout attacks by reducing inflammation. In the study, the effectiveness (slowing HCV disease progression) of colchicine (6 mg po bid) was compared with low dose Peg-Intron (0.5mg/kg/wk) in patients with advanced fibrosis (Ishak >3), who failed prior interferon based therapies.
Five hundred and thirty-four patients are enrolled in the study to date. Of these, 264 received colchicine and 270 received Peg-Intron. Patient characteristics were well matched. Seventy percent of the patients have received 2 years of therapy or have reached an endpoint. Of these, 59 patients (39 treated with colchicines; 20 treated Peg-Intron) have reached a clinical verified endpoint for an annual event rate of approximately 5%. (The primary endpoints are death, liver failure, variceal bleeding, liver cancer or liver transplant). The authors found that the primary endpoint showed a benefit in favor of Peg-Intron when compared to colchicine.
Overall 83 patients (14%) failed to comply with the study and are being followed off treatment or on alternative treatment. Thirty-eight (7%) discontinued for an adverse event (15 of colchicine; 23 of Peg-Intron). There were no unexpected or unusual serious adverse events in either group.
The authors concluded that “Low dose maintenance PEG is superior to COLC in preventing clinical complications of cirrhosis over 2 years of treatment, particularly in patients with portal hypertension and hypoalbuminemia. Maintenance therapy with PEG may be an option in cirrhotic patients who fail interferon based therapies.
The results of the use of Pegasys in the HALT-C trial are eagerly awaited. In the meantime, the results of a study conducted by Gregory Everson and colleagues on the benefits of Pegasys monotherapy on histologic improvement was reported on at AASLD.
The data for this study was obtained from a randomized controlled trial that compared 48 weeks of treatment with peginterferon alfa 2a (Pegasys) 90 ug/week or 180 ug/week or interferon alfa-2a (Roferon) 3 million units three times a week in 271 patients with cirrhosis or bridging fibrosis. Of these, pre- and post-treatment biopsies were available from 184 patients graded and staged (Metavir) by one pathologist blinded to treatment and to time of biopsy.
The primary end-points were improvement in fibrosis stage (defined as ≥ 1 stage improvement) and inflammatory grade (defined as ≥ 1 grade improvement) from baseline. The patient characteristics were similar between the three groups. The results of this study found that the SVR rates were higher in the Pegasys 180 ug/week group. In addition, the most significant decease in the inflammatory grade was 27.9% in the Pegasys 180 ug/week group; 31.1% in the Pegasys 90 ug/week group and 10.9% in the Roferon group. Improvement in the fibrosis score was seen in 35.3% of the Pegasys 180 ug/week group; 24.6% of the Pegasys 90 ug/week group and in 27.3% of Roferon group. The greatest decrease in the inflammation and fibrosis scores was seen in all patients who achieved an SVR.
The authors concluded that “although the greatest benefits were seen in patients with an SVR, patients with virological relapse and non-response also obtained moderate histologic improvement.”
Consensus interferon (Infergen) plus ribavirin is being studied for the treatment of naïve patients and the retreatment of prior interferon non-responders. Stephan Kaiser and colleagues reported on the positive results of a clinical trial of 120 patients (91% genotype 1). The average weight of patients was 79 kg. Liver biopsy was performed in all patients, with 28% of patients reported as having bridging fibrosis or cirrhosis. The patients were either treated with Infergen 18 ug daily for 4 weeks, followed by Infergen 9 ug daily for 8 weeks (group A), or with Infergen 27 ug daily for 4 weeks, followed by 8 weeks of Infergen 18 ug daily (group B). Groups A and B were than treated with Infergen 9 ug daily plus weight-based ribavirin for another 36 weeks.
The SVR results were 39% for group A and 44% for group B, which are impressive results for retreatment of non-responders. In this study 17% of patients had to be dose reduced and treatment was discontinued in 6% of patients. The most common cause for dose reductions were significant reductions in white blood cells and platelet counts, especially in the 27 ug Infergen group. No growth factors were used in this study. The overall tolerability of Group A was comparable to standard therapy, while Group B was less tolerable during the high dose induction period. Patient drop out rates were not different between the two groups.
Ribavirin monotherapy has minimal antiviral activity against the hepatitis C virus, but when combined with interferon the combination greatly improves SVR. The reason for the synergy of interferon and ribavirin is not clear. However, it has been speculated that the ribavirin acts against the HCV polymerase to create HCV mutants that make the hepatitis C virus ineffective. An NIH study of randomized, placebo controlled trials of ribavirin monotherapy between 1992-1994, in which patients were treated for 48 weeks was reported on at AASLD. There were thirty one patients (20 men, mean age 43.3 years) of whom 18 patients received ribavirin (1,000-1200 mg/day) and 13 patients received placebo. It was found that there were no significant differences in the clinical, virologic or histologic findings between the two groups. Comparing the ribavirin treated group to the placebo patients, there were no significant differences in the error generation rate, or the total number of mutations. The authors concluded that “Error catastrophe as a result of lethal mutagenesis is unlikely to be the mechanism of action of ribavirin during therapy for chronic HCV.”
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HealthWise: "Training with Slogans"
Lucinda K. Porter, RN, CCRC
“In all activities, train with slogans” is a Buddhist saying. I am a fan of catchphrases, so I particularly like this one because it uses a slogan to make a point about slogans. I use slogans to remind me of what is important in life. Like many humans, when I am under stress I am prone to self-neglect. This is not a healthy approach for anyone; particularly for one living with hepatitis C. Stress can influence the body’s immune system, both negatively and positively, depending on the type of stress and our response to it. High quality health relies on a functioning immune system.
Slogans or mantras are tools I keep in my “health toolbox.” Catchphrases help me to maintain focus. According to Merriam-Webster OnLine, the word slogan comes from Scottish Gaelic and it means “a war or rallying cry.” Another meaning is “a word or phrase used to express a characteristic stand or a goal to be achieved.” Slogans can help me rally around an issue and remind me to focus on my goal.
The use of mantras is not a bunch of New Age psychobabble. The concept has captured scientific interest. The field of cognitive behavior therapy (CBT) specializes in examining the thought process, finding negative thoughts, and trying to replace these with positive ones in order to make behavioral changes. Although written prior to the formalization of CBT, psychologist and philosopher William James summed it up beautifully when he stated, “Human beings, by changing the inner attitudes of their minds, can change the outer aspects of their lives.”
The idea of using slogans to influence behavior has been around for thousands of years. One only has to look at nearly any spiritual tradition to find a wealth of sayings. If you have any doubt about the power of slogans to influence both body and mind, just look at advertising. The field of advertising relies on jingles and phrases to catch our attention, influence our thinking, and affect the choices we make. “Having it your way” is an illusion, because in choosing a burger made by the corporation behind this advertising phrase, we are really having it their way. Having it “our way” for health conscious people involves healthy food choices – not fat-laden burgers and fries.
Catchy phrases come from all sources. In my younger days I had a job that involved manual labor. Whenever I was spending too much time perfecting a project, my supervisor would tell me, “It ain’t a Steinway.” To this day, when I find myself overly absorbed in trying to produce something perfectly, I tell myself, “It ain’t a Steinway.” However, there are times when it is important to strive for perfection and the corollary of this saying may not be true. For instance, when I am involved with direct patient care, patients are Steinways.
The New Year is traditionally a time for resolutions. For some of us, this is traditionally followed by foiled attempts. This year, instead of making resolutions, try “training with slogans.” Pick a slogan that has meaning, focuses on a reasonable goal, and is one you can remember. Write it down and place it where you will see it at least once a day. Writing it down several times and putting it in more than one place can be reinforcing. Write it in your own hand rather than type it. This engages the brain more actively. The length of the slogan is your choice. The point is to choose words that are meaningful and you can remember. You can use your own words or someone else’s. Sit down at least once a day in a quiet place, preferably early, relax, and say the words to yourself. Say them out loud. Throughout the day, try to find moments to recite your slogan. Repeating or chanting your slogan can be even more powerful.
To get you started I have provided a list of slogans and resources:
“I am content.”
“Count my blessings.”
“Patience is a virtue.”
“This too shall pass.”
“I am free of suffering.”
“I love and accept myself.”
“I have all the time I need.”
“Forgive others, forgive myself.”
“Be here, now.” – Ram Dass
“I am enough, I have enough, I do enough.” – Unknown
“Be the person your dog thinks you are.” – Unknown
“The darkest hour is that before the dawn.” – Euripides
“Do what you feel in your heart to be right.” – Eleanor Roosevelt
“Old dreams chase away new ones.” – Gary Trudeau Doonesbury
“Challenges are opportunities in work clothes.” - Unknown
“That which does not kill me, makes me stronger.” – Unknown
“If I am not for me, who is? If not now, when?” – Abraham Heschel
“Only I can change my life. No one can do it for me.” – Carol Burnett
“When it is dark enough you can see the stars.” – Ralph Waldo Emerson
“You must be the change you wish to see in the world.” – Mahatma Ghandi
“Keep your face to the sunshine and you cannot see the shadow.” – Helen Keller
“If we don’t change, we don’t grow. If we don’t grow, we aren’t really living.” – Gail Sheehy
“A strong positive mental attitude will create more miracles than any wonder drug.” – Patricia Neal
“When you arise in the morning, think of what a precious privilege it is to think, to enjoy, to love.” – Marcus Aurelius
“We must be willing to give up the life we’ve planned, so as to have the life that is waiting for us.” – Joseph Campbell
Bartlett, John. Familiar Quotations: This reference book is in its 17th edition and can be found in any library or bookstore. An Internet search using the phrase “Bartlett’s Quotations” will yield a treasure of quotes. Two specific web sites are:
I am interested in learning your favorite slogans and quotes. Please send them to my attention, Lucinda Porter, email: email@example.com. Write the word slogan in the subject line and if I get enough responses I will include them in next year’s January column. Include the source of the slogan, and if you wrote it, let me know if you give permission to use your name if the quote is published.
William James wrote, “If you want a quality, act as if you already had it.” May you live your life well this New Year.
Copyright, January 2005 Lucinda Porter, RN and Hepatitis C Support Project / HCV Advocate www.hcvadvocate.org – All Rights Reserved.
Reprint is granted and encouraged with credit to the author and Hepatitis C Support Project Back to top
and Your Liver
The pain-reliever acetaminophen is one of the best-selling over-the-counter medications, used by 100 million people each year. It is sold under many brand names, including Tylenol, and is an ingredient in hundreds of combination medications, both over-the-counter (such as Excedrin, Midol, NyQuil, and Sudafed) and prescription (such as Vicodin).
Most people believe that acetaminophen is safe, but it can cause serious liver damage—and even acute liver failure—if it is taken in high enough doses. In fact, it is one of the leading causes of liver failure in the United States, accounting for more than 56,000 emergency room visits and 100 deaths each year. Unsafe At Any Dose?
Most people are only at risk for liver toxicity if they take more than the normal recommended amount of acetaminophen. Most cases of liver damage occur in people who have taken at least 10-15 grams—more than twice the recommended dose. Many of the emergency room visits and deaths linked to acetaminophen poisoning are due to accidental or intentional overdoses (for example, suicide attempts).
But some people are more susceptible to acetaminophen toxicity and can experience liver damage even at the recommended dose. A study by the U.S. Food and Drug Administration (FDA) showed that about 20% of people with acetaminophen-related liver toxicity had taken less than the recommended daily amount. For other people, a dangerous dose is not much higher than the recommended dose—that is, the “window” between a therapeutic dose and a toxic dose is smaller for acetaminophen than it is for many other drugs. Some experts also believe that taking acetaminophen for several days in a row may cause a dangerous build-up of the drug in the body.
Acetaminophen is more likely to cause liver toxicity at near-normal doses when used by people who drink alcohol. In fact, people who drink regularly may be more prone to liver damage even if they do not consume alcohol and acetaminophen at the same time. There appears to be added risk even if people take acetaminophen a few hours, or in some cases longer, before or after drinking. Since the mid-1990s, the Tylenol package has included a warning against drinking alcohol when using the drug.
How Acetaminophen Harms the Liver
Like many drugs, acetaminophen is metabolized by the liver. If the normal processing pathway is overwhelmed by a high dose, a different pathway known as the cytochrome P450 enzyme system kicks in. When this happens, a toxic metabolic byproduct called NAPQI is produced that can kill liver cells. Alcohol and many other drugs also use the cytochrome P450 processing system, and the risk of a “bottleneck” is greater if the liver has to deal with both acetaminophen and these other substances at the same time.
Acetaminophen poisoning has three stages. During the first 12-24 hours after taking the drug, a person may experience nausea and vomiting. During the second phase, from 24-48 hours, the person usually feels better. After 48-72 hours, however, liver enzyme (ALT and AST) levels start to rise, indicating liver injury. In the most severe cases, a person may develop acid buildup in the blood, excessive bleeding, and coma. At this stage, only a liver transplant can prevent death.
Fortunately, there is an antidote for acetaminophen poisoning. NAPQI is normally detoxified by a naturally occurring antioxidant called glutathione. But if too much acetaminophen is present, the body’s supply of glutathione can be used up. An amino acid called N-acetylcysteine (NAC), which restores glutathione in the cells, can be administered to reverse acetaminophen toxicity. NAC is most effective when used within 16 hours after taking acetaminophen; however, people often do not recognize that gastrointestinal symptoms could be an early sign of acetaminophen poisoning.
An FDA advisory panel recommended several times (most recently in September 2002) that products containing acetaminophen should carry a warning on the label about the risk of liver toxicity. In January 2004, the FDA launched a new public education campaign warning consumers about the potential risks of acetaminophen and other pain-relievers. Some companies now clearly label their products containing acetaminophen. This is important because unintentional overdoses can occur when people take two or more medications together without realizing they all contain acetaminophen. However, the FDA still does not require that such products carry a warning label concerning liver toxicity.
Acetaminophen for People with Hepatitis
What does all this mean for people with chronic hepatitis B or C? Doctors often recommend acetaminophen to relieve symptoms such as body aches and fever, which are common side effects of interferon therapy. For most people, acetaminophen is safe and effective. According to the FDA’s Dr. John Senior, “It’s very clear the average dose for the average person is very safe. But we are not all average people.” For many individuals, acetaminophen is still a good choice, especially considering that other over-the-counter pain-relievers can cause problems of their own (such as stomach bleeding with aspirin and nonsteroidal anti-inflammatory drugs).
The following tips can help prevent acetaminophen-related liver toxicity:
• Do not take more than the recommended dose of 4 grams within a 24-hour period (for example, 12 regular strength or 8 extra strength Tylenol tablets)
• Do not take the full day’s dose at one time; space it out over the course of the day
• Do not take acetaminophen for more than 10 days in a row
• Avoid drinking alcohol; this is important for people with hepatitis whether or not they use acetaminophen
• People who do consume 2-3 alcoholic drinks per day should not take more than half the usual recommended dose of acetaminophen (2 grams within 24 hours)
• People with advanced liver fibrosis or cirrhosis should avoid acetaminophen
• Write down how much acetaminophen you take, and when, if you have trouble remembering
• Check the labels of all medications; small doses of acetaminophen in combination remedies can add up to big trouble.
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How to Start a Support Group: Part 4
Alan Franciscus, Editor-in-Chief
A peer led support group is very different from a therapy group that is led by a therapist who is educated and professionally trained to guide people through complex emotional issues. A peer led support group is usually led by someone who has not been professionally trained as a therapist. While peer led support groups should not be intended as a substitute for professional therapy, members may find emotional support from the group members that is therapeutic in nature. It is not overly difficult to learn how to run a support group. Some people are born with the talent to become a support group leader; but with education, experience and help from others, almost anyone can become a support group leader if their heart is in the right place.
A support group requires that someone lead or oversee the entire group process. The role can be defined as total or limited, depending on how much time and energy the individual wants to invest. Most people starting a group take on the role of facilitator, but it is not required. Some people prefer to work behind the scenes and leave the leadership to another member. Others may set up the group (by agreement with other members) to rotate facilitation among the members of the group. There are also groups that have no leader and rely on a true peer led support concept in which there is equal power and decisions are made by consensus of the group members. Alcoholics Anonymous (AA) is an excellent example of a peer led support group where specific principles and rules have been developed and applied and where the leadership role is rotated between the members.
The Role of the Facilitator
If you have decided that you would like to facilitate a support group or mentor someone else to become a leader there are some important steps to take before the first meeting. The first step is to understand the role of the facilitator. Basically, a facilitator’s job is to help guide and support the entire support group.
There are certain traits that a good facilitator possesses—many of these traits can be learned from experience or from reading and attending seminars on group facilitation. Some people take naturally to the role while it may be more difficult for others to be an effective group leader.
Qualities of an effective group leader include:
• Knowledge of hepatitis C: A person does not need to be an expert on hepatitis C, but should be knowledgeable about HCV to some extent to help correct inaccurate information.
• Compassion: Feeling empathy for people.
• Conflict: Able to deal with conflict and effectively manage potential conflicts between group members.
• Communication skills: Be able to listen and to convey that you understand what is being said.
• Real: Express your feelings in an honest and open way.
• Present: Be in the moment and not thinking about situations outside of the group.
• Positive: A healthy outlook on life so that the group can always draw from your positive traits.
• Boundaries: Set clear goals about what steps are needed to help, and be able to set your emotions aside. Not internalize or take on the emotional needs of the other members.
• Non-Judgmental: Always open to someone’s experience and not making any judgment calls based on what they have done or tell you.
• Open mind: Be able to look at ideas and situations openly and honestly.
• Observant: Be aware of others in the group in regard to verbal and non-verbal language—vocal intonations, facial expressions and body language.
• Energetic: Positive energy for other members to draw upon.
• Look for the positive in people instead of the negative.
Of course we are not all saints, but these characteristics are important to have or to strive or work toward. It may seem like a monumental list of characteristics, but you may be surprised how many you possess or how easy they are to obtain.
Is There a Need for a
A co-facilitator is highly recommended for groups that have a large membership. In fact, the responsibilities of facilitation can be shared on a rotating basis. A co-facilitator can take off some of the pressure on the facilitator and monitor the other group members while the lead facilitator is busy interacting with the members. A co-facilitator can also monitor the other group members and intervene if there are times when things are stuck or when there are potential problems. If you should decide to seek out a person to co-facilitate, look for the same traits that would make a good facilitator and for someone with whom you feel comfortable working in the support group environment.
How do you get people to join the support group? Sometimes, it can actually be difficult to recruit members. This can be for a variety of reasons, but probably the most important reason is that since it is a emotions based support group it takes a leap of faith for people to trust that the group will be a safe environment for people to discuss their very private feelings, especially at first when all the group members are strangers.
Strategies for recruiting members:
• Develop a flyer for the support group that would motivate people to want to join a support group – proactive, positive and caring.
• Post the flyer in doctors’ offices, medical institutions, community-based organizations, public health departments or any other agency that may serve and support people with hepatitis C. It would help to personally talk to organizations about the new group, and to get permission to post the flyer.
• Newspaper advertisements can be a good way to attract members. Look for community based or local papers that cater to various communities or to a specific population that you would like to attract.
• Develop a press or media kit (a general press kit is available on the HCV Advocate Web site) and send it to local newspapers, radio, television or any other media that may be available.
• Contact a national or local self-help clearing house. A clearing house may be able to list the support group in their directory.
Develop a flyer that is upbeat and positive:
• List the objectives or mission of the support group: be clear and concise in your objectives:
*“The mission of HepCats is to provide peer support and education for hepatitis C positive people.”
•List the affiliations on the flyer, such as medical providers that endorse the group:
*“The HepCats support group is endorsed by the Sunnybrook Medical Center.”
•List the approximate location time, duration or any other important information.
*“Title: HepCats Support Group
Time: Every Wednesday of the month from 6:30 – 8:00PM
Location: 1225 Market Street, San Francisco, CA 04112
Purpose: To provide peer support to people with hepatitis C
Please call: 555-1212 for more information.”
• For a drop-in type of support group, list the exact address:
* “Would you like to meet others with hepatitis C and learn how they live positively with HCV? A support group meets every Wednesday from 6:30-8:00 at 1255 Market St., San Francisco, CA 04127. Check us out!”
• If you decide to name your support group – make it upbeat or specific to the members you would like to attract to the group:
* “The HepCats: For living positively. Being well,” or
* “The Positive Partners meet to support partners of people with HCV
• List a phone number or another means of contacting you if you want to interview people before they attend a meeting. If you are listing a personal phone number you may want to consider adding a new telephone line or a new voicemail box to your existing voicemail options. A word of caution—if you list your home phone, you may want to make sure that you have an option for turning the ringer off in case you receive calls at odd hours of the day or night. Some people prefer having a voicemail box separate from their personal or home phone.
•Talk with other support groups that are currently serving the needs of the HCV community – you may have a particular type of support group that they can support or endorse. For instance, a current support group may endorse and send people to your group if it is a support group for
family and friends.
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