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Making a Difference in Your Community

a quarterly training newsletter from the Hepatitis C Support Project

Welcome to HepSquads, a new newsletter published by the Hepatitis C Support Project. The goal of this newsletter is to provide HCSP trainers with the necessary tools to help support them in their outreach efforts with timely updates, personal stories and other pertinent information.

Regular features of “HepSquads” will include a quarterly news summary, personal success stories from HCSP trainers, training tips and more.

Help us make this newsletter as effective as possible by telling us what you would like to see in the newsletter to help in your efforts. You can mail us at HCSP, PO Box 427027, San Francisco, CA 94127 or email us at alanfranciscus@hcvadvocate.org with your suggestions.

Alan Franciscus
Editor-in-Chief, HepSquads

To learn more about HCSP Trainings and the upcoming schedule, click here.

Vol 14: October, 2006
Table of Contents

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Harm Reduction in Hepatitis C Trainings
Heather Lusk, Hepatitis C Coordinator Hawai`i Department of Health

Incorporating harm reduction concepts, strategies and evidence-based practices into hepatitis C trainings is important because of the disproportionate rates of hepatitis C among current and former injection drug users. According to the Centers for Disease Control and Prevention, 60% of new hepatitis C infections occur in persons who inject drugs and other substances and approximately 80% of people with a history of injection drug use have contracted hepatitis C. Harm reduction is a philosophy or way of working with people that focuses on ways to decrease the potential harms associated with behaviors instead of working to stop the behaviors from occurring altogether. While harm reduction has its roots in drug using communities, it can be applied to almost any behavior that has the potential for harmful consequences. This article will focus on ways to integrate harm reduction into the structure of your hepatitis C training, reflect on harm reduction techniques in the transmission and prevention information shared with participants and provide tips on how to discuss hepatitis C treatment in active drug users.

Harm reduction is more about the process of working with someone rather than the specifics of your work together. Many of the concepts of harm reduction reflect this and hepatitis C trainers can model these elements throughout the training. Harm reduction tenets such as “meet people where they’re at” can support a two-way flow of information and decision-making. Modeling these concepts as a trainer not only involves your participants in the learning process but acknowledges the necessity of using the same perspective with people at-risk for and living with hepatitis C. Incorporate harm reduction concepts into group agreements/ground rules at the beginning of the training. For example, “unconditional positive regard” may be an appropriate agreement to create safety in discussing controversial topics. Brainstorming participant expectations of the training and trying to meet them reflects the harm reduction philosophy of having people define their own goals and using options, not directives. Another way to model harm reduction is to be mindful of language that may be perceived as judgmental or which portrays a moralistic view of drug use. For example, using the term “substance or drug use/users” instead of “substance or drug abuse/abusers” demonstrates an understanding of the complexity and continuum of drug use while not labeling people based on their behaviors.

Discussing HCV transmission and prevention information provides another opportunity to dialogue with participants about ways to support active injection drug users in preventing the transmission and acquisition of hepatitis C. Many hepatitis C educational materials list abstinence from injection drugs as the only way to prevent hepatitis C transmission, although this is not realistic for all drug users. Therefore, additional options to reduce the risk of transmission enhance a person’s ability to take care of themselves and others. Having access to clean and sterile syringes, cookers, water, cotton and other injection equipment is the most effective way to reduce the spread of HCV among active injectors. Data strongly suggests HCV transmission also occurs outside of the syringe which requires comprehensive health messages for drug users to address every aspect of their injection ritual to avoid blood exposure. In areas without access to sterile injection equipment, other prevention measures should be explored. While bleaching syringes has not been proven to prevent hepatitis C transmission, it may reduce the risk. Other harm reduction HCV prevention measures may include using more lubrication during sex to avoid trauma and blood which have been linked to sexual transmission of HCV, not sharing intranasal equipment and using mouth guards on pipes to avoid burning the lips which creates a point of entry for the virus. Encouraging creative thinking among training participants for harm reduction measures for active drug users can yield new and innovative options.

One of the biggest challenges in the harm reduction and hepatitis C movement is increasing access to hepatitis C drug-based therapies for active drug users. Despite federal guidance suggesting drug users should not be denied HCV treatment, many healthcare providers, 3rd party payers and policymakers continue to restrict access to these potentially lifesaving medications for people who use drugs, according to a study published earlier this year in Clinical Infectious Diseases. The 2002 National Institutes of Health Consensus Statement on the Management of Hepatitis C recommends that “active injection drug use in and of itself not be used to exclude such patients from antiviral therapy.” This guidance is based on research that suggests some drug use during treatment doesn’t negatively affect treatment response. In fact, a recent study published this month by Dr. Diana Sylvestre found that patients on methadone who were on interferon/ribavirin therapy and used marijuana were more likely to adhere to treatment, stayed on the treatment longer and had a higher sustained virologic response rate than those who didn’t use marijuana.1 Trainers may need to remind participants about group agreements prior to this often heated discussion, and activities such as a mock debate or brainstorming the pros/cons may facilitate dialogue. Another contentious issue to discuss is how to reduce the harm in people with liver disease who continue to drink alcohol. Abstaining from alcohol use may be the best action for liver health, but unrealistic for some people. Include messages about spacing of alcoholic drinks and drinking lower alcohol content drinks such as beer or wine instead of hard alcohol. One step further would be to discuss safer drug use in persons with hepatitis C since some drugs (psilocybin, amphetamine) have been proven to be harder on the liver than others and some methods of administering the drug (swallowing) affect the liver more directly than other methods. The harm reduction concept of “any positive change” can be applied to any behavior a person wants to modify to support a healthier liver, including diet, exercise, water consumption and limiting exposure to liver toxins.

There is a strong social justice component to the harm reduction movement as there is in the hepatitis C movement, and integrating aspects of harm reduction into your trainings creates an opportunity for participants to explore the ways these two communities are intertwined. Being an advocate for people affected by hepatitis C often means being an advocate for people with a current or former history of injection drug use. Hepatitis C trainings create a unique opportunity to raise awareness about the concept of harm reduction and encourage participants to create services that meet the needs of those at-risk for and living with hepatitis C, which means broadening our approach to working with active drug users.

1 DL Sylvestre, B J Clements, Y Malibu. Cannabis use improves retention and virological outcomes in patients treated for hepatitis C. European Journal of Gastroenterology and Hepatology 18(10): 1057-1063. October 2006.

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News Roundup
Liz Highleyman

Liver Awareness Month Calls Attention to Hep C
Hepatitis C was in the news recently, as October 1 was World Hepatitis Awareness Day and October is liver awareness month. It is estimated that more than half a billion people have either hepatitis B or C, but many do not know they are infected. The World Health Organization took the opportunity to encourage people to get tested for HBV and HCV. “Stigma, shame and fear can suffocate awareness. These barriers prevent people from getting tested, receiving treatment, and clearing themselves of this disease,” said Live Aid founder Sir Bob Geldof. “People can be infected with the virus for years and not know. The good news is that hepatitis C can actually be cured in many people. The worst situation is to be diagnosed when the disease has progressed too far to be treated.” To increase your own liver awareness, check out “Not Trivial Liver Trivia” in the October 2006 HCV Advocate.

Steven Tyler: “I Have Hep C”
Another celebrity, Aerosmith lead singer Steven Tyler, announced in late September that he has been battling hepatitis C for years, but now appears free of the virus after receiving a course of interferon therapy. Tyler, 58, was diagnosed with the virus three years ago, which he attributed to past substance use. Now clean and sober for more than a decade, he told Access Hollywood that he was nearing the end of his 12-month treatment, and the virus was “nonexistent in my bloodstream as we speak.” If HCV remains undetectable six months after the completion of therapy – sustained virological response, or SVR – a patient is considered “cured.” Tyler said he decided to reveal he had hep C in order to raise awareness of the disease, joining fellow stars such as Pamela Anderson and country singer Naomi Judd.

New California HCV Policy Alliance
After two conferences in May and June, HCV advocates formed the new California Hepatitis C Alliance. The alliance brings together policy-makers, caregivers, and activists throughout the state to foster collaboration and create unified policies on issues such as increased funding and clean needle availability. The first issue of the coalition’s newsletter is available on the HCV Advocate web site at www.hcvadvocate.org/community
/community_pdf/ California%20HepC%20Alliance

Medical Marijuana Improves HCV Treatment Response
Medical cannabis can help people with hepatitis C stay on treatment and achieve better outcomes, according to a study in the October 2006 European Journal of Gastroenterology and Hepatology. Dr. Diana Sylvestre and colleagues studied 71 patients with HCV at OASIS (a substance use clinic in Oakland) who had been on methadone maintenance for at least three months. About one-third used marijuana while undergoing anti-HCV treatment with conventional interferon plus ribavirin. The researchers found that 54% of cannabis users had undetectable HCV six months after completing treatment, compared with 18% of non-users. While the frequency of side effects was similar in both groups, cannabis users were more likely to stay on therapy.

But this doesn’t mean hep C patients should indulge without restraint: in the OASIS study, those who used the largest amounts of cannabis did not show as much benefit as moderate users, and a previous study found that HCV positive people who smoked marijuana every day were more likely to experience rapid liver fibrosis progression. Nevertheless, in an accompanying editorial, a group of hepatitis C experts recommended that while further research is underway, “we advocate that in the interim existing barriers to cannabis use are removed for drug users undergoing HCV treatment.”

Hep C and Your Heart
Some past research has suggested that HCV infection is associated with atherosclerosis, insulin resistance, and other risk factors for heart disease, giving people with hepatitis C one more thing to worry about. But a case-control study reported in the September 15, 2006 electronic edition of Clinical Infectious Diseases found no link between HCV and elevated risk of acute myocardial infarction (MI), or heart attack. In this study of male active-duty U.S. army personnel aged 30-50, HCV infection was no more common among patients hospitalized for a first heart attack than among those with no history of cardiovascular disease. Not surprisingly, smoking, high cholesterol, and work-related stress were linked to increased heart attack risk. The authors concluded that, “The results of this study do not indicate any relationship between HCV seropositivity and acute myocardial infarction,” but noted that active-duty military personnel tend to be in overall good health and below the age at which most heart attacks occur.

In related news, another research team recently reported that high levels of total and LDL (“bad”) cholesterol predicted better response to interferon-based therapy for hepatitis C. This may occur because HCV appears to use LDL receptors to enter cells, and a high amount of LDL may “use up” these receptors and block viral entry. Much remains to be learned about how HCV influences – and is influenced by – metabolic factors such as blood fat and glucose levels. Another recent study, for example, found that HIV/HCV coinfected patients were less likely to experience drug-related blood fat increases when starting anti-HIV therapy. Until more is known, the usual advice to eat a well-balanced diet remains in effect, since there is ample evidence that obesity contributes to liver disease progression and poorer response to anti-HCV therapy.

HCV Transmission News
Several recent journal articles have explored various aspects of HCV transmission.

Three recent studies looked at risk factors for HCV infection among injection drug users (IDUs). In the October 2006 issue of Addiction, Australian researchers reported that among 368 initially HCV negative IDUs followed for up to three years, the HCV seroconversion rate was 30.8 per 100 person-years; among participants who had been injecting for less than a year, however, the rate was more than four times higher (133 per 100 person-years). Factors that predicted HCV infection included female gender, shorter duration of injection, injecting cocaine, and sharing cotton or other drug filtering materials. A second study, in the August 2006 Journal of Viral Hepatitis, likewise found that “sharing of materials other than syringes/needles indeed seemed to contribute substantially to the spread of hepatitis C among injecting drug users.” A study in the September 15, 2006 Journal of Infectious Diseases found that 78% of recent drug injection “partnerships” involved behavior that could transmit HCV – including nearly 25% that involved syringe sharing. HCV-infected and uninfected IDUs engaged in similar injection behavior, however, leading the authors to conclude that “seroconversion was mostly an accident of network position – that is, injecting with more individuals who happened to be HCV infected.” Together, these studies suggest that prevention programs should educate IDUs about the risk of sharing equipment such as filters, cookers, spoons, and rinse water, as well as needles and syringes.

HCV prevention guidelines also often advise against sharing toothbrushes, razors, and other personal care items. As reported in the September 2006 Journal of Viral Hepatitis, researchers collected and tested saliva and toothbrush rinse waters samples from 30 HCV positive individuals. They found that HCV was more likely to be present in saliva after tooth-brushing than before (37% vs 30%), and that 40% of rinse water specimens tested positive for HCV. In a study of nearly 8000 college students, however, researchers found no evidence of increased risk of hepatitis B or C associated with tattooing, piercing, or intranasal drug use (“snorting”).

Finally, in the August 2006 issue of Sexually Transmitted Infections, British researchers provided further information about risk factors associated with an ongoing outbreak of apparently sexually transmitted HCV among HIV positive gay and bisexual men in London. Factors linked to acute or recent infection included unprotected anal intercourse, more than 30 sexual partners in the past year, a higher number of new sex partners in the past month, use of sex toys, oral-anal sex (“rimming”), intranasal drug use, and especially anal fisting. Men who practiced fisting were about six times more likely to be infected with HCV, but most also engaged in other risky practices, making it hard to determine which activities might be responsible for transmission.

HIV/HCV Coinfection
In August, the largest-ever International AIDS Conference took place in Toronto, followed by the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in San Francisco in September. Both meetings featured several reports on hepatitis C coinfection in people with HIV, including treatment of acute infection in men with sexually transmitted HCV, effectiveness of retreatment with pegylated interferon plus ribavirin, and liver toxicity due to antiretroviral drugs. For a summary of these and other presentations, see the November 2006 HCV Advocate.

The HCV Drug Pipeline
Development of new anti-HCV agents continues at a rapid pace, with several experimental candidates in the pipeline. A list of Hepatitis C Treatments in Current Clinical Development is available on the HCV Advocate web site at www.hcvadvocate.org/hepatitis
. Drug resistance is one factor that can interfere with the effectiveness of antiviral agents. For an overview of resistance and drug development, see “New HCV Antivirals and Drug Resistance” in the August 2006 HCV Advocate.

One investigational drug candidate – Viramidine (taribavirin), a relative of ribavirin – recently failed to demonstrate “non-inferiority” to ribavirin for the second time, manufacturer Valeant Pharmaceuticals announced in September. The international VISER2 study, which included nearly 1000 participants, found that twice-daily Viramidine was not more effective than twice-daily weight-based ribavirin, when both were used in combination with Pegasys (overall SVR rates of 40% for Viramidine vs 55% for ribavirin). These results are similar to those of the VISER1 trial, announced earlier this year. But study subjects who took Viramidine did have a lower rate of anemia (6% vs 22%), which often necessitates ribavirin dose reduction. Valeant said it would continue development of the drug using higher doses. For more information on Viramidine and the recent study results, see the October 2006 HCV Advocate.

Further back in the pipeline, researchers at ICAAC reported data from preclinical studies of three anti-HCV candidates: ViroPharma and Wyeth’s non-nucleoside HCV polymerase inhibitor HCV-796, Roche’s polymerase inhibitor R1479, and Merck’s nucleoside inhibitor MK-0608. In August, ViroPharma and Wyeth, which are jointly developing HCV-796, announced that they had achieved a “proof of concept” milestone in an early study of drug in combination with pegylated interferon, and that they would initiate a Phase II trial.

Enrolling HCV Clinical Trials
More than 100 clinical trials are currently underway to test new anti-HCV agents and novel treatment strategies. A few open studies are listed below; for more, see the federal government’s clinical trials web site at www.clinicaltrials.gov and search for “hepatitis C” or “HCV.”

• A Study Evaluating the Safety and Clinical Activity of HCV-796 in Treatment-Naive and Non-Responder Subjects

• Study of AVI-4065 in Healthy Volunteers and Chronic Active HCV Patients

• APOLLO Study: A Study of HCV Polymerase Inhibitor Pro-Drug in Combination With Pegasys With or Without Copegus in Patients With Chronic Hepatitis C Genotype 1 Infection

• Individually Adapted Therapy Duration for the Treatment of Chronic Hepatitis C Genotype 1 Infection

• Maintenance Therapy and Liver Disease Progression in People Infected With Both HIV and Hepatitis C Virus (HCV)

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Attention Trainers

The Hepatitis C Support Project has launched a new program to help trainers with their educational efforts. Included are tools to help you educate others. Listed below are various files to download and use for your training needs.

1. One Day 2006 is the entire slide presentation that we are currently using for our trainings. Included in the slides are notes – just click on the note function. Format: MS PowerPoint

2. Overview of HCV in English is a template for general information about hepatitis C in English. Included in the slides are notes – just click on the note function. Format: MS PowerPoint

3. Overview of HCV in Spanish is a template for the above file in Spanish. Format: MS PowerPoint

4. HCV Myths is a presentation about various myths about hepatitis C. Included in the slides are notes – just click on the note function. Format: MS PowerPoint

5. Game: Hepardy contains a sample game board, questions/answers. Format: MS Word.

6. Crossword Puzzle: Puzzle #1 and answers Format: Adobe pdf.

To access these files just cut and paste the following into your browser:

Your browser must be enabled for ftp.

To enable ftp in Internet Explorer
1. In internet explorer, click on tools, internet options, advanced
2. Then click on Enable folder view for ftp
3. Scroll down
4. Click on Use passive ftp

Please keep checking back – we will be posting additional files to help educate people about hepatitis C. If you have any suggestions for information that will help you, please email alanfranciscus@hcvadvocate.org

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