|
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 6: October, 2004
Table of Contents
 PDF (download)
A Simple Guide to Effective HCV Presentations: Part 1
Alan Franciscus
ONE OF THE MOST DIFFICULT
tasks as an HCV educator is
to present information in a
way that encourages learning and understanding of the
complexities surrounding
hepatitis C. In general, presentations
can be a profound
experience for the presenter
as well as the audience.
Information can be presented
in a variety of ways.
HepSquad trainers typically
use two common formats.
One is the formal lecture or
didactic (educational or
teaching) style. The second
presents information in an interactive
environment such as
in a workshop. These types
of presentations require different
teaching techniques.
Since techniques differ depending
on the format, it is
common for a person to excel
at one type of presentation
but not the other. This is
most likely due to the experience and comfort level of
the presenter.
This article is part one in
a series of tips for HepSquads
trainers to help them improve
their educational efforts. Part
one will focus on general information
about presenting
in a workshop environment.
HCSP Train the Trainer
workshops, held across the
United States, are two-day
workshops conducted in an
interactive format, usually
limited to 50 people or less.
But many of the principles
described in this article can
be applied to any type of educational
workshop. Future articles
in this series will offer
more in-depth information to
provide trainers with practical
tools. It should be noted
that people’s teaching styles
differ, just as people have different
ways of learning. This
is by no means a definitive
guide for presentations, but
a compilation of ideas that
have worked for our trainers.
I would be interested in hearing
what works well for you
or how you convey information
on the subject of hepatitis
C. I am especially
interested in interactive exercises,
so if you have any to
share, please contact me at
alanfranciscus@hcvadvocate.org.
Beginning a Training
Session
The beginning of a presentation
is one of the most important
components of any
successful teaching session.
Your introduction sets the
tone. This is usually the
most difficult part of the entire
presentation, since the
presenter is setting the goals
of the training and trying to
win over the participants. As
the saying goes, “you never
have a second chance to
make a first impression,” so
use this opportunity well.
Classroom Environment
The room where you teach
should be comfortable (not
too cold or hot), with good
lighting and plenty of room
for participants to move
around or break into smaller
discussion groups. Make
sure you can be heard by everyone
in the room. You may
want to use a microphone,
but be careful that you still
connect with the audience.
Too much technology can
sometimes interfere with
achieving the rapport you
need to establish with your
audience.
The Presenter - BE REAL!
The first part of the presentation
establishes your expertise.
You can mention a
degree or title you have
earned, the work that you do,
and/or how the topic has
affected you. A word of caution,
though: Don’t ramble
on about yourself. Instead try
to make your introduction
brief, interesting, and to the
point, and connect it to the
topic at hand.
Some examples:
• I am a counselor at a local
community-based organization
that provides
support and services for
people with hepatitis C.
• I am a street outreach
worker living with
hepatitis C.
• I am a medical provider
giving care and support
to people living with
hepatitis C.
• I am a person living
with hepatitis C. HCV
has greatly affected my
life and I want to do
what I can to help
provide support and services
for other people
with hepatitis C.
Tell your audience the
purpose of the workshop.
Be as specific as you can.
For example:
• This workshop is geared
towards street outreach
workers, and I’m going to
talk about the ways you
can catch hepatitis C as
well as ways to prevent
transmitting hepatitis C
to others.
• The goal of this workshop
is to provide you
with a basic understanding
of hepatitis C.
• The goal of this workshop
is to provide you
with counseling messages
that you can use with
your clients.
• The goal of this workshop
is to provide you
with information that will
make it easier to communicate
with your patients.
A presenter should know
the audience and dress accordingly.
Wear comfortable
and appropriate attire that
will not offend anyone. The same applies to the use of
language. Project your
voice clearly (loud but not
too loud) and pace your
presentation. This will help
people to absorb and understand
information and allows
time for questions.
Connecting with the
Audience
People listen, connect with,
and care about a presenter
who is willing to put himself
or herself out in front of a
group of people. It is intimidating
to be in front of
strangers, but remember that
most people in a workshop
have given presentations, are
aware of how vulnerable you
are, and will try to make you
feel as comfortable as possible.
Try to put your physical
person out in front of the
audience—don’t hide behind
a lecture stand or notes.
Make sure your notes don’t
block your face. Speak in a
conversational tone that is
evenly paced and spoken
with authority. When you are
speaking, avoid standing in
one place. Move around (but
not too much) and make eye
contact with people in the audience.
Look for friendly
faces and concentrate on
those people first. After a
while, you will be able to
read body language so well
you will be able to know
when to reiterate key points
or simply ask if the audience
understood the information
presented.
Questions are an essential
aspect of the teaching process.
Questions give you
valuable information about
your audience and can give
you feedback as to whether
or not your presentation is
coming across clearly. The
question and answer process
can build greater rapport with
members of your audience.
Encourage questions from
audience members who are
less vocal or less likely to
speak up. Be sure to make
eye contact while listening
to and answering questions.
Also, try to anticipate what
kinds of questions you are
likely to get. It is important
to have a thorough knowledge
of the topic in order to
handle any questions. It is
easier to answer a question
if you have prepared for it
in advance. If you do not
know the answer to a question,
say so. Never try to
bluff your way through an
answer. Your audience will
know if you are bluffing, and
this can lower your credibility.
People will respect a response
of “I don’t know” or “I’ll have to get back to
you with an answer.” However,
if you do choose the
latter, make sure you get
back to the person asking
the question.
Encourage interaction
among the audience.
Sometimes the most valuable
information is what
the participants hear from
others in the group. People
respond and learn from
their peers and “real
world” situations.
Setting Ground Rules
There is nothing worse than
having a chaotic workshop.
It helps to have everyone set
the ground rules. This
simple act gives your audience
more ownership in the
group. People are more
likely to adhere to guidelines
they have helped create
rather than to those set by
someone else. The most important
issues that need to be
decided are cell phone usage
and cross-talking. I have
never conducted a workshop
where the audience wants
cell phones ringing or people
cross-talking or carrying on
side conversations during
the presentation. These can
disrupt the entire workshop.
Content and Timing
Focus the content of your
presentation on the major
points you want to convey.
Do not try to cover too much
material. Stick to the main
points you want to cover.
During the presentation, if
someone asks a question that
is not pertinent to the topic,
would require too much time
to cover, or may confuse
people, don’t be afraid to
say:
• Your question is important,
but I’m afraid we
just don’t have enough
time to cover it in this
workshop.
• The short answer is
_________. Unfortunately,
we can’t really
answer the question in
the detail it deserves with
the remaining time.
• I’m afraid that we don’t
have time to discuss your
question. If you like, we
can talk about it privately
during a break or after
the workshop.
If there are too many
questions, let the audience
know that time is running
short. However, limiting
audience questions should
be discouraged, since it can
interfere with the crucial
interactive nature of workshops.
It is perfectly reasonable
to ask people to hold
their questions until the end
of the presentation or a particular
topic you are discussing.
Your audience also
wants to stay on track and
will respect your efforts to
stay focused.
Use Humor
Use humor, but use it wisely.
When the session is becoming
overwhelming or intense,
add some levity and
try to move on. There is
nothing worse than gloom
and doom when you are trying
to motivate people to
make positive changes.
Speak with Passion
Use passion when you
speak. Speaking from the
heart can be powerful.
People are usually moved
by hearing from someone
who cares enough to share
his or her feelings.
The Medium
Convey information in as
many different forms as possible,
such as written materials,
lecturing, and group
discussion. It is best to mix
technology forms (Power-
Point, overheads, flip charts,
props, and visuals). The
more variety you use, the
more the audience will be
engaged. However, be careful
that you don’t overwhelm
people with too
many visuals. Another rule
of thumb is be prepared for
technology glitches. It is inevitable
that equipment will
not work, so prepare a backup
plan that can replace a
presentation that depends on
technology. For example, a
simple question and answer
session can be rewarding for
you and your audience. A
back-up plan can transform
a potential disaster into a
more powerful experience if
the presenter really knows
the topic.
Lastly, make sure you reiterate
and summarize any
important information that
you want your audience to
learn. This can be accomplished
by asking the audience
for “take home”
points. You may also want
to restate the goals that you
set at the beginning of the
presentation.
Future HepSquads articles
will provide more indepth
discussion of the
topics in this article as well
as other tools to help in your
efforts. With time and practice,
you will increase your
skills and comfort level. Before
you know it, you may
find this a rewarding and enjoyable
experience.
A special thank you to Lucinda
Porter for her advice and help
with this article
Back to top
News Roundup
Liz Highleyman
SCHWARZENEGGER SIGNS
NEEDLE SALE BILL
On September 13, California Governor Arnold
Schwarzenegger signed SB 1159, a bill that allows cities
and counties to authorize the sale of up to 10 syringes in
pharmacies without a prescription. Sharing needles to inject
drugs is one of the primary routes of hepatitis C, hepatitis B,
and HIV transmission. Studies show that expanded availability
of clean needles—either through syringe exchange
programs or through over-the-counter sales—significantly
reduces infectious disease transmission without increasing
rates of drug use. “My administration supports this measure
because it will prevent the spread of HIV, hepatitis, and other
blood-borne diseases among injection drug users, their sexual
partners, and their children,” Schwarzenegger said. Only four
states now prohibit the non-prescription sale of syringes.
At the same time, the governor vetoed AB 2871, a bill
that would have made it easier for local governments to operate
needle exchange programs. Currently, in order to run a
needle exchange, cities and counties must declare a public
health emergency, which must be renewed every 2-3 weeks.
According to bill sponsor Representative Patty Berg (DEureka),
the proposal was intended to reduce “red tape.” A
dozen California cities and counties currently operate needle
exchange programs, but more have said they would do so if
the law were changed.
HCV TREATMENT FOR
METHADONE PATIENTS
A German study published in the July issue of Hepatology found that hepatitis C treatment is “reasonably safe and sufficiently
effective” in HCV positive individuals receiving
methadone maintenance therapy. The study included 100
subjects, 50 on stable methadone maintenance for at least
six months and 50 who had not used illicit drugs or opioid
substitution for at least five years. All were treated with Peg-
Intron plus ribavirin. During the first eight weeks of treatment,
patients on methadone were five times more likely
than non-methadone control subjects to either ask to stop
HCV therapy or to discontinue due to nonadherence (22%
vs 4%). After eight weeks, however, rates of discontinuation
were similar (10% vs 8%, respectively). Treatment
discontinuation due to side effects or virological failure was
somewhat more common in the methadone group (20% vs
12%), but the difference was not statistically significant. No
serious psychiatric events occurred in either group (although
15 patients in the methadone arm and 10 in
the non-methadone group took antidepressants during
therapy). End of treatment response rates were 50% in the
methadone group and 76% in the non-methadone arm. After
24 additional weeks of follow-up, however, the corresponding
sustained virological response (SVR) rates were
42% and 56%, indicating that the relapse rate was higher in
the non-methadone group. (Since relatively few patients
completed a full course of treatment, the difference did not
reach statistical significance.) Although the response rate
was lower among patients on methadone—which the researchers
attributed to lower “compliance and reliability”— a substantial proportion did achieve SVR, supporting the
recommendation in the latest National Institutes of Health
consensus statement that hepatitis C patients receiving
methadone should be considered for therapy on an individual
basis.
HCV/HIV COINFECTION
Data from two major studies of hepatitis C treatment in patients
coinfected with HIV were published in the July 29
issue of the New England Journal of Medicine, followed by
a third related study in the September 3 issue of AIDS. In
Roche’s APRICOT trial, 860 HCV/HIV coinfected patients
were randomly assigned to receive standard interferon plus
ribavirin, Pegasys monotherapy, or Pegasys plus ribavirin
for 48 weeks. After 72 weeks, 40% of patients treated with
Pegasys / ribavirin achieved SVR, compared with 20% of
those receiving Pegasys monotherapy and 12% of those receiving
standard interferon/ribavirin. Among patients with
genotype 1, the corresponding rates were 29%, 14%, and7%; for those with genotypes 2 or 3, the rates were 62%,
36%, and 20%.
Study ACTG 5071 included 133 participants randomly
assigned to receive standard interferon or Pegasys, both with
escalating doses of ribavirin. After 72 weeks, the overall SVR
rates were 27% for Pegasys/ribavirin and 12% for standard
interferon/ribavirin. Among subjects with genotype 1, the
corresponding SVR rates were 14% and 6%; for those with
genotypes 2 or 3, the rates were 73% and 33%, respectively.
The Spanish study reported in AIDS included 95
coinfected patients assigned to receive either standard interferon
or Peg-Intron plus daily ribavirin. The overall SVR
rates were 44% for Peg-Intron/ribavirin and 21% for standard
interferon/ribavirin. Among those with genotypes 1 or
4, the corresponding SVR rates were 38% and 7%; among
subjects with genotypes 2 or 3, 53% and 47%, respectively,
achieved SVR. These are the highest SVR rates yet seen in
a coinfected population, and were particularly impressive
for patients with genotype 1.
It remains unclear why the SVR rates varied in these studies.
Although the differences in response rates between the
various treatment arms were statistically significant in all
three trials, it is not possible to make comparisons between
them due to different study populations and trial designs.
While a good end-of-treatment response rate was seen in
ACTG 5071, the relapse rate was high for subjects with genotype
1, perhaps because the study started patients at a lower
initial dosage of ribavirin. In addition, ACTG 5071 included
more blacks (about 33%) than APRICOT (about 10%), a
group that responds less well to interferon-based therapy.
Interestingly, both brands of pegylated interferon yielded
impressive results—Pegasys in APRICOT and Peg-Intron
in the Spanish study. However, APRICOT was much larger
than the other two trials, and thus has more statistical power.
ROCHE SEEKS NEW
INDICATIONS FOR PEGASYS
Based on promising results such as those seen in the APRICOT
trial, Hoffman La Roche in September asked the U.S.
Food and Drug Administration (FDA) to approve Pegasys
plus ribavirin for the treatment of HCV/HIV coinfected individuals.
The FDA gave the request “fast track” status,
meaning the company’s application will be considered more
quickly. It is estimated that some 300,000 Americans are
currently coinfected with HCV and HIV, and there is, at
present, no treatment regimen approved for this population.
The Pegasys/ribavirin combination is approved only for the
treatment of hepatitis C alone, although many doctors already
use this regimen for their coinfected patients.
In related news, in July Roche requested that the FDA
approve Pegasys for the treatment of chronic hepatitis B.
The three medications currently approved for hepatitis B
treatment are standard interferon alfa-2b (Intron-A),
lamivudine (3TC or Epivir-HBV), and adefovir (Hepsera).
Clinical trials have shown that Pegasys works better than
either the older standard interferon or lamivudine in patients
with both HBeAg-positive and HBeAg-negative variants of
HBV. In a study reported in the September 16 issue of the
New England Journal of Medicine, 537 subjects with
HBeAg-negative HBV (which is more difficult to treat) were
assigned to receive Pegasys monotherapy, lamivudine
monotherapy, or both drugs together. After 48 weeks of
therapy and a 24-week follow-up period, 43% of patients
treated with Pegasys alone achieved HBV viral loads less
than 20,000 copies/mL, compared with 29% of those receiving
lamivudine alone. Those who received both drugs
had a response rate (44%) similar to that seen in the Pegasys
monotherapy group. Patients receiving Pegasys were also
more likely to achieve normalized ALT (59% vs 44%) and
disappearance of HBV surface antigen. Roche said it expects
the FDA to grant approval of Pegasys for hepatitis B
in early to mid-2005.
LIVER TRANSPLANT OUTCOMES
Over the past 10 years, outcomes for liver transplants in
people with hepatitis B have improved dramatically, according
to a study published in the August issue of Liver Transplantation.
Today, post-transplant survival is similar in HBV
positive and HBV uninfected patients. Much of this success
is due to the introduction in 1990 of hepatitis B immunoglobulin
(HBIG), injected antibodies that prevent recurrence of
HBV infection of the new liver graft. The advent of
lamivudine has also improved survival rates.
Unfortunately, there is no equivalent antibody therapy to
prevent post-transplant recurrence of hepatitis C, which is
the most common reason for liver transplants in the U.S.
Some past research (including a recent analysis of the United
Network for Organ Sharing transplant database) suggested
that liver transplantation is less successful in hepatitis C
patients than in people with other types of liver disease, primarily
because HCV usually reinfects the new liver soon
after the procedure. According to a study in the September
issue of Liver Transplantation, however, long-term transplant
outcomes are similar in patients with hepatitis C and
those with liver failure due to other causes. Researchers examined
the medical records of 165 HCV positive patients
who underwent liver transplantation; subjects were followed
for up to 12 years. The most common cause of transplant
failure or death among these patients was HCV recurrence.
Nevertheless, 10-year outcomes in the hepatitis C patients
were similar to those in patients undergoing liver transplants
for other reasons. After 10 years, liver graft survival rates
were 64% for HCV positive individuals, compared with 51%
for uninfected patients. Poor outcomes were associated with
older age of both the recipient and the donor, high HCV viral load, and decreased immune function. “Long-term outcomes,
specifically patient and liver graft survival, are as
good for patients with hepatitis C as they are for patients
with almost any other cause of liver disease,” study author
Michael Charlton told Reuters Health.
In related news, a recent Spanish study published in the
September issue of Hepatology showed that post-transplant
HCV recurrence was more severe when using livers from
living donors rather than cadavers. Researchers analyzed 116
consecutive patients undergoing liver transplantation at a
single medical center. After a median follow-up of about two
years, severe hepatitis C recurrence (indicated by the development
of biopsy-proven cirrhosis or clinical symptoms of
liver decompensation) occurred in 22% of patients overall.
But the rate of severe recurrence differed significantly based
on the source of the donated liver: 18% (17 of 95 cases)
among those who received cadaver livers, compared with
41% (9 of 22 cases) among those who received livers from
living donors. The researchers could not say with certainty
what factors accounted for this difference, but suggested that
higher rates of biliary complications might contribute to fibrosis,
or that liver regeneration, when using a graft from a
living donor, might promote HCV replication.
Back to top
Back to Training Resources |
