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Hepatitis C
Once known as Hepatitis NonANon B, Hepatitis C is
being discussed a lot in the using community.
Here, BH goes behind the 'Hep C test' where many
of us stop, discovering why further tests are so important
in getting to the bottom of your own Hep C diagnosis.
Research by M.M, B.L, E.O
I n the last issue,BH 'introduced' the liver- briefly discussing what it does and how it does it This issue, we want to look more closely at a virus that has affected the livers of an estimated 250,000 - 600,000 peoplein the UK alone, 170 million people worldwide with some 3 million more joining the
global ranks each year. BH wanted to find some straightforward answers to some essential questions on Hepatitis C and what you may want to consider if you have been diagnosed Hep C (HCV) positive. (BH will look into treatments for HCV next issue).
Hepatitis C is?...
The actual word "hepatitis' means inflammation or swelling of the liver. This can be caused by chemicals, drugs, drinking too much alcohol or by different kinds of viruses. Hepatitis C is just one of a number of hepatitis viruses (including A, B,D, E, G) and they are all completely different from one another. It can be hard to get your bead around just how small viruses really are. HCV is estimated to be 80 nanometers in diameter (around 30 billion would fit on this dot {,} - another reason why handwashing before and after injecting is so important; be especially vigilant if someone injects you after they've just had a hit - they could have microscopic particles of blood on their fingers and then may place them on your injection site. HCV is known to be remain active outside the body for some time so wash your hands and tell others to wash theirs! The hepatitis C virus is in fact a group of viruses, similar enough to be called HCV virus, yet different enough to be classified into subgroups.
Genotypes
Several families of hepatitis C have been observed around The world and these are known as genotypes, because they differ in their genetic make up. They arc usually classified as HCV genotype 1 ,or 2, or 3, etc. Some genotypes respond better to treatment than others so it is important to identify your genotype when considering treatment for Hep C..
Subtypes
Within each genotype, there are subtypes. These are classified as HCV subtype la, or Ib, Ic, etc and within a subtype, incredibly minute differences will exist among individual viruses, called quasispecies - several million quasispecies would exist within a subtype.
How Might HCV Affect Me?
Hepatitis C affects people differently; some are not affected by it while others can be affected seriously. If you contract hepatitis C, your body will produce antibodies to try and destroy it A HCV lest (referred to as an anti-HCV test) will look for the presence of these antibodies and if found, your result will be HCV antibody positive. However, too many of us stop here, terrified that we now have Hep C. But an antibodym positive test is only showing 'exposure' to the virus - it does not tell you whether you have 'active' virus in the blood. Research shows that of 100 people infected wilh HCV, 25 will clear the virus from their bodies completely with 2-6 months of infection but will continue to carry the antibodies for some time. (These are usually people who were infected when they were
younger).
This is why if you have received an HCV antibody positive test, further tests are necessary to determine whether there is still an infection present (see PCR tests opposite) and of course, get yourself some follow up tests for your Hep C, certain discoveries might make all the difference. to help identify the extent of any liver complications or disease - and your suitability for the newer HCV treatments. (BH investigates this next issue). Research estimates the other 75 who do not clear the virus will have ongoing (chronic) infection and some arc at risk of developing complications or liver disease. Of these75 people, approximately 20 may never experience any noticeable symptoms and although they can still transmit HCV, they won't develop illness or liver disease.
Symptoms Related to HCV
After 10-15 years, the majority of people with hepatitis C will have developed different levels of liver damage that will result in hepatitis C
symptoms. These could include;
tiredness and fatigue, headaches, vagueness,
depression, altered sleep patterns, abdominal
pain, itches and rashes, nausea, vomiting
and/or loss of appetite, swelling of the ankles
and/or stomach area, red blotches occurring
on the upper body, easy bruising.
Some aspects of the disease are still not fully understood and it can be difficult to predict what will happen for any one person. Symptoms can
stay at a certain level and dont always get worse. They can come and go with no real pattern. Over a 40 year period of infection, it isbelieved that: less than 4% of people with chronic hepatitis C would develop liver failure or liver cancer.. Over a 40 year period, 20% of people with chronic (ongoing) HCV infection will develop cirrhosis of the liver.
I'm Hep C Positive - Now What?
After you receive your antibody positive diagnosis, you can be offered
(or request) a referral lo see a specialist. They should then offer you a
series of tests such as:
PCR Test, Blood Platefc* Count, Liver Function Tests (LFTs), liver
Biopsy, Ultrasound or doppler ultrasound, or CT scan
Many doctors advise people with hepatitis C to have the hepatitis A and B vaccinations. Although the viruses are unrelated, such vaccinations will help prevent possible additional liver complications caused by having more than one viral infection at the same time.
What is a PCR Test?
PCR stands for polymerase chain reaction. PCR tests detect or measure the actual hepatitis C virus in a sample of blood There are three types of PCR test - viral detection, viral load and viral genotype. These tests
assist people to:
+ Determine whether you may have cleared the virus (but still have antibodies)
+ Determine your level of infectivity
+ Confirm inconclusive hepatitis C antibody test results
+ Assess your response to treatment
PCR viral detection test (Qualitative test)
The PCR viral detection test is mainly used as a confirmatory test when
an antibody test result is inconclusive. It is important as you may have
received an antibody positive test only to have cleared the virus at a later
date. The PCR viral detection test can also be used by HCV positive pregnant women to determine the chance of them transmitting HCV to their child.
PCR viral load test (Quantitative Test)
This PCR lest measures the amount of HCV circulating in someone's
blood. Measuring the level of virus in someone's blood before treatment
can help determine whether a 6 or 12 month treatment regime is preferable.
PCR viral genotype test
PCR genotype tests can determine what HCV genotype and subtype a
person has. This is useful information as it has been shown thai people
who have particular genotypes generally respond better to drug treatment
Important note: PCR tests look for virus in the blood. Levels of virus
in people's blood can fluctuate and, at times, the level of virus in someone's blood might be too low for the PCR test to detect it. Therefore, a negative PCR test result may not always mean that a hepatitis C antibody positive person doesn't have hepatitis C just that the test couldn't detect the virus in (hat particular sample of blood. For this reason, people should rely on a series of at least two PCR tests done over a 4-6 month period, rather than a single PCR test.
How Can I Tell What’s Happening to my Liver?
Liver function tests (LFTs) (see BP Issue 1) are used to measure the general condition of the liver. Liver function tests measure levels of particular enzymes or proteins in a person's blood. If liver cells are damaged, increased levels of these substances "leak out" into the bloodstreamand show up as raised or abnormal results in liver function tests. The tests provide only a rough indication of possible liver damage. Liver function tests may be suggested monthly or up to once per year depending on a person's condition. Liver function tests do not provide conclusive evidence of what is happening in the liven some people may feel quite ill yet have little liver damage. For other people, damage may be occurring even when liver enzyme levels arc normal. It is important to remember that raised liver function test results may be caused by medical conditions other than HCV In cases where ALT readings are consistently high for a long time, where they fluctuate greatly or when readings don't seem to match with how a person feels, a specialist may suggest a liver biopsy be done. Some doctors recommend a routine liver biopsy after 15 years of infection and then every five years thereafter.
What is a Liver Biopsy?
A liver biopsy provides the most accurate report on the condition of someone's liver. Using a special instrument, a specialist doctor takes a small sample which is then examined under a microscope. Ultrasound and other x-rays can indicate certain liver-related abnormalities but have difficulty distinguishing cirrhosis (scarring of the liver) from other conditions such as fat accumulation in the liver. This is particularly true in early cirrhosis. The diagnosis of cirrhosis can only really be made by liver biopsy. However, the presence or absence of cirrhosis is only part of the information available from liver biopsy. Apart from showing the amount of scar tissue (an indication of what has happened to the liver in the past), liver biopsies also show how active the hepatitis C is now and if there are other factors interacting with the hepatitis C to damage the liver such as excess alcohol or iron accumulation in the Even (BH will cover biopsy's in more detail in an upcoming issue).
How Accurate Are Liver Biopsy's?
A liver biopsy sample is just a tiny piece of the liver and people have saidit can be hit and miss depending on the bit of the liver taken, but a properlytaken sample is generally representative of changes throughout theliver. Hepatitis C affects the whole liver and although there may be somevariation within the liver,this would be a minor, rather than major, variation.A doctor will usually explore two major issues in looking at theliver biopsy: Firstly, are the features consistent with HCV as the causeof the liver test abnormalities? ie. Are there other Ever illnesses present? Secondly, if the biopsy is consistent with HCV, then how badly is the liver damaged? This can be estimated by studying three main parameters:
+The amount of portal inflammation - this is the inflammation
around liver cells, bile ducts and veins in parts of the liver
+The amount of tabular inflammation - the amount of inflammation
in separate lobules (the left, right and smaller subdivisions of the liver)
+The amount of fibrosis - this is an early stage in the development of
liver cell scarring (cirrhosis).
Is Treatment Successful?
It is important that you develop a partnership with the healthcare professional who will be responsible for your cart. It may be your GP, specialist or alternative healthcare practitioner or better still, a combination of the three. There are some real strides being made in terms of treatment for HCV and treatment outcomes, though variable depending on each individual (lifestyle and viral factors and certain lifestyle changes made can also impact positively on your quality of life). The best course of treatment currently available involves a combination of two drugs; pegylated interferon and ribavirin. Treatment response rates using pegylated alpha interferon plus ribavirin are in the order of 55% (with genotype 1 results of 45%, and genotype 2 and 3 results of about 80%). For the few people unable to tolerate combination therapy, alpha interferon on its own is sometimes beneficial. However, not everyone is considered suitable for treatment Some people need only regular assessment to detect if damage to their liver is occurring or progressing. NB As of 2006, new treatment therapies for HCV are looking much more promising. Be sure to check out the links at the bottom of the Science on Substance Page and ask your liver specialist about them.
Discriminated Against for Being HCV+?
If you feel you have been discriminated against because of your status
or treated unfairly, there is a group who may be able to advise you on
your rights relating to almost any matter that you feel is connected with
your hepatitis C. You can call the Disability Rights Commission (DRC)
on 0207 211 4110 or try their helpline number 0845 7622 633.
Thanks to British Liver Trust & The Australian HEP C Council of NSW www.hepatitis.org.au for their excellent resources and information, some of which is represented here.
Bacteria - Information by drug users for users
Shooting Clean?
"Licking the end of your spike before a hit, re-using a filter, sipping the water out of the cup you're going to use to draw up from, touching your spike with your fingers???"
What occurs between you picking up that gear and then putting the spike in your vein, is a lot of idiosyncratic practices, habits picked up over an injecting career. A closer look usually tells us there's a few ingrained habits that could prove to be - dodgy to downright dangerous! B
But Before We Start....
We all know how important good hygiene is for injectors in the prevention of bloodborne viruses like HIV, Hepatitis C or B; Using your own or sterile syringes for each and every hit and the more recent but just as important message of never sharing any spoons, filters, water or tourniquets. All these continue to play a critical part in a hygienic injecting regimen and will, if religiously adhered too, offer you protection against blood-borne viruses (but don't forget the condoms). So what about other infections and bacteria?. How susceptible are injectors to these?
The answers seem to lie in you're injecting routine and, to some extent, how hygienic your dealer is when they're fiddling around with the powder that is soon to be in your spoon. What occurs between you picking up that gear and then putting the spike in your vein, is a lot of iidiosyncratic practices, habits picked up over an injecting career.
Like, for example: licking the end of your spike before a hit, re-using a filter, sipping the water out of the cup you're going to use draw up from, touching your spike with your fingers - all these seemingly small details carry risks of some pretty unpleasant bacteria entering your bloodstream or skin tissue. Long ingrained habits can be hard to break but they are just that - habits and so they can be broken. If you can replace just one unhygienic practice with a safer one, you will be reducing your chances of experiencing future infections or complications -complications that can end up life-threatening, and that's gotta be worth a change . It may sound a bit cliché: but taking a bit of extra care whenever you can, will be protecting your health now and for the future, And since newer injectors pick up injecting practices from other injectors, it's up to all of us to try and pass on safer injecting techniques.
How do bacteria affect injectors?
It seems that you carry slightly more risk of getting certain infections if you inject street drugs IM (intramuscularly), under the skin (subcutaneously), or from trussing your hit (similar thing). Bacteria entering your body this way can cause skin or soft tissue abscesses for example, from bugs like staphylococcus that normally live happily on the skin's surface; streptycoccus - within in your mouth and throat, to the sorts that can be picked up from your drugs such as Clostridium, a bacteria that some readers may of heard of already through the terrible infections and deaths that occurred over the last couple of years to a small number of injectors.
Bacteria, when given the chance to enter your bloodstream through your venous system, can travel to your heart (causing endocarditis) joints and bones (septic arthritis) and osteomyelitis (a bacteria] infection of the hone and bone marrow) , or induce other infections like septic thrombophlebitis, septicemia blood poisoning), meningitis, cellulitis (when bacteria infect deeper levels of the skin), brain abscesses and less commonly, tetanus and even malaria!
While the boiling up of a hit of heroin does appear to reduce or kill certain bacteria, those who hit up cocaine, speed, Ketamine, pills etc and use no heat at all when mixing up, are often at greater risk. The practice of repeated injections during a long coke session for example, can often mean that water, syringes, filters and spoons are all left out on the table for hours at a time - increasing the chances of bacteria entering your mix, your skin, and your bloodstream. But from our experience and research, al I injectors are vulnerable and all must take extra care when using their drugs IV. While it's not a good idea to keep any hit mixed up for later, the reality is we all do it sometimes.
If you've got to keep a hit for later, it's much safer to keep it in its powder form rather than mixed up with liquid. If you must, then keep any saved hits, filters, dex wash-outs, etc in the fridge. And not for more than 8 - 12 hours at an absolute maximum.
Anyone, who has any sort of infected sore on the skin i.e abscesses, cellulitis, wounds, even infected pimples etc must be EXTREMELY CAREFUL AND HYGENIC when shooting up and should absolutely avoid injecting anywhere near the infected area. It doesn't take much for the bacteria involved to get on your fingers (especially if your a `picker or squeezer') and travel to your injecting site, particularly when one must feel for a vein.
Never cough over your injecting site/equipment either as a spray of `strep' bacteria is the last thing you want! Powder dealers - take note!
Sources of Bacteria
There are 3 main sources of bacteria that are responsible for infections associated with intravenous use. They are the air. the skin and tile blood.
SKIN:
The skin IS the main source of bacteria responsible for intravenous associated infection. Any bacteria found oil the skin are usually referred to as resident or transient. Resident bacteria are those that are usually present on the skin. being relatively constant on each individual. They adhere tightly to the skin and as mentioned usually include Staphlcoccu.s albus as well as diphtheroids and bacillus species. And since not all bacteria are removed by scrubbing. one must take particular care not to touch any of your injecting equipment - sterile or otherwise, with grubby fingers. Transient flora is loosely attached to the skin and is composed of bacteria which have been picked up by you from your environment and it varies from day to day in it’s quantity and quality. There isn't that much of it on clean protected skin but there can be loads of it on greasy, dirty exposed areas of the body. It is here that handwashing before a hit becomes essential to avoid transferring germs to your injection site or to your equipment.
AIR:
While the actual number of 'microbes' per foot of an varies whenever an infection is pre-sent bacteria escape in body discharges, contaminating clothing, bedding, dressings etc. If you have an infection on your body, any sort of activity such as throwing off your shirt, bed making etc, sends bacteria flying into the air - particles of lint and pus and dried skin! These contaminants can then find easy access to unprotected intravenous fluids, for example: A water filled glass that you use to draw water from for injecting, is left open to the air – and any bacteria that has just flown off someone’s bandages can find it’s way in. This also goes for spoons, and filters. In Order to avoid contamination, dispose of all the equipment you use after your hit - and if you have another one soon after. well. -get Yourself clean equipment! The alternative of' course is to have a pack of sterile syringes water ampoules and a regularly
cleaned spoon etc. Note - never use a silver spoon because Of silver tarnish). Trv and cover your water container with a clean lid but only if you have no other way to get more fresh water.
BLOOD:
As we all know all too well, blood can harbour potentially dangerous organisms. The Hepatitis virus as well HIV is certainly a testament to that. As such it is crucial to wash your hands before and after each hit to ensure you don't transmit or pick up often minute blood particles unseen to the eye that have been left behind to be picked up by another person.
lt doesn't matter what you inject, it is essential for injector to keep themselves healthy. Groin Injectors need to pay particular attention to keeping their site clean and always take care to wash regularly if you inject here as any infection has the potential to be extremely serious. Those who use in their feet or leg, must also take particular care to keep their sites clean as all are areas that regularly get exposed to a variety of germs that can easily gain access to your bloodstream after being pushed in on the end of a spike.
Hepatitis C Training Manual
This training manual is used by OUT. Feel free to adap t this to suit your group.
Equipment needed:
Literature
Training manual x 2
Flipchart paper and pens
Certificates of attendance
CASH (£10 x number of attendees)
Petty cash slips
Progression of illness poster
Refreshments
Evaluation forms
You will need 2 people to deliver this workshop. Most sections need one person to talk and one to write on the flip chart (scribe). All the text in bold in this manual is an instruction for the trainers. The bold text tells you how to write things up, how long each section should last and how to get the attendees involved. The text in normal font covers things you should state to the attendees. You can add your own bits in if you know they are facts.
0-10mins (First hour)
Introduction
Trainers to give an introduction to the group about why you are giving these workshops, about your user group and why you have set up. Here is a brief intro you could use:
The NTA distributes funding to D(A)ATs for drug treatment services around the country. The Department of Health allocated a small amount of funding to all D(A)AT’s in 2002 to tackle drug related death locally.
Hep C is increasing with each day and drug users are the highest % of the population that this condition is affecting. We have put these workshops together with the input of local Hep C specialists. There are still many drug users around who do not realise the importance of preventing themselves from contracting Hep C. In this workshop we will advise you what to do if you think you may have Hep C, how to prevent catching or spreading it, and discuss what treatment is out there for those who are infected.
OUT want to get the message to users that anyone who has Hep C does not have to pass it on and that those who do not have it do not have to contract it. The info we are giving over in these workshops is for you to take away with you, but it is up to you to change your injecting behaviour accordingly.
Show the picture below (also on the CD Rom) and ask attendees what they think of it. Discuss the lack of a co-ordinated campaign to raise awareness and the limitations of the message in the poster.
10-15 mins (First hour)
Facts and figures
Ask the audience to guess what the figures are for infection in this country and the world. Once they have had a go at guessing, state the WHO estimated figures below. Write the figures in large print on the flip chart and keep that on the wall throughout the session for a reminder to the participants of how large the problem is. Write it up as shown below for easy reading for the attendees.
Numbers of people
infected
Worldwide
Hep C - 170 million 5
HIV - 42 million 7
In this country
500,000 chronically infected with Hep C
The above figure for UK infection isw estimated to be low as many users have not been tested .
Hep C is now recognised as an important public health problem worldwide. The World Health Organisation estimates that there are some 170 million people chronically infected with Hep C in the world compared to 42 million people infected with HIV. In England the figure is estimated at 200,000. The majority of these people are unaware they are infected. Hep C is often referred to as a ‘hidden epidemic’ because symptoms rarely occur at the time of infection.
Even the tiniest drop of blood, invisible to the naked eye, can transmit a blood borne virus. It is widely thought that the Hep C virus can live outside the body in dried blood for up to 3 months. It is a much more robust virus than HIV which dies in seconds in normal atmospheric conditions.
15-30 mins (First hour)
How do you believe Hepatitis C is transmitted?
Tell the audience you will forget about IV infection for now and concentrate on other routes of infection to dispel any myths that may be hanging around the room on how you can get infected.
Ask participants how they believe HEP C to be transmitted. When the ideas have all been given, write the route of infection e.g. blood transfusions and then the % next to it. It is written out below for easy reading for the attendees. Explain that these % are those who have been diagnosed since 1989.
TRANSFUSIONS
In the past people have been infected with Hep C via blood transfusions. All blood products are now screened for any viruses like Hep C and HIV. The percentage of those infected by transfusions is 1.4%. If you have Hep C or are injecting drugs you should not attempt to give blood. Some countries still do not screen blood so if you are planning any trips to underdeveloped countries be aware of this in the event of needing any blood products or surgery.
ACUPUNCTURE, TATTOOS, BODY PIERCING
All blood borne viruses can be transmitted by using needles that are not sterilised. Fortunately in this country all professional tattoo artists, body piercers and acupuncturists use clean needles, but there are still a number of people who get tattooed whilst in prison or by mates. There is no figure for infection in this way. These are recorded as ‘other known’ along with razors, toothbrushes.
UNPROTECTED SEX
There is a minimal risk that Hep C can be passed on through unprotected sex. A risk arises if there is passing of blood with sexual fluids. Therefore vaginal sex is better than anal penetration and sex should be avoided if the woman is on her period. The chance of becoming infected through sex is less than 1.5%.
PREGNANCY
If you are female and started injecting drugs before the birth of one of your children, there is a small chance that your child will have been infected with Hep C during birth. This chance is increased if you had HIV a t tha t time as well. If you are planning to become pregnant you should go and see your Hep C consultant. The statistics show tha t transmission from mother to child in delivery is 0.9%. New mothers are told it is okay to breastfeed, unless they have cracked or bleeding nipples.
SHARING TOOTHBRUSHES, RAZORS ETC
All of these things carry a risk of infection if a person with the Hep C virus has used them. So it is good to be aware of this if you are ever in a position where you may have to share these items. See tattoos etc.
THIS MEANS THAT THE REMAINING 92.3% OF THOSE WITH HEPATITIS C CONTRACTED IT THROUGH IV DRUG USE.
Write the figure under the other %: IV Drug Use 92.3% 8
30-45 mins (First hour)
Now concentrate on transmission through injecting equipment
Once the other routes of infection have been discussed concentrate on infection via injecting drug use. Ask the audience what they think they should do to avoid infection whilst injecting. Write up their answers on the flip chart. If they have missed some out suggest them and write them down too. Keep repeating the fact that Hep C is only caught through blood-to-blood contact.
It is important that out of those who have contracted the Hep C virus since 1989 92.3% have been, or are, IV drug users.
Because it only takes the tiniest amount of blood to infect someone, using injecting equipment that has been used by someone else can easily lead to infection. It is not just sharing needles that can lead to infection; you can contract Hep C from any injecting equipment.
45-50 mins (First hour)
NEEDLE EXCHANGES
Ask the group to list the places where they can get clean needles. Perhaps write the list on a flip chart as there may be places that some people do not know about – information share between the group. Leave the information up on the wall throughout the session, especially if holding the workshop in an area where needle exchanges are scarce.
50-55 mins (First hour)
HOW TO CLEAN USED NEEDLES
Use your own experiences to describe situations when you have had to use old works or someone else’s old ones.
For example, when I had been let out of the Cop Shop at 3 in the morning and was rattling I would have to go to a sin bin in a public loo or my sin bin at home and break it open. Many users do this even if they won’t admit and know it is not safe. It is something that you feel you have to do, if you are an injector, not a chaser, a smoke just will not do, especially if you are seriously rattling!
There may be times when you really feel the need to inject but do not have any new needles or syringes. In these circumstances it is important to minimise the risk of infection by cleaning the equipment you use. We will explain to you how to do this properly. However you must remember that no method of cleaning needles, syringes or drug injecting equipment can completely guarantee that you will not become infected.
Explain how to clean used works. Be sure to state that if you squirt the water back in to the cup when you are rinsing it will effectively contaminate the water.
The following method reduces the risk of contracting HIV, but it is not yet known how much protection it offers against Hep C, however it is still better than doing nothing.
You will need the needle and syringe, clean cold water, two clean cups (or large bottle tops), thin household bleach and a sink (or a place to dispose of used bleach and water). Each step is repeated several times, this is necessary to ensure you get as much of the old blood out of the needle as possible:
First pour bleach into one cup and water into the other.
Draw cold water up from the cup and flush it away into the sink. Do not flush the water back into the cup. Do this a couple of times.
Now you need to disinfect the needle and syringe. Draw up bleach into the needle and syringe. Now hold the syringe over the sink and press the plunger back in to empty the bleach down the sink. Do not put the bleach back into the cup.
Repeat this step at least 3 or 4 times.
The final step is to rinse the bleach out of the syringe. Using a needle with traces of bleach in it could cause damage to your veins and may be very painful. Draw cold water up into the needle and syringe, and again flush away down the sink. Not back into the cup!
BREAK FOR 10 MINS
05-10 mins (Second hour)
Testing and Support
Each area will have places to go for testing for Hep C. You should find these out before your workshop so you can signpost the users to testing. Your area may have a STD clinic, homeless hostel, or drop-in clinic that will test for Hep C. GPs also provide testing for HCV infection. If your doctor does not provide this service he/she will refer you to a testing centre. Pre and post-test counselling is not always available although it should be provided if services are following recommendations set out in Models of Care 3.
10-15 mins (Second hour)
The Hepatitis C Test
Explain the test as written below. Make sure you explain it clearly.
An initial antibody test will be done. The first test will show if the person has ever been infected with HCV.
About 20% of people who become infected by HCV will clear the virus at the acute stage , however, these people will still have a positive antibody result.
In order for doctors to detect if the virus is still present another blood test will have to be done. This will also determine what genotype you are. Then they can tell you if your genotype usually responds well to treatment.
15-25 mins (Second hour)
Presenting for testing
Talk to the attendees about the things they need to consider when they present for testing. Talk about the following, adding your own personal experiences if you have them:
Before you present for testing you should consider the consequences of a positive result. You will have the opportunity to discuss any concerns you have when you go for initial testing, when you go for your results or when you see a specialist at the hospital. You may have concerns relating to:
Your personal relationships: they may change as a result of a positive test result. There is some risk of passing Hep C on to your family, but the risk is very small. Follow the guidelines we give you on sharing razors, toothbrushes etc. Family members can be a good source of support for those affected by Hep C, although they may need reassurance to deal with their own worries. If you think it is important to tell a family member that you have Hep C, consider carefully how they may react.
Lifestyle: Your lifestyle should not change drastically as a result of a positive test result. If you are still injecting it is very important to take your own measures to avoid passing Hep on to someone else. You may wish to tell your partner of the result to give them the opportunity to make choices on protection and to find more about the risks of contracting Hep C through sex. You should inform your dentist of a positive test result so they can take extra time and care. However there have been cases of dentists refusing to treat patients who are either HIV + or have Hep C.
Employment: Your employment should not be affected by you having a + result for Hep C, although there have been several cases in which people have lost their jobs. Hep C is bad news for those considering a career in the medical profession as the government is now screening all of those new to the job.
Treatments: You will be told about all the treatments available for Hep C if you are given a + result. The treatments are available in hospitals around the country and you will have a chance to discuss these at your appointment with the specialist after your result.
REMEMBER IT IS YOUR RESPONSIBILITY TO INFORM THOSE WHO YOU THINK SHOULD KNOW
25-30 mins (Second hour)
PROGRESSION OF ILLNESS
Explain the diagram below to attendees 1. You may want to either print this off the CD Rom or draw it out yourselves on a flip chart. Study it yourself beforehand or you will confuse yourself and others. It is a diagram that shows how the illness progresses in your body. It is to show that some people clear the virus themselves and that you are not going to drop down dead tomorrow if you have Hep C. Make sure you get over the point that you could have Hep C and live till you are 80 and then get run over by a bus. However the fact is that Hep C is a massive problem and can be avoided.
Progression of Illness Diagram
(Page 10 – Hepatitis C Strategy for England)
30-35 mins (Second hour)
Your liver
Talk about the liver, what it does in your body and what can go wrong with it.
The liver is by far the largest organ in your body. Your liver is sometimes described as the chemical processing factory in your body. It breaks down food, converting it to energy. Everything that goes in your body has to go through your liver to break it down, that means everything, drugs, alcohol, and food. There are many things that can go wrong with your liver. If you have a Hep C + result you should take the time to talk to your clinic and talk about illnesses that can affect your liver. Excessive alcohol use is particularly bad. If you have Hep C one thing guaranteed to make it worse is alcohol.
35-45 mins (Second hour)
Treatment
Explain about the treatment for Hep C, what it is, what it does, how it works, and when and how you would be given it.
State these facts:
The hepatology specialists in this country have to be selective when giving out the treatment for Hep C. The treatment is very expensive and only approximately 1000 Hep C+ people a year in this country receive it. In places such as Germany and France approximately 15,000 people per year are treated.
It costs £10-15,000 for the treatment for Hep C and roughly £50,000 for a liver transplant.
Concerns have been raised by specialists about the limited treatment available for Hepatitis C in this country and lack of government action in raising awareness. It is argued4 that those in power have been slow in confronting a problem that could be facing this country in the future. OUT urges investment in preventative measures to curb the spread of the disease and believes that testing and treatment for Hepatitis C should be prioritised.
Intravenous drug users are highly unlikely to be offered the option of treatment in case they re-infect themselves.
If your Hep C test proves positive your consultant will let you know about treatment options. Your consultant will consider your plan of treatment based on many different things:
Whether you are likely to benefit from treatment
When to start treatment
Which treatment will be the most effective
How long treatment should continue for
These factors will be influential
The extent of liver damage
Whether or not you have symptoms
Your ability to stick to a treatment plan
Genotype
The consultant will take into account whether you are clean or still using. If you are injecting drugs the treatment will not usually be offered as the chance of re-infecting yourself would be high. If you lead a chaotic lifestyle your ability to stick to a rigid treatment plan will be questioned.
If you are not using and you fit the criteria you may be offered treatment. The treatment is a combination therapy of Interferon taken with Ribavirin.
This medication would be administered by yourself and you would be shown how to do this. Interferon is injected either once or three times weekly and Ribavirin is in tablet form. These medications also cause side effects, which can be hard to cope with at times. This is why your lifestyle would be looked at to determine if you should have treatment. The side effects for Interferon include feeling flu-like after injecting the medication, and patients may experience nausea, anxiety, irritability, sweating, fatigue, muscle aches, headaches and depression. It can give you problems with your joints and your hair can thin. The side effects from Ribavirin may include insomnia, anaemia and nausea.
Some of those who receive the treatment are not able to last the whole course as the side effects can be very overpowering. If this is the case doses can be reduced. The severity of the side effects will vary from person to person.
A Personal Account of Treatment
“I was on a clinical trial of the combination therapy Interferon and Ribavirin. It was very heavy going. I am rarely ill and felt no effects from Hepatitis C before undertaking the treatment. It knocked me for six. I had no energy, became very low and depressed, my hair thinned noticeably and came out in handfuls when I washed it, and my skin became very dry. I did not take time off work but I certainly wasn’t my usual self. I was supposed to be taking the therapy for one year but gave up after six months. Luckily for me it worked. I would advise anyone thinking of going for it to make sure they are settled and have support.” (OUT member)
The hepatology specialists at the John Radcliffe Hospital in Oxford have found that for people who have taken the combination therapy that are on Methadone, the side effects will be significantly reduced or cancelled out completely. This is something to bear in mind for the future if you are considering taking the therapy.
Taking the treatment does not guarantee that the virus will disappear altogether but studies have shown that if it does not disappear then it may reduce the swelling of the liver. There are a number of factors that will be unique to you that will contribute to clearing the virus, as everyone’s bodies are different. It will also depend on the virus itself - some genotypes respond better to treatment.
45-55 mins (Second hour)
Initiating into injecting 5
The next part of the workshop is abou t trying to reduce the number of injecting drug users. If the numbers of heroin users who smoke their gear rise then subsequently the numbers of drug users infected with Hep C will fall.
We are giving you the opportunity to think about injecting yourself and/or injecting others. Explain that we don’t want them to confess to anything, just think to themselves about the questions we are asking them and it will begin a discussion.
Injecting for the first time:
Think about when you had your first hit - who gave it to you? What made you want to begin injecting? Did you believe that you could do it once and leave it at that? Did you believe you wouldn’t ever have a problem with injecting sites?
Do not inject in front of non-injectors, as people can be tempted to try their first hit if they see others injecting.
The initiation of others:
Most users would state that they would not give someone their first hit but everyone was shown how to do it by someone. Ask attendees to think about a time when another drug user has asked them to give them their first hit. Did the person hassle them?
Discuss the difficult situations that we get ourselves in and as drug users we can be very manipulative. We can find it very easy to get what we want when we put our minds to it. Getting someone else to inject you or persuading someone to let you inject them can be very easy.
Tell the attendees that the facilitators are going to do some role-play. Decide before the workshop which character each facilitator will play. Here are some situations that can occur, let’s see if we can do the right thing or is it just too hard to change your habits! Here is the scenario:
A female is telling her boyfriend that she wants a hit.
Girl user: I’m fed up with this, we both go out earning together, doing whatever we have to do for money for gear. I earn just as much as you but because I smoke it I hardly get anything off it. You bang it up so you’re getting more off it than me!!
Boy user: Listen, you may not feel like it but I can assure you you’re looking pretty out of it to me.
Girl user: It isn’t fair I want to get out of it as well and I’m getting fuck all off smoking it, give me a hit, just this once.
Boy user: No chance. I don’t want you moaning to me when your veins are fucked and you can’t get a hit.
Girl user: Just this once.
Now ask attendees to tell you what they would do in a situation like the one described. If they do not come up with anything, give them suggestions.
Talk about the risks you face injecting someone. Some of your group may have people they know who have been nicked for manslaughter if the person they injected overdosed. If not tell them it is possible and happens more often than people realise.
Possible risk for the person giving someone their first hit
The risks of OD increase when heroin is injected
There is a 1 in 20 chance of a new injector contracting Hep C 5
The person you are injecting may have a medical condition you do not know about that could affect them differently to anyone else
List more risks
Possible risks to the person receiving the hit
You could face criminal prosecution if you give someone a hit and they die
You could get the blame from family and friends of the person you injected if they get more chaotic
List more risks
55-60 mins (Second hour)
We have tried to cover the facts of Hep C that are useful for the drug user or ex-user.
Ask all participants to complete an evaluation form and sign a petty cash slip for their cash and certificate.
Invite attendees to take home a couple of booklets giving detailed advice and information on Hep C from getting tested to treatment. Ask them to pass one on to a friend.
References
Hepatitis C: Strategy for England (2002) London: Department of Health
AIDS Epidemic Update (2002) UNAIDS Joint Nations Programme of HIV/AIDS
Models of Care: for substance misuse treatment (2002) Department of Health: London
Daly, M. and Shapiro, H. Blast from the Past (2003) Druglink Vol.18; 6-7
Break the Cycle Preventing Initiation into Injecting (2002) Drugscope: London
HIV/ AIDS - HIV
stands for Human Immuno Deficiency virus. AIDS stands for Acquired Immune Deficiency Sydrome.
HIV is a virus which damages the immune system so that people cannot fight off normal infections. When someone has HIV they are said to be 'HIV positive'. They have HIV in their blood. When someone first gets HIV they may still be very well but over time their body defences weaken against illness and they may eventually get life threatening illnesses like pneumonia, lung diseases or certain cancers. It is then that they have AIDS.
Some users who inject drugs share their 'works' with other users. Tiny traces of blood left in the syringe, on the needle or on other equipment used to make injection possible can carry the HIV virus, hepatitis B and C and other blood-borne infections. Some drug users have passed HIV to each other in this way.
In 2002, 2 per cent of people with HIV became infected by sharing injecting equipment with someone with HIV [1]. The UK figures are small compared to some other countries. In the USA and Canada about 25 per cent of newly acquired HIV infections have been attributed to injecting drug use [2].
The rates of HIV infection amongst injecting drug users vary widely in different parts of the UK. In Liverpool it is very low. In London it is higher but it is highest of all in Edinburgh. This probably has something to do with the fact that Liverpool got off the mark early with widespread needle exchange schemes whereas this happened later and to less extent in Edinburgh.
There is a tendency to assume that all of these people are injecting heroin. Many of them will have used heroin, but in some areas other opiate-type drugs are injected as well as tranquillisers such as temazepam. Amphetamine injecting is quite common in some areas and in some, such as South Wales, possibly more prevalent than injecting heroin. Cocaine is also sometimes injected and there has been an increase recently in the number of people who inject steroids.
It does not matter which drug is being injected from a hepatitis or HIV risk point of view. All sharing of injection equipment is high risk with regard to hepatitis and HIV, no matter which drug is in the syringe.
Drug injectors should be encouraged to use the needle exchange schemes which have now been established in most parts of the country as part of the battle against hepatitis, HIV and AIDS. 'Clean works' are now available free of charge for all drug injectors to help them avoid becoming infected with these viruses or infecting others.
Introducing the Liver...Part 1
Part one in our liver series, BH starts with giving the liver the once over - what does it do, how does it do it and gives a starting point from which to understand other liver issues such as Hepatitis B, C, Cirrochis, fibrosis etc.
The liver is the largest internal organ. It is reddish-brown, weighs approximately three pounds (in the adult male) and is about the size of a football. It is located behind the ribcage on the upper right side of the abdomen. The liver has the unique ability to regenerate its own tissue-as much as three-quarters of the liver can be lost, and the organ can grow back within several weeks. This allows people who need transplants to receive part of the liver of a living donor. The liver is divided into four lobes; these are in turn composed of multiple lobules, which contain the hepatocytes, or working liver cells. The liver has an extensive blood supply, receiving oxygen rich blood from the hepatic artery. The portal vein delivers blood containing nutrients, toxins, and other substances absorbed from the intestines to the liver. The liver filters this blood, then sends it on to the heart via the hepatic vein.
Functions of the liver
The liver is responsible for some 500 bodily functions. It plays a role in digestion, sugar and fat metabolism, and the body's immune defense. It processes almost everything a person eats, breathes, or absorbs though the skin. About 90% of the body's nutrients pass through the liver from the intestines. The liver converts food into energy, storesnutrients, and produces blood proteins. The liver also acts as a filter to remove pathogens and toxins from the blood. In the developing fetus, blood cells are produced in the liver.
Digestion
The liver plays an important role in the digestion and processing of food. Liver cells produce bile, a greenish-yellow fluid that aids the digestion of fats and the absorption of fat-soluble nutrients. Bile is delivered to the small intestine
through the bile duct; when there is no food to digest, extra bile is stored in a small organ called the gallbladder located beneath the liver.
Byproducts from the breakdown of drugs and toxic substances processed by the liver are carried in the bile and excreted from the body. A person with a damaged liver may experience impaired bile production and flow. When this happens,the body may not be able to properly absorb nutrients. Liver cells also convert heme (a component of hemoglobin that is released when red blood cells are broken down) into bilirubin. When the liver is damaged, bilirubin may build up in the blood, causing jaundice (yellowing of the skin and whites of the eyes).
Metabolism
The liver carries out many metabolic functions, providing the body with the energy it needs. It regulates the production, storage, and release of sugar, fats, and cholesterol. When food is eaten, the liver converts glucose (blood sugar) into glycogen, which is stored for later use. When energy is needed, the liver converts glycogen back into glucose in a process called gluconeogenesis.
The liver regulates the storage of fats by converting amino acids from digested food into fatty acids such as triglycerides; when the body does not have enough sugar, the liver converts fatty acids into ketones, which can be used for fuel. The liver also controls the production, metabolism, and excretion of cholesterol, which is an important component of cell membranes and certain hormones.
Storage
The liver stores several nutrients,
including vitamins A, D, B9 (folate), and B12. It also stores iron and plays a role in converting iron into heme, a component of hemoglobin (the oxygen-carrying molecule in red blood cells).
"The hardworking and often misunderstood liver performs over 500 bodily functions, processing everything that you eat, breathe and absorb through your skin."
Protein Synthesis
The liver synthesizes (builds) several important proteins, including enzymes, hormones, clotting factors, and immune factors. Liver enzymes called amino transferases or transaminases (ALT and AST) break down amino acids from digested food and rebuild them into new proteins needed by the body. When liver cells are damaged, these enzymes can leak out and build up to high levels in the blood; these enzymes can be measured using a simple blood test. Several of the proteins synthesized by the liver are needed for proper blood functioning. These include various binding proteins (which bind and transport substances such as vitamins, minerals, hormones, and fats) and albumin (a protein that helps maintain proper blood volume). Clotting factors produced by the liver include fibrinogen, prothrombin (Factor II), and Factor VII. These enable the blood to clot following an injury; low levels can lead to prolonged bleeding and easy bruising. Other proteins synthesized by the liver include alkaline phosphatase, gamma-glutamyl transferase (GGT), and insulin growth factor.
Detoxification
The liver plays a crucial role in detoxifying substances that are harmful to the body, including alcohol, drugs, solvents, pesticides, and heavy metals. When a person is exposed to high levels of these chemicals, the liver can become overwhelmed. Toxins are delivered to the liver by the portal vein. The liver processes these chemicals and excretes them in the bile. The liver also processes and excretes toxic byproducts of normal metabolism (such as ammonia) and excess hormones (in particular, sex hormones such as estrogen). Many drugs-including common over-the-counter drugs such as acetaminophen (Tylenol), most anti-HIV drugs, and certain herbal
remedies-are processed by the liver and can cause liver damage.People should be especially cautious about combining multiple drugs or herbs. If the liver is damaged it may not be able to break down and excrete drugs efficiently, which could potentially lead to dangerously high blood levels and intensified side effects.
Liver Damage
Chronic hepatitis C or B, heavy alcohol use, and other factors can lead to serious liver damage. Given how many vital functions the liver performs, it is not surprising that liver injury can have an affect on almost all body systems, including the digestive, endocrine, cardiovascular, and immune systems. As the liver sustains damage, normal liver tissue becomes fibrous (fibrosis), fatty (steatosis), and scarred (cirrhosis). If the liver becomes too heavily damaged, it isno longer able to carry out its normal functions. In compensated cirrhosis, the liver is scarred but can still function relatively normally. In decompensated cirrhosis, the liver has sustained so much damage that it is unable to function properly. Scar tissue may block the normal flow of blood through the liver, causing blood to back up. This can lead to portal hypertension (high blood pressure), the development of varices (stretched and weakened blood vessels) in the esophagus and stomach, and internal bleeding.
People with severe liver damage may also develop ascites (fluid accumulation in the abdomen), edema (swelling, especially in the legs and ankles), and kidney damage. If the liver is unable to filter out toxins and metabolic by products such as ammonia, these chemicals may build up in the blood, leading to impaired mental functioning, personality changes, and (in severe cases) coma. People with long-term liver damage may also develop liver cancer.