Overview of Hepatitis C & Working with Drug Users Narelle Ellendon, HCV Director Harm Reduction Coalition, NYC www.harmreduction.org ellendon@harmreduction.org
Hepatitis C??? What is it? Who gets it? How can we prevent it? What happens if you get it? What can we do to support people who have Hep C or at risk of getting Hep C?
What is hepatitis? A non specific term that means “inflammation of the liver.” Hepatitis can be caused by: heavy, long-term alcohol use, medications (including prescription drugs), chemicals, auto-immune disorders. Viruses, like Hepatitis A, B, C (less commonly, D and E), can also cause hepatitis.
Causes of Hepatitis Immunologic Damage
Infections
Inflammation
-
Viruses Bacteria Fungi Protozoa
Toxic Damage - Alcohol - Drugs - Poisons/ Chemicals
Viral Hepatitis A & B …and others
Hepatitis A (HAV) Spread by Fecal – Oral contact Acute disease Symptoms: - if present, occur 10-40 days after exposure - can include low fever, muscle/joint aches, fatigue, jaundice, pale stools, dark urine Rarely serious and usually lasts a few weeks No treatment, HAV Immune globulin & IV fluids can reduce symptoms
Hepatitis A : Prevention Vaccination for Hepatitis A, (2 shots over 6 months) Wash hands, food, dishes Practice safer sex, especially when having anal/anal-oral sex Clean sex toys Reduce/avoid eating raw shellfish
Hepatitis B (HBV) Spread by blood-to blood & sexual contact 5–10% HBV infections become chronic & of those chronic infections 15– 25% can be fatal. 90-95% of people infected with HBV will clear the virus. Can be spread from mother to infant (transmission can be reduced 95% with immune globulin and infant HBV vaccine at birth)
Hepatitis B (cont) Symptoms can be flu-like, 30% experience none HBV Immune Globulin within a week of exposure can prevent disease or reduce symptoms There are effective treatments for chronic HBV, more complicated when coinfected with HCV
Hepatitis B: Prevention Vaccination, 3 shots over 6 months Use latex condoms Screening for chronic infection, esp. if pregnant Safer injection techniques Be blood aware, avoid sharing personal care items e.g. razors, toothbrushes Care with tattooing & body piercing, sterile tools, new needles, own ink supply
Hepatitis D, E & G Hepatitis D requires presence of Hepatitis B therefore vaccination for Hep B protects from Hep D Hepatitis D/B co-infections has faster more serious disease progression Hepatitis E is similar to Hep A, ( can be fatal to pregnant women) Hepatitis G, similar to Hep C, little currently known
What to remember… If chronically infected with Hepatitis C & then get infected with Hepatitis A or B, liver damage can be more severe. No vaccine for Hepatitis C Anyone who uses street drugs or has unprotected sex should get vaccinations for Hep A & B
Hepatitis C (HCV)
How common is Hepatitis C? World, 170 Million
U.S.: >4 million have been infected (compare to ~ 1 million HIV+ in US) ~ 35,000 new cases of HCV infection every year in U.S. HCV is 10th leading cause of death in U.S. (CDC) ~ 10,000 people will die from HCV Complications every year in U.S. (CDC)
Hepatitis C in the U.S: High Prevalence Populations Many other studies of specific sub populations (including groups excluded from NHANES) have seen higher-than-average prevalence rates among: ● Veterans: ● HIV+ People: ● Prisoners: ● Homeless: ● Current/former IDUs: (Injecting Drug Users)
6.6%-21.7% 25-30% 30-40% >40% 50-95%
Hepatitis C Transmission Hep C infected blood
Risk Behavior
Opening into Bloodstream
Hepatitis C Testing Recommended Anyone who has ever injected drugs Received a transfusion/blood products before 1992 Received clotting factor before 1988 All HIV-positive people Healthcare, emergency, safety workers Children born to women with HCV Liver disease Good idea for: all drug users, sex workers Anyone concerned about blood-to-blood transmission
Risk Factors Shared injection equipment is the #1 cause of new HCV infections. IDUs are at highest risk; most infected within first years of beginning to inject.
It’s All About the Blood
Hepatitis C Harm Reduction Project
Injection Methods Intravenous injection (Mainlining) Intramuscular Injection (Muscle Popping) Subcutaneous Injection (Skin Popping)
Sexual Transmission Rare: Possible when blood is present during sex Virus has been seen in seminal and vaginal fluids, but in tiny amounts, and may not be infectious, unless blood is present in them. Long term studies of sero-discordant couples have found very low transmission rates; where it’s been seen in studies, is among MSM.
Risk factors (continued) People who received blood products or transfusion prior to 1992 have high risk. Kidney Dialysis also a risk, when centers do not practice infection control procedures. Mother to child transmission—associated only with blood, not breast milk.
Theoretical Risks Tattooing using un-sterilized equipment, especially in prisons, or amongst people (teenagers) doing it at home. Sharing things that hold blood, such as razors or nail clippers. Sharing snorting straws and pipes
Hepatitis C is NOT transmitted by… • • • • •
Coughing or sneezing (casual contact) Hugging & Kissing Food or Drinks Sharing eating utensils or cups Breast Feeding, (unless nipples are cracked or bleeding)
Safer Injection Obstacles for Drug Users What hinders IDU’s from injecting safely?
Injecting Drug Users Many IDUs not using Syringe Exchange Programs, (SEPs) More then half acquire syringes from potential unsterile source Nearly half report “sharing” syringes and other equipment Generally participants of SEPs have been injecting for some time Large number of IDUs already infected with HCV Likelihood of HCV infection from 1st injection 1.5 years – 3.5 years (source: H Hagan)
Safer Injection Obstacles for Drug Users They don’t have a safe place to use They are in a big hurry They don’t have enough money to buy a hit on their own, so often have to buy & split drugs with friends Sterile equipment unavailable, SEP not accessible, may not give enough supplies, in jail, unplanned use Relationship factors effect how they inject.
Stigma… Stigma effects behavior, substance use and internalized self-hatred. It exacerbates high risk behavior such as poor negotiation of safer sex and safer injection practices. Stigma of drug use is compounded by other factors, stigmatization based on race, gender and gender identity, class, sexuality and sexual identity, culture, dress, and hygiene.
Well meaning Hep C Prevention messages….
Never inject If you haven’t started, don’t start Switch to snorting If you get high, don’t share drugs Use a new set each time you inject Never share equipment Divide dry Be the ultra-hygenist each and every time.
Safer Injecting #1: Always try to avoid contact with other people’s blood. Think of all the ways blood can be present during the injection process. Mark your needles, and don’t share needles for shooting. Do not share water, cookers, or cottons. If you must share cooker, use sterile syringe to draw from cooker and load. Whenever possible, take control of your injection.
Preparing & Dividing Injectable Drugs
(Dry Divide, Frontloading, Back loading)
Staying Safe Project Investigate IDUs who have been injecting 8-15 years in NYC and have remained HIV & HCV negative How do “They” do it? Long-Term Prevention, is it possible? NDRI, (NIDA grant)
IDUs more likely to NOT be infected with HIV or HCV if….. Apply knowledge about HIV & HCV transmission to various risk situations. You can’t tell who is infected Sexual risk versus Injection risk. Relying on testing does not protect from infection.
IDUs more likely to not be infected with HIV or HCV if….. Avoid situations that threaten safe injection: - withdrawal period - lack of syringes - high-risk contexts - institutionalization Maintain social ties with family, friends and neighbors
Think strategically & Plan Ahead… Store syringes Diversify sources of syringes - pharmacies - diabetics - belong to multiple SEPs Match equipment supply with amount of drug
Access to sterile injecting equipment is crucial for IDUs to avoid infection with HCV & HIV
When withdrawal sickness is inevitable Sniffing what heroin is available rather then injecting Coping with the symptoms while getting clean syringe Using Methadone Credit with dealer
What happens if you get Hep C?
The Liver The liver weighs between 3 to 5 lbs. Largest internal organ Can be felt under the right side of rib cage Can regenerate if damage is not too extensive
The Liver
Filters toxins & waste from bloodstream Stores vitamins, minerals, and iron Converts nutrients into energy Helps regulate levels of sugar & hormones Produces cholesterol Makes bile necessary for digestion Produces platelets, which help clot blood
Hepatitis C & The Liver: What Happens? Person infected with Hepatitis C through blood exposure. The virus goes to liver cells where it can replicate itself. There is Inflammatory/Immune response, where the body can clear the hepatitis C virus. If the HCV is not cleared then they are chronically infected When inflammation continues, it leads to liver cell death.
Natural History of HCV Infection 100%
Acute Infection
Alcohol, HIV, hepatitis B
Chronic
Resolved
75 - 85%
15 - 25%
Cirrhosis
Stable
20%
80%
Slowly Progressive 75%
Liver failure, cancer, transplant, death 25%
Hepatitis C: Course of Infection Exposure: A person gets HCV-infected blood into their bloodstream Antibody Response: typically 6-7 weeks, can be longer (up to 24) Clearance: About 15-25% of people infected clear the virus on their own; variation amongst certain groups. About 75-85% go on to have chronic hepatitis C infection.
Hepatitis C & The Liver: What Happens? Like a sore on your skin, the liver will scab as it heals, but it will also scar. Dead cells are replaced by scar tissue (fibrosis) The scar on your liver makes it harder for your liver to work the way it's supposed to. The more your liver scars, the less it can do. Over time the fibrosis increases leading to cirrhosis. The liver can regenerate cell tissue, repair itself, but is limited if advanced liver disease.
Liver Damage
Stages 0-2: Little effect on liver function Stage 3: Liver cell function negatively affected: blood flow is altered, fluids and bile may begin to build up causing liver discoloration Stage 4: (Cirrhosis) advanced scarring of the liver; at this stage, scar tissue has replaced most of the normal, healthy tissue in the liver. The liver is hardening and shrinking, making it very difficult for blood to flow freely and severely limiting the liver’s vital functions.
Liver Disease: Cirrhosis Cirrhosis  Compensated - Lots of scarring, but liver is still functioning normally, can live for years  Decompensated - Liver extensively scarred, affecting its normal functions, leads to HCC/liver failure/death. Symptoms include: jaundice, fluid build up in abdomen and legs (ascites), mental confusion, stretched & weakened blood vessels,(varices), internal bleeding.
Factors Associated with Liver Disease Progression Alcohol Intake Age greater than 40 at time of infection. HIV coinfection Male Chronic HBV infection
Symptoms: Chronic Infection Symptoms often do not appear until or unless serious liver damage has occurred
Depression Fatigue Joint and muscle pain Skin conditions Difficulty concentrating (brain fog)
Symptoms of Hep C
Mild fever Nausea/vomiting Loss of appetite Mild stomach pain Diarrhea
Slide 6c
Loss of taste for cigarettes Dark urine Light colored stools Jaundice (skin and/or the whites of the eyes look yellow)
What to remember… Hepatitis C can cause liver damage and the liver is very important. It effects everyone differently, most people with Hep C do NOT die from it. For most people it takes 10 -30 years before there is any liver damage You could have liver damage and NO symptoms, don’t wait till you’re sick to get checked out. Some people, 15-25%, when they get infected with Hep C, their bodies can CLEAR the virus
HCV Monitoring Tests Blood tests: HCV Antibody Test HCV RNA (viral load, PCR) Liver enzyme levels HCV genotype Other Tests: Ultrasound/Liver scan Liver biopsy CAT scan MRI Physical Exam
HCV Antibody Test Tells you if were ever infected, but it doesn’t tell you if you are currently infected. This test tells that your immune system tried to fight it, but not if it was successful. 15-25% of people infected with HCV are able to clear the virus within 6 months of being infected. Your can be HCV Antibody POSITIVE and HCV RNA (PCR/Viral test) NEGATIVE.
HCV Antibody Test Antibodies are part of your immune system. If your immune system is affected, (e.g. HIV+) then you may not develop HCV Antibodies if infected with HCV. Only a PCR/HCV RNA test can confirm whether the participant cleared the Hepatitis C Virus or is currently infected.
All who have a HCV Antibody POSITIVE result or are HIV POSITIVE should have a HCV RNA/PCR/Viral Load test.
HCV RNA Viral Load: PCR testing Used to detect if chronically infected with Hepatitis C  Blood test  2 types: Quantitative PCR- number of virus Qualitative PCR- looking for the virus, more sensitive
HCV RNA Viral Load/PCR testing Low: Less than 800,000 IU or 2,000,000 copies High: 2-4 million copies Treatment most effective on people who start with viral loads less than 2 million. Viral load is to measure HCV treatment success, and to help gauge when to start HCV treatment.
HCV viral load does not correlate with disease progression or how sick a person might be
Liver Enzymes Simple, common blood test. Liver Enzyme Panel also called Liver Function Tests, (LFT) or liver panel. Liver enzymes include ALT, AST, GGT, bilirubin Liver Enzymes are one indicator of increased stress on the liver but DO NOT PREDICT liver disease in people with HCV. 1/3 of all people with Hepatitis C have normal liver enzymes, even when biopsy shows some evidence of liver damage.
Genotype • Blood Test • Six genotypes, many subtypes. • Genotypes 1a and 1b are most common in US • Genotypes 2 & 3 respond best to treatment and is generally for only 6 months Different genotypes do NOT cause different amounts of liver disease
Liver Biopsies A biopsy is the best way to determine how much, if any, damage HCV has caused to your liver. A long, thin needle is inserted through the skin on the middle right side of your abdomen, directly into your liver. A small piece of liver tissue is extracted. A lab looks at the liver cells and determines the amount of scarring
Liver Biopsies Sometimes is painful Can have complications like bleeding and infections Are contraindicated in people whose platelet counts are too low, and in other people who have blood clotting disorders Not always needed to start HCV treatment
Assessing Liver Damage: Less Invasive Tests Serum marker panels, such as FIBROTEST: being
used in some clinical contexts, but not yet ready for prime time, especially for HIV+ people FIBROSCAN uses sound waves to picture the liver, also not ready for prime time. CAT scan, Liver scan, MRI, Ultrasound. Child-Pugh for cirrhosis is done by blood tests instead of biopsy: Class A, B or C (in order of severity).
Liver Biopsy still regarded as “gold standard” to assess liver damage
HCV Treatment Today Pegylated Interferon (once weekly injections) + Ribavirin (daily pills) • Interferon : a synthetic version of a chemical messenger produced by the human body. It stimulates the immune system and fights viruses. • Ribavirin: a nucleoside analogue drug – from the same family as many HIV drugs, but it does not work against HIV, or against HCV when it is used alone. • Treatment Duration: 6 months to 12 months, depending on HIV status, genotype, and early response (EVR)
Hepatitis C Treatment: Goals of Treating Goals of treatment: 1. Sustained Viral Response (SVR) = undetectable HCV viral load 6 months after finishing treatment. CURE 2. Prevent or delay disease progression 3. Improve health of liver tissue by reducing inflammation.
Hepatitis C Treatment Treatment response is measured at: 3 months - to decide whether to continue-if no response may be stopped Conclusion of treatment (end of treatment response, ETR) Six months after treatment ends (sustained viral response, SVR) RVR (Rapid Viral Response) 4 weeks
Why get HCV Treatment? Why get Treated: You have cirrhosis You have debilitating symptoms You are genotype 2 or 3 You want to intervene early
NIH recommends treating patients with Detectable HCV RNA Presence of fibrosis Some liver inflammation Persistent elevated ALTS “patients with an increased risk of developing cirrhosis.” (The National Institutes of Health 2002 Consensus Statement on the Management of Hepatitis C)
Response to HCV treatment influenced by: Genotype (Geno 1 42-46%, Geno 2 or 3 76-82%) Race/Ethnicity (African Americans do not respond as well to current HCV treatment) Liver condition: cirrhosis and/or steatosis (fatty liver) Age Weight Alcohol use Ability to take/ tolerate the medication consistently Treatment Regimen (duration, dose, adherence) HIV HCV Viral Load (lower viral load, better response)
Hepatitis C Treatment: Common Side Effects Depression Nausea Extreme Fatigue Inability to concentrate Flu-like symptoms Hair loss Appetite/weight loss Anemia
Hepatitis C Treatment: Less Common side effects
Diabetes Suicidal or violent tendencies Vision problems, including vision loss Hearing problems, including hearing loss Severe acidosis Thyroid problems Complete inability to function Risk of relapse to active drug use
Hepatitis Treatment Concerns The current medications can have very difficult, and sometimes severe/debilitating side effects. HCV viral load often rebounds The treatment can help stop future damage, but may not repair past damage. Very difficult—but not impossible—for people facing many life challenges.
Hepatitis C Treatment
Special Issues for Drug Users They have to manage habits Do not have peers that have taken HCV treatment May not have a support network May be dealing with homelessness, poverty, stress and poor diet. May have pre-existing mental health issues Unpleasant experiences dealing with medical system
“I was totally ignorant about the virus or that it could be treated…All I heard was the ‘word on the street’ type of information…I was used to being misinformed by the uninformed” - Donald Lynch
Hepatitis C Treatment Considerations: Drug Users & Health Care It's a good idea to look for a doctor who understands—and respects—the special needs of active users. Until very recently, most doctors wouldn't treat users unless they had been drug-free for at least 6 months New federal guidelines for Hep-C treatment include active drug users.
What to remember….. Everyone does NOT need treatment, but everyone needs to get checked out to see if they do. Everyone is different, some will have no side effects, some will have some, some will have many. Get support, don’t do this alone. Talk to others about how they managed treatment.
Treatment does not have to begin right away, there is time to plan carefully, it is rarely an emergency.
What to remember….. Let the doctor know if you have any sideeffects, it could be serious and they can help. You can stop current HCV treatment at any time, and try again later.
Concerns around treatment are real and legitimate!
HIV/HCV Coinfection
HIV/HCV Coinfection Both viruses are transmitted by injection drug use. If you have one disease get tested for the other. Hep C is transmitted easier and much more common
HIV/HCV Coinfection Disease Progression Having both diseases is worse then having just on. HIV accelerates HCV disease progression. Liver damage can be more serious and can advance more quickly. Coinfected people w <200 CD4 cells are at greatest risk for serious liver damage. HCV added to the list of CDC list of AIDSrelated complications in 2000.
HIV/HCV Coinfection HIV meds Liver damage may make it hard to tolerate certain HIV drugs, resulting in hepatotoxicity. Some are less liver-friendly than others, but everyone’s body reacts differently. Liver enzymes must be monitored more regularly in the setting of coinfection.
HIV/HCV Coinfected Treatment Issues Higher HCV viral loads in HIV+ impedes HCV treatment. Often longer HCV Treatment, up to 18 months Doctors want to start when CD4 counts > 200 More severe side effects from HCV treatment & can lower CD4 cells temporarily. Greater monitoring and caution needed for treating either disease.
HCV treatment does not work as well for HIV+ people; yet these people may need it most.
Complimentary & Alternative Medicine, (CAM) • • • • • •
Traditional Chinese Medicine/Modern Chinese Medicine Herbal Practitioners Ayurvedic Medicine Homeopathic Medicine Naturopathic Medicine Complementary Medicine, (massage, acupuncture, Reiki, meditation)
No scientific evidence that alternative therapies can CURE HCV Some CAM may help to protect the liver from further damage They may help symptoms of Hep C & Hep C Treatment
Herbs & Vitamins Most herbs are safe in low doses, and have very mild effects There are some vitamin & herbal treatments that are toxic to your liver. If you have any liver disease or suspect you have hep C, make sure you consult a professional herbalist and a doctor before you take herb combinations. Get the best quality you can afford, from sources you can trust. Vitamin & Mineral supplements may be helpful, ask a doctor Let your doctor/nurse know if are using or plan to use any herbal or alternative therapies
Taking Care of Your Liver Cut back on alcohol use Discuss with doctor if other medications could be causing liver damage Drink lots of water!
Be careful with cleaning products, chemicals & pollutants Get vaccinated against Hepatitis A and B
Find a doctor who understands Hepatitis C Explore if HCV Treatment is for you Slide 6g Diet and Stress Reduction
Taking Care of Your Liver: Alcohol • The most important step you can take is to stop or reduce your consumption of alcohol. • Studies have shown that drinking alcohol speeds up liver damage for people with hep-C. • The more you drink, and the more often you drink, the more damage you can cause to your liver. • People who drink and have both serious liver scarring (cirrhosis) AND hepatitis C are more likely to advance very quickly to liver cancer or liver failure.
Standard Drink Size
Alcohol Consumption At risk for alcohol-related problems if alcohol consumption is: Men: greater than 14 drinks per week, or greater than 4 drinks per occasion Women: greater than 7 drinks per week, or greater than 3 drinks per occasion Low-Risk Drinking: Men: no more than two drinks per day Women: no more than one drink per day Over 65: no more than one drink per day
Alcohol Management Try to reduce drinking: The less, the better Count your drinks!!! Try to limit the AMOUNT you drink (for example, no more than three drinks on a single occasion, or one drink a day). ROTATE alcoholic and non-alcoholic drinks. Cut down on the FREQUENCY of drinking (Drink moderately only on weekends; drink moderately several times per week rather than daily). Avoid drinking alone Don’t keep alcohol at home Know your triggers
Taking Care of Your Liver: “Street” Drugs Speed and Ecstasy have been blamed for liver damage in some studies, but there is still disagreement on how they affect the liver Heroin and cocaine are not harmful to the liver Marijuana is not toxic to your liver Street drugs are almost never pure, they may contain other substances that may be damaging to the liver
Taking Care of Your Liver:
Methadone
Methadone is not toxic to your liver. Methadone does not make hepatitis C worse, Methadone can be taken with hepatitis C treatment. People taking methadone, whether through a program or on their own, don't have to stop--or even cut down-- if they are diagnosed with hepatitis C. If methadone helps people reduce their use of street drugs, alcohol, and prescription drugs that are hard on the liver, then people are more likely to stay healthy! Staying with a methadone program can be a big help.
Taking Care of Your Liver: Prescription medications and over-the-counter ď&#x201A;§ Many medications are processed in the liver, and some can tax your liver. ď&#x201A;§ Acetaminophen, the main ingredient in Tylenol, also an ingredient in Percocet, Vicodin and other painkillers, can be very difficult on the liver, especially in combination with alcohol.
Talk to a doctor or pharmacist before taking new medications you're unfamiliar with.
How Can We Address Hep C?
HCV Counseling Strategies Every Interaction is an opportunity to educate Provide relevant, accurate and legible info to pt when its appropriate for them. Include more in-depth HCV questions to explore the context of an individuals injecting practices. Do you inject yourself? How do you prepare your shot? Do you have enough equipment? Do you use alone or with others?
Tools & Resources to Integrate. All service delivery forms: • • •
Intake forms Health assessment Periodic reassessments
Questions to include: HCV Status, HIV Status, Hepatitis Vaccinations, Hepatitis monitoring, HCV Treatment, HCV Follow up, Hepatitis information/knowledge, HCV risk(share equipment with others), Support/emotional networks, Alcohol consumption, Mental Health issues.
Opportunities Provide sterile injecting equipment. Peer Syringe Delivery, (Secondary Exchange) Validate & Share IDUs strategies to avoid HCV Infection. Work with people to find and develop relationships with appropriate health care providers.
Training for Peers Create program based Hepatitis C Peer Training Have peers attend off-site HCV trainings Arrange for peers to attend HCV conferences. Have HCV Peers present at & facilitate support groups. Peer representation in program decision making & service provision. http://www.oasiscliniconline.org
Opportunities Changes to Alcohol consumption, Diet, Housing Status, can have a major impact on people’s health. Provide food, shower, sleep, etc, to help maintain emotional and behavioral balance. Connection with community and children increase motivation to remain safe and engage in care
Opportunities Encourage people to get vaccinated for HAV & HBV Encouraging confirmatory testing & liver monitoring everyone living with HCV. Discuss liver biopsies. Provide clear expectations/info about testing, medical appointments, and treatment options. Develop strong referral networks; talk to people about their experiences with specific providers.
Opportunities Know where people can get….. HCV Testing HAV/HBV Vaccinations Get monitoring for HCV & Explore Treatment options Syringe exchange supplies Support groups Supportive Services, (Substitute Therapies, Mental Health, Primary Care) Others that can give good info & support
Opportunities Establish HCV services at your agency Incorporate into existing support groups, medical services, staff meetings/trainings Provide medical escorts Create patient advocates Empower the participant to be own advocate
Opportunities Assess your program and the needs of your participants. Create a Hepatitis resource directory & share it. Create a Hepatitis C Strategic Plan for your program.
Opportunities Contact your health departments Hepatitis C Coordinator. ( http://www.cdc.gov/hepatitis/Partners/AVHPC.htm )
Participate in HCV Advocacy bodies. ( http://www.hcvadvocate.org/ http://www.projectinform.org/advo/hepc/080707.shtml http://www.statuscunknown.org/ )
Tap into resources of your staff, participants and other programs…you don’t have to do this alone.
Acknowledgments Photos: Ayelet Rosen, Luis Ortiz, Wilfredo Rodriguez, Adam Binder, James Horton. HCV Peer Consultants: Liam, Hilda, Queen, Walter, Margaret, Francisco, Donald, Martha, Ricky, Marina. Others: Irene Soloway, Donald Lynch, Annie Bandes, Donald Davis Writers: Narelle Ellendon & Jen Curry