C
Hepatitis
Community News December 2010
#50
Editorial
The Hepatitis C Council of South Australia provides information, education and support to the hepatitis C community and those at risk. Street: Mail: Phone: Fax: Web: Email:
3 Hackney Road, Hackney PO Box 782, Kent Town SA 5071 (08) 8362 8443 1300 437 222 (08) 8362 8559 www.hepccouncilsa.asn.au admin@hepccouncilsa.asn.au
STAFF Executive Officer: Kerry Paterson Administration: Megan Collier Kam Richter
The Hepatitis C Community News began as a fairly simple publication in October 1997: six photocopied pages of text and clipart. Like the Council which publishes it, it has grown and changed significantly during the intervening 13 years. This issue begins with a look back at some of the more important developments in that period, and reminders of some of the many projects and programs the Council has run over the years. This is aso the first issue to be published after our 2010 AGM. We thank all of those who stood for the board, and congratulate those elected. The two guest speakers at the AGM were Jo Morgan, of the Parks Primary Health Care Services, and Rosalie Altus, of Flinders Medical Centre. Finally, please feel free to contact us any time about what you’d like to see in the magazine. We’d be thrilled to hear from you, and we are now offering a prize for the best letter each issue (see page 9 for details).
Info and Support Line Coordinator: Deborah Warneke-Arnold Info and Support Line Volunteers: Fred Will Debra Michele Steve Karan Antoin Louise Janette Coordinator of Education Programs: John McKiernan Educator: Mahdi Nor
About the Cover On the front, the evolution of the Hepatitis C Community News masthead. On the back, the first 49 covers.
Educator: Nicole Taylor
Correspondence: Please send all correspondence to The Editor at PO Box 782, Kent Town, SA 5071, or email james@hepccouncilsa.asn.au.
Rural Educator: Michelle Spudic Peer Education Coordinator: Maggie McCabe
SA Health has contributed funds towards this program.
Information and Resources Coordinator: Cecilia Lim Info and Resources Volunteers: Dayna Gauri Kat Phil Philip Yvonne
Mark
Publications Officer: James Morrison
Contents 1
50-Issue Retrospective
ICT Support Officer: Bryan Soh-Lim
4
Another Search
Librarian: Joy Sims
for the Great Hep C Novel
Peer Educator Mentor: Fred Robertson
6
BBV Health Awards
7
The CHI Study
8
Rural Education Program
Chairperson: Arieta Papadelos
9
Letters to the Editor
Vice Chairperson: Kristy Schirmer
10
Hep C & Indigenous Australians
Secretary: Stefan Parsons
12
Insulin Resistance
Treasurer: Darrien Bromley
14
HCV/HIV Coinfection Research
Info and Resources Officer: Rose Magdalene
Peer Educators: Anya Karan Megan Philip
Mark
BOARD
Senior Staff Representative: Kerry Paterson Ordinary Members: Lisa Carter Bill Gaston Shabeena Laundy
Catherine Ferguson Carol Holly Justine Price
Disclaimer: Views expressed in this newsletter are not necessarily those of the Hepatitis C Council of South Australia Inc. Information contained in this newsletter is not intended to take the place of medical advice given by your doctor or specialist. Please do not sue us. We welcome contributions from Council members and the general public. “Maybe, just once, someone will call me ‘Sir’ without adding, ‘You’re making a scene.’”
50 Issues: A Retrospective Some highlights from the last 13 years of reporting on hepatitis C in SA #1: October 1997 HCCSA library opens Hepatitis C support groups established #3: February 1998 Interferon/Ribavirin trials begin at RAH #4: April 1998 Combined hepatitis A/B vaccine announced WA allows live liver donor transplants for emergency liver patients #5: July 1998 Hepatitis C PCR test available on Medicare Interferon s100 eligibility no longer excludes HCV/HIV coinfection Adelaide Dental Clinic funded for free dental work for HCV patients #6: September 1998 Positive Speakers program launched #8: April 1999 Volunteers begin training for Info & Support Line #9: July 1999 Development of State Hepatitis C strategy Launch of Peer Support Telephone Information Line #10: October 1999 Combination therapy approved for Interferon relapsers Noarlunga Hospital opens liver clinic #11: December 1999 First National Hepatitis C Strategy released #12: April 2000 HCCSA website launched SA celebrates its first Hepatitis C Awareness Day Hepatitis C Community News # December 2010 •
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#16: April 2001 The first Hepatitis C Awareness Week in SA Combination therapy availability expands #18: October 2001 PEACE established #20: July 2002 C-Clearly program launched SA Prisons Hepatitis Helpline starts operation #22: April 2003 The RAH’s Viral Hepatitis Centre celebrates first anniversary #25: February 2004 Yarnin’ Up Hep C launched #26: July 2004 HCCSA begins educating Prison Peer Support workers #28: April 2005 Tune Into Your Health music CD launched Calming the C support group celebrates first anniversary #29: July 2005 Getting It Together rural program launched HCCSA devises first strategic plan #30: October 2005 Second National Hepatitis C Strategy launched #32: April 2006 Liver biopsies no longer compulsory for HCV treatment HeplinkSA launched #33: July 2006 HCCSA Mascot O’liver introduced at Awareness Week Hepatitis C Community News • December 2010 • #
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#36: June 2007 Getting It Together launches Get Linked Up program HCCSA begins collecting photo-stories of life with hepatitis C #37: September 2007 Nunkawarrin Yunti opens liver clinic Don’t Be Buntha animated film project begins #38: December 2007 ‘Chopped Liver’ tours SA successfully ‘Meeting Reg’ play runs as centrepiece of Awareness Week #39: March 2008 Turning Point DVD launched ‘Rhythm Exchange’ project plays final concert #42: December 2008 Retreatment becomes available #43: March 2009 ‘Make a Noise’ launched HCCSA’s Peer Education project begins #44: July 2009 SA Hepatitis C Action Plan launched #45: September 2009 eBox project begins Warinilla hepatitis C treatment clinic reopens #48: June 2010 C-Pix art exhibition launched New national strategies for bloodborne viruses released
What will the next 50 issues bring?
Read all past issues of the magazine at http://issuu.com/hepccsa.
?
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Another Search for the Great Hep C Novel Does it exist yet?
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n 2007, this magazine asked the question ‘Where’s the Great Hep C Novel?’ (see issue 36). Looking at hepatitis C and its representation in literature, I found a big black hole. This was especially apparent when comparing hepatitis C with AIDS, because there is a big and significant library of AIDS novels. The AIDS novel developed through the 1980s and ’90s as an attempt to capture and commemorate the experiences of those who lived in the thick of the coming of the ‘gay plague’. Hepatitis C as a subject for stories suffers in comparison because of the lack of any equivalent political force which has led to a distinct lack of any equivalent visibility. Everyone who lives with or works with hepatitis C knows about this. In that article, I found that fiction which included hepatitis C tended to fall into one of four unfortunate groups. Here’s how I categorised them at the time. 1. The Dreary List: Hepatitis C features as one of many ills afflicting the modern world, but there’s no actual engagement with the reality of the disease. 2. The Minor, Minor Character: Someone nearly or totally irrelevant to the plot has hep C. 3. The Misguided Throwaway Remark: Someone in the book—or sometimes the author—talks about hep C, and gets all their facts wrong. 4. Tacky Erotica: Don’t go there! Hepatitis C Community News • December 2010 • #
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attractive or heroic, but they’re fully realised, three-dimensional people. For an example of the first type of book, see Mary Gaitskill’s 2008 novel Veronica. A story of troublesome female friendship and jealousy, it’s narrated by Alison. Her HCV-positive status is just another aspect of who she is, not her sole defining characteristic, or a morality-tale punishment. Here she discusses it at a barbecue with a neighbour:
Unfortunately, most HCVfeaturing fiction that has been published since that first article appeared still falls into one or more of these groups. See the awful vampire erotica novels of J. R. Ward, like Dark Lover, in which a vampire kills a woman, and then says that as “she had an advanced case of hep C”, he was “doing her a favour, sparing her an unpleasant, creeping death.” Or the scene in Joseph Wambaugh’s Hollywood Station where a man, suspecting his girlfriend has hepatitis C, decides to dump her. But there is also reason for optimism. Several books have emerged which treat hepatitis C and the people who live with it as normal and unsensational. Others have been published which feature narrators and primary characters who have hepatitis C. Not all of them are
Rita has hepatitis C; so do I. We don’t discuss it much; she doesn’t remind me that codeine by the fistful is like dropping a bomb on my liver. I don’t remind her that while charcoal smoke is not a problem, her fried-food diet is. And here a walk in the woods:
When I first moved here, I lived in this town. I didn’t live in the canyon, but I’d come to walk in it. I’d come especially when I felt afraid, knowing I had hepatitis but not feeling sick yet. I’d look at the big trees and the mountain and I’d think that no matter how big any human sickness might be, they were bigger. Now I’m not so sure. How much sickness can even a huge heart take before it gets sick itself? The canyon is full of dead and dying oaks.
An example of the second type of book would be Patrick deWitt’s Ablutions (2010), an extremely black comedy about a bartender with a sociopathic streak and a taste for pity. Here he acts on impulse against a former child actor who makes his life miserable:
One night he actually weeps at the bar and you hear him repeating lines from films he starred in [...] He screams himself hoarse and slaps the bar for another rum; you have just slashed your finger on a broken pint glass and the dripping blood gives you an idea [...] As you pour his drink you point your wounded finger downwards and blood trickles in as a mixer. You do this because you hope to give the child actor hepatitis C...
And later, there’s a visit to a health food shop:
[...] you browse the aisles for forty-five minutes, putting things in and taking them out of your cart and speaking with the store employees, telling them you contracted hepatitis C through a blood transfusion (lie) and are now in need of advice, and in their scrambling sympathy they refer to magazine articles and websites and they give you bottles of every sort, pills and muddy-looking juices, and also a pound of trail mix and a large container of blueberries, evidently a strong antioxidant. Somewhere in between is Mary Robison and her One D.O.A., One on the Way, an unusual Southern Gothic novel whose narrator discovers early on that her husband has been diagnosed as being hepatitis C positive.
I found out a little while ago that my husband has hep C. It’s symptomless! And yet, he has an active strain. He could be lying! He isn’t, though. “It’s all right,” he says now, with a hand patting my back. “I feel good. Be just fine. It’s really all right.” I say, “Well, goddamn you.” “Underway,” says he.
Over time his condition worsens:
“Why is Adam walking on that side of the wall, in the construction area?” Petal asks me. “Because he thinks people are following him,” I say. “Like, gangster people?” “No, I guess, more like government people.” “Aw, I don’t believe that,” she says. “That can’t be true. Adam isn’t paranoid. Are you sure you’re right?” “Positive.” “Then his brain is going,” she says. (continued over page) Hepatitis C Community News # December 2010 •
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(Continued from page 5
I say, “Well, yes and no. With hepatitis, you can experience—it’s actually ammonia leaking into the brain.” “You lie,” says Petal. “Never about this stuff,” I say.
None of these books are happy, feel-good stories, but they approach life with hepatitis C with complexity and nuance. There’s even room for humour. In ancient Greek myth, Prometheus stole the secret of fire from the gods, and was sentenced to be chained to a cliff-face, with his liver pecked out by an eagle every day, only to have it grow back each night. In one entry in Will Self’s 2008 story collection Liver, his extensive liver damage leads to his being misdiagnosed with hepatitis C, and he’s recommended a course of Pegasys treatment. Finally, how about a thriller? Victorian biotechnologist Richard Jagger has just published a conspiracy action novel about evil
forces willing to kill to steal the secret of a newly discovered hepatitis C cure. This selfpublished novel, simply called The Cure, is an interesting attempt to combine hepatitis C education with high-tension excitement. Of course, if that’s what you’re after, you could just volunteer to work at the Council! James Morrison
BBV Health Award The Hepatitis C Council of SA congratulates Steve Parker and Anna Kemp for their recent awards. Steve Parker (Adelaide Health Service) received the Minister’s Innovation Award in the 2010 SA Health Awards for his work on the Healthy Body Art primary school program. This very successful program teaches young people about the risks associated with body Hepatitis C Community News • December 2010 • #
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art and about blood-borne viruses like hepatitis C. Anna Kemp (Bowden Brompton Community Group) received the 2010 South Australia Works Adult Educator of the Year award. Anna is a volunteer educator who works with women released from the criminal justice system, providing them with opportunities to build skills they need to for life
after release. She has worked with the Council during AntiPoverty Week and helped us in our Women’s Circle of Health project. We will be bringing you more details about Steve and Anna’s work in the next issue.
The CHI Study An open letter from ARCSHS
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he CHI (Charting Health Impacts) Study is about how hepatitis C affects peoples’ lives and how people respond to hepatitis C.
Why is this study so unique? Unlike most research studies, which are really a snapshot of a situation at a specific time, the CHI study contacts a group of people over
available, new treatments may be offered, new friends and supportive environments might form or they might break up. People who have lived with the virus for many years may feel very different about having hepatitis C than someone recently diagnosed. Someone who has just decided to go on treatment will probably be experiencing not only a range of new feelings but also have more interaction
is a study about people who have hepatitis C. The study outcomes will help community organisations, the medical profession and governments when they plan for or deliver services and when decisions are made about funding. It will help these organisations and service providers to gain a better understanding of what it is like to live with hepatitis C.
Joining the Study The study is all online. Joining the study involves taking an anonymous survey online. We then contact you in three to six months so you can tell us how things have changed for you. This contact is done with an automated email reminder system that is not connected to any personal information. time, giving them a chance to share many of their experiences, good and bad, while they are happening. Circumstances change for all of us. Because many people with chronic hepatitis C live with the virus for many years it is very likely that their lives will change. There may also be many changes to how people are able to deal with the virus from year to year. New information might become
with the medical profession due to treatment demands. Having hepatitis C means different things for different people, it affects people in different ways. We hope the study will tell us about many experiences which have never before been documented. The study is an opportunity to talk about many experiences, which includes a range of health issues, but also broader social aspects of life. It is not a study just about health; it
If you have ever been told that you have hepatitis C and you want to find out more about CHI, you can access the website at www. chistudy.org.au. Let your experience count and let us know about your experiences of having hepatitis C. Australian Research Centre in Sex, Health and Society La Trobe University
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Rural Education Where we’ll be when in SA
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e have two new workers at the Council: Michelle Spudic, the new Rural Educator, and Nicole Taylor, the new Metro/Rural Educator. Michelle and Nicole will be visiting at least one rural region each month to provide education sessions for workforce and community. Towns they will be going to in the next three months are:
MARCH: YORKE PENINSULA including... • Wallaroo • Maitland • Yorketown • Pt Pearce Our Educators can tailor free education sessions to meet the needs of your workforce or client groups, including information on: • Hepatitis C prevalence in Australia
DECEMBER • Whyalla • Murray Bridge JANUARY: ADELAIDE HILLS including... • Gumeracha
• Transmission and prevention • Testing and treatment • Stigma and discrimination • Services available for people affect by Hepatitis C; and
• Mt Pleasant
• Free resource and information packs
• Mt Barker
• Values and beliefs
• Murray Bridge • Mannum • Strathalbyn FEBRUARY: FLEURIEU PENINSULA & KANGAROO ISLAND including... • Victor Harbour • Kingscote • Noarlunga • Meningie • Point McLeay • Tailem Bend
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Sessions can be tailored for healthcare workers and community members. Anyone interested is welcome. If you would like to request a session in one of these areas, or just want to know more, please contact us on 1300 437 222 or 8362 8443, or else email admin@hepccouncilsa.asn.au.
WIN!
From now on, the best letter printed in each issue of the Hepatitis C Community News will receive a $25 shopping voucher. Write to us about anything to do with the magazine, the Council, living with hepatitis C, or living well ideas. This issue the prize goes to Isabelle for her reflections on hepatitis A/B inoculations.
Letters to the Editor Dear Editor For many years now, SAVIVE (SA Voice for IV Education) has been serving the injecting drug using community through their Clean Needle program. They have always provided an excellent service—not only providing sterile 1mL syringes, but also specialised injecting equipment, hepatitis C information, referrals to other services, and peer support. In January, the SAVIVE Norwood site will be moving to Richmond. Unfortunately, this will mean there will be a void in the Eastern suburbs for injecting drug users wanting to access non-judgemental clean needle programs. I and some of the injecting drug using community are beginning to wonder where we can access equipment and education in the Eastern suburbs once SAVIVE has moved. It would be fantastic for the Hepatitis C Council of SA to have a clean needle program, even if it were only for the last half of each day. For me, it makes sense that a harmreduction organisation provide a clean needle program to support the education and information currently provided. I hope to be able to walk down to Hackney Road one day soon to get equipment from a smiling face, rather than having to present to a pharmacy where I may be judged as a ‘useless junkie’. Regards, Jack Back
Hepatitis A and B—should I be inoculated against them? Yes, in these uncertain times, if it is available free you have nothing to lose. I am in a rehab for drug and alcohol abuse, so along I went, played with other people’s babies and toddlers while waiting for the shot... then gave them back, because I could. Into the surgery, a quick prick in the arm and I was done. No pain, no side effects, but lots to gain. A second jab in a month and then the final shot in six months and then I will be immune for life—easy-peasy. How do you catch hepatitis A & B? Hepatitis A comes from contaminated water and food; NSW had an outbreak through oysters and tomatoes a few years ago, so it can lurk anywhere. Hepatitis B can be spread sexually through intercourse and also through the sharing of injecting drug equipment or the sharing of blood. What are the symptoms? Both are detrimental to the liver, but with hepatitis A there is no chronic illness (it lasts for about 50 days). With hepatitis B, the liver is damaged if the infection becomes chronic, but 95% of adults will clear it naturally. So how do you know if you have been infected? Whenever any adult feels physically unwell or suffers from lethargy or depression, it is wise to have a comprehensive blood screening, which might not only identify hepatitis A or hepatitis B, but many other abnormalities. Will I complete the course of inoculations? You bet! Isabelle Hepatitis C Community News # December 2010 •
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Hepatitis C and the Aboriginal Population Contrary to a decreasing national trend, the rate of HCV diagnosis among the Aboriginal population is on the rise. The rate of new HCV infections in the Aboriginal population is between two and ten times higher than that in non-Indigenous populations, depending on location. While Aboriginal people only make up 2.4% of Australia’s total population, they constitute 8.3% of the Australian population living with HCV. That equates to an estimated
The future of Australia
incidence rate of 10,000 new infections each year. There are substantial medical costs associated with living with HCV. In 2005 in Australia, 37% of all liver transplants stemmed from chronic HCV infection. Between 2000 and 2005, the number of liver transplants nearly tripled for those living with chronic HCV. The lifetime [medical] cost for a person living with HCV is estimated at $46 600, resulting in a cost of Hepatitis C Community News 10 • December 2010 • #
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22 000 Aboriginal people who have HCV. One reason that might contribute to the higher prevalence of HCV amongst the Aboriginal population is the disproportionate amount of Aboriginal people in priority populations for HCV: people who inject drugs (PWID) and people within the prison system. People who inject drugs are at risk for various health problems,
most notably HCV infection. Over 91% of new infections were acquired through injecting drug use (IDU). HCV prevalence among PWID in Australia has been estimated at around 55%. Twelve per cent of NSP survey respondents identified as Aboriginal Australian. This represents a proportion five times the proportion of people who identify as Aboriginal within the general population. Identifying as Aboriginal has also been found to be associated with early onset injecting and commencing heroin use via injecting. Being of Aboriginal origin increases the likelihood of experiencing social, economic or family disadvantage; and injecting drug use is more likely to occur among people who experience such hardships and are disadvantaged in a particular society. Aboriginal PWID may be at increased risk of contracting HCV and of other risks associated with sharing of injecting equipment. Research shows rates of sharing among Aboriginal IDU to be high and HIV knowledge to be low. Aboriginal people report sharing their injecting equipment more than other Australians. Sharing of equipment among Indigenous people has been linked to cultural norms associated with sharing, especially where sharing with kin is not seen as sharing. Additionally, when knowledge might be high in some places, there are still other barriers to preventing HCV such as limited access due to low income, issues with transport, and less access to appropriate services.
Alexandra Crosby (www.flickr.com/photos/alimander/2543875518/)
Hepatitis C is a major public health issue in Australia. By the end of 2008 it was estimated that 284,000 people were infected with HCV with an
$9.2 billion to the health care system.
Photo
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epatitis C (HCV) is an increasing issue among Aboriginal Australians. Aboriginal people are overrepresented in prison and in injecting drug using (IDU) populations, both of which are high priority groups for HCV. However, recognition of the significant impact of HCV amongst this community has been slow to occur.
Incarceration is an independent risk factor for HCV. The incidence of HCV within custodial settings has been reported between 40% and 59% in various locations. With Aboriginal people constituting 27% of the prison population, it is 14 times more probable for an Aboriginal person to be imprisoned than a non-Aboriginal Australian. The disproportionate rate of incarceration might contribute to the increased risk of initiating injecting, sharing of equipment and increased exposure to HCV. Half of all prisoners report a history of IDU, and Aboriginal inmates specify prison as being an important point for transition to IDU. Beyond IDU, there are other forms of transmission that are also high risk for people incarcerated, such as tattooing or piercing. Inmates report commonly sharing and reusing equipment when injecting drugs, tattooing and piercing. There is an increased propensity for HCV to further spread into the larger Aboriginal community due to the combination of higher rates of Aboriginal people in prison, the higher rates of HCV in prison, and the shorter sentences Aboriginal prisoners typically carry out. Despite the high prevalence of HCV within the Aboriginal community compared to the non-Aboriginal community, there is relatively sparse research that focuses on this population. Where such research does exist, the Aboriginal community is not usually the focus, but rather is a subgroup within a larger study with a mainstream focus;
or, alternatively, where the Aboriginal community is the focus, HCV is not. For example, in Victoria the Victorian Aboriginal Controlled Health Organisation (VACCHO) and the association for harm reduction and prevention programs (ANEX) are currently working in partnership to tangibly improve health outcomes for Aboriginal Victorians who inject drugs. However, these programs do not focus specifically on HCV, but, rather, on Aboriginal health more broadly. The available research is often limited to small groups and most is over ten years old. Therefore, there is a need for targeted research focusing specifically on Aboriginal people and HCV, IDU, and prison. This will lead to a greater understanding of injection risk practices and issues around HCV knowledge and prevention among Aboriginal people. Perhaps one reason for a lack of specific attention to HCV within Aboriginal communities is the high rates of competing health and social factors. While treatment uptake for HCV is low across all Australians at approximately 3,500, competing co-morbidities are often cited as a barrier for Aboriginal people. Aboriginal communities have limited knowledge of HCV and available treatments. They have poorer health and access to health care as well as lower socio-economic status than non-indigenous Australians. They are faced with real and perceived discrimination surrounding race, IDU, and HCV together with shame and stigma associated with HCV
within the community resulting in PWID unwillingness to use Aboriginal-specific and mainstream health services. However, it is clear that much more research focused directly on HCV within the Aboriginal community as well as within the general population is needed. Research should address educating Aboriginal people on safe injecting practices, HCV knowledge, and available treatments, as well as finding and promoting effective ways to relieve the burden of living with HCV and to prevent its transmission. Interventions need to focus on cultural competency among health care professionals working with Aboriginal people, making services more attractive and accessible to Aboriginal people, and supporting Aboriginal-specific services to deliver a range of HCV programs. Additionally, culturally appropriate models to deliver treatment need to be developed. Ilyse Resnick & Loren Brener National Centre in HIV Social Research, The University of New South Wales Based on Social Research Brief 16 Reproduced with permission
Further material and references can be found online at http:// nchsr.arts.unsw.edu.au/media/ File/SRB16_Hepatitis_C_and_ the_aboriginal_population.pdf
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Insulin Resistance and Treatment
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here is a growing body of evidence linking hepatitis C with insulin resistance. A person who has insulin resistance has a body in which the normal amounts of insulin (a hormone produced by the pancreas) cannot produce the usual response from muscle, fat and liver cells. Insulin usually causes these cells to take up glucose from the blood, storing it in the form of glycogen in the liver and muscle. It also stops the body making use of its fat reserves as an energy source.
Insulin resistance can thus lead to free fatty acids in the blood, to reduced glycogen storage and more glucose in the muscles, and to reduced glycogen storage and overproduction of glucose in the liver.
These raised glucose levels are believed to contribute to both metabolic syndrome (with symptoms like obesity and high blood-pressure) and type II diabetes.
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The origins for these problems lie in the human race’s evolutionary past. As hunter-gatherers, early humans tended to go long periods without food, and then to have a sudden glut (from an animal kill or a rich fruit find, for example). The body needed a way to store up energy in the good times so as to keep itself going in the bad times. The way it found to do this was with adipose tissue.
Broadly speaking, when food is available, the body’s adipose tissue stores the energy which is not needed immediately as fat. Later on, that fat can be converted back to energy as needed. Insulin is central to the way in which this is done, and so insulin resistance can play hell with this energy storage and release happening in the proper way.
People living with hepatitis C are much less likely to respond to hepatitis C treatment if they also have insulin resistance, according to a study published in the Journal of Acquired Immune Deficiency Syndromes. The effectiveness of the treatment may be even lower if the person is coinfected with HIV.
There are a number of factors that determine whether someone will respond successfully to hepatitis C treatment, with success defined as maintaining undetectable HCV levels in the blood for at least six months following the conclusion of a course of HCV treatment. This is usually known as a sustained virological response (SVR).
Some factors that reduce the likelihood of achieving an SVR, such as having certain genotypes of the hepatitis C virus, or being coinfected with both HIV and HCV, are not controllable. Other factors, such as low CD4 counts (a measure connected to T-Cell levels, which shows how well the white blood cells are working for the immune system) or insulin resistance, can potentially be treated.
Several recent studies in people infected with only HCV have suggested that insulin resistance can lower the odds of responding well to HCV treatment.
There have been no studies until now, however, to determine what impact insulin resistance might have on HCV treatment in people coinfected with both HIV and HCV.
To answer this question, Pablo Ryan, MD, from the Hospital Gregorio Marañón in Madrid, and his colleagues reviewed the medical records of 134 coinfected individuals who received standard HCV treatment (pegylated interferon plus ribavirin) between July 2000 and March 2007. The majority of the study participants, 67%, had HCV genotypes 1 or 4, the most common in the West. Of the participants, 31% had insulin resistance. Roughly 85% were on antiretroviral HIV treatment.
Ryan and his colleagues found that people with insulin resistance did indeed respond less well to HCV treatment than those without insulin resistance. Overall, 67% of the participants achieved an SVR, provided that they had no insulin resistance. Meanwhile, only 25% of those with a high degree of insulin resistance achieved
an SVR. In coinfected people with HCV genotypes 1 or 4, success rates ranged from a high of 43% in those with little to no insulin resistance to as low as 21% in people with a high degree of insulin resistance.
After accounting for a number of risk factors, those least likely to achieve an SVR were those with HCV genotypes 1 or 4, those with insulin resistance, and those who’d once had a very low CD4 count. Fortunately, many people can use antiretroviral therapy to
avoid the loss of CD4 cells, and insulin resistance can be improved in many with a proper diet, exercise and weight loss.
The authors conclude that health care providers should look for insulin resistance in their coinfected patients who are considering starting HCV treatment. On top of this, it would be a good idea to look for, and treat, insulin resistance in anyone seeking hepatitis C treatment, whether they also have HIV or not.
References P Ryan, S Resino, P Miralles, and others. Insulin resistance impairs response to Interferon plus Ribavirin in patients coinfected With HIV and hepatitis C virus. Journal of Acquired Immune Deficiency Syndromes 55(2):176-181, October 1, 2010
Main image: Six insulin molecules assembled in a hexamer, the zinc ions holding it together at the centre. Insulin is stored in the body in this form. Image Isaac Yonemoto Small images: Various rotations of the insulin hexamer #
Hepatitis C Community News December 2010 • 13
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HCV/HIV Coinfection Research Update Recent developments in research
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aving both HIV and HCV is not uncommon. It’s estimated that about 13% of HIV positive Australians also have HCV. This combination is also common for people with bleeding disorders who received blood transfusions before proper tests for both viruses were available. There is still some debate about how hepatitis C affects HIV. Some studies have suggested that infection with HCV can lead to more rapid progression of HIV, but others have not.
Hepatitis C is a more serious illness in people with HIV disease, as it progresses more rapidly in these patients. The reasons for this are not known completely, but probably relate to the possibility that the body’s ability to control hepatitis C may be reduced if you have HIV because of the latter’s effect on the immune system. As time has gone on, valuable research on the effects of coinfection has Hepatitis C Community News 14 • December 2010 • #
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continued. Here are some of the most recent findings.
Neurocognitive Effects A study by Alan Winston from Imperial College, London, and his colleagues set out to measure neurological and cognitive function in HIV-positive people newly infected with HCV.
Effects of both chronic viruses on the central nervous system have been widely reported, and impairment has been found to be worse when they co-exist. But these effects have never been clinically examined before now. The study, reported in the Journal of Viral Hepatitis, found that HIV-positive people with acute hepatitis C coinfection showed evidence of impaired function based
on magnetic resonance spectroscopy brain imaging and neurocognitive testing. This suggests that the neurocognitive effects previously reported may begin to happen very soon after HCV acquisition. As Liz Highleyman, senior writer at HIVandHepatitis. com, explains, “This small analysis included 10 individuals with chronic stable HIV-1 infection with documented acute HCV, as indicated by a positive HCV RNA polymerase chain reaction assay but negative HCV antibody test. These patients were compared with 2 matched control groups: 10 people with HIV but no evidence of HCV, and 10 with no evidence of either HIV or HCV. “Participants underwent cerebral proton magnetic resonance spectroscopy (MRS)—a technique for assessing brain function based on chemical signatures—to quantify myoinositol/creatine (mI/Cr) ratio in the right basal ganglia, which play a role in various brain functions including motor control. The patients also received computerized neurocognitive assessments.” The test results that this mI/Cr ratio was significantly lower in coinfected patients than in those with only HIV, and those in the uninfected control group. Half of the acute coinfection patients actually had a mI/Cr ratio
below the lowest observed ratio in either of the other two groups.
September 15, 2010 Journal of Infectious Diseases.
Predicting Therapy Results
Standard therapy for chronic hepatitis C consisting of pegylated interferon plus ribavirin leads to sustained virological response (SVR) (continued undetectable HCV viral load at 24 weeks after completion of treatment) for about half of people with hepatitis C alone, with most studies showing somewhat lower sustained response rates for HIV/HCV coinfected individuals.
HIV/HCV coinfected people who show changes in levels of certain antibodies against hepatitis C virus (HCV) and HIV were more likely to experience sustained response to HCV therapy using pegylated interferon plus ribavirin, suggesting that antibody measurement might help determine which patients are likely to achieve a cure, according to a study by National Institutes of Health (NIH) researchers described in the
The usual length of chronic hepatitis C treatment is 24 or 48 weeks (depending on HCV genotype) for HCV monoinfected patients, but most experts recommend the longer duration for all HIV/HCV coinfected people regardless of genotype. Some patients who reach undetectable HCV RNA by the end of treatment experience HCV rebound or relapse after stopping therapy, and therefore do not achieve sustained response.
Based on these findings, the study authors concluded, “Acute HCV in HIV-1 infected subjects is associated with central nervous system involvement,” and that “Clinicians should be vigilant of early CNS involvement when assessing subjects with acute HCV.”
Peter Burbelo from the NIH National Institute of Dental and Craniofacial Research and colleagues assessed antibody responses and their relation to hepatitis C treatment outcomes in HIV/HCV coinfected patients. They compared levels of antibodies targeting the entire set of proteins produced by HCV in blood samples taken before and after treatment with pegylated interferon plus ribavirin. Analysis of pre- and posttreatment samples showed that antibodies targeting certain HCV proteins decreased significantly in patients who achieved SVR, while remaining stable in non-responders. These results, the study authors concluded, “suggest that profiling anti-HCV antibody is useful for monitoring HCV therapy, especially in discriminating between those who experience relapse and those who have SVRs at 48 weeks.”
References A Winston, L Garvey, E Scotney, and others. Does acute hepatitis C infection affect the central nervous system in HIV-1 infected individuals? Journal of Viral Hepatitis 17(6): 419-426 (Abstract). June 2010. PD Burbelo, JA Kovacs, KH Ching, and others. Proteome-wide anti-hepatitis C virus (HCV) and anti-HIV antibody profiling for predicting and monitoring the response to HCV therapy in HIV-coinfected patients. Journal of Infectious Diseases 202(6): 894-898 (Abstract). September 15, 2010.
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Are you happy with your GP? If you are, we need to hear from you.* We are updating our Hep C-friendly GP list for metro and rural areas. Individual Membership will continue from year to year without the need for renewal, as long as contact details provided remain current. You are able to resign your membership at any time. To update contact details for continuing membership or to resign your membership, please phone HCCSA Administration on 8362 8443.
Please call Deborah on 1300 437 222. *We approach GPs for permission before putting their names on our list, and we do not reveal who nominated them.
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Useful Contacts & Community Links Hepatitis C Council of SA
Provides information, education, support to people affected by hepatitis C, and workers in the sector. The Council provides information and education sessions, as well as free written information. The Calming the C Support Group is also run by the Council. Call the Council’s Info and Support Line for information on 1300 437 222 (for the cost of a local call anywhere in SA).
MOSAIC & P.E.A.C.E.
Relationships Australia (SA) provides support, education, information and referrals for people affected by hepatitis C through the MOSAIC and P.E.A.C.E. services. MOSAIC is for anyone whose life is affected by hepatitis C, and P.E.A.C.E. is for people from non-Englishspeaking backgrounds. (08) 8223 4566
Nunkuwarrin Yunti
An Aboriginal-controlled community health service with a clean needle program and liver clinic. (08) 8223 5011
Clean Needle Programs
To find out about programs operating in SA, contact the Alcohol and Drug Information Service. 1300 131 340
Partners of Prisoners (POP)
Facilitates access to and delivery of relevant support services and programs which promote the health, wellbeing and family life of partners of prisoners who are at risk of hepatitis C, HIV/AIDS or are people living with hepatitis C or HIV. (08) 8218 0700
SAVIVE
Provides peer-based support, information and education for drug users, and is a Clean Needle Program outlet. (08) 8334 1699
Hepatitis Helpline
This hotline operated by Drug and Alcohol Services South Australia provides 24hour information, referral and support. Freecall: 1800 621 780
SA Sex Industry Network (SA-SIN)
Promotes the health, rights and wellbeing of sex workers. (08) 8334 1666
Vietnamese Community in Australia (SA Chapter)
Provides social services and support to the Vietnamese community, including alcohol and drug education, and a clean needle program. (08) 8447 8821
The Adelaide Dental Hospital has a specially-funded clinic where people with hepatitis C who also have a Health Care Card can receive priority dental care. Call the Hepatitis C Council for a referral on (08) 8362 8443.
Aboriginal Drug and Alcohol Council of SA (ADAC) Ensures the development of effective programs to reduce harm related to substance misuse in Aboriginal communities. (08) 8351 9031
AIDS Council of SA (ACSA) Aims to improve the health and wellbeing of gay/ homosexually active people, people who inject drugs, sex workers and people living with HIV/AIDS in order to contribute to the overall wellbeing of the community. (08) 8334 1611
Are you interested in volunteering with the Hepatitis C Council of SA? Please give us a call on (08) 8362 8443 or drop us a line at admin@hepccouncilsa.asn.au and let us know. We rely on volunteers for many of our vital services.