Hepatitis C Harm Reduction Project

Hepatitis E in the News

Hepatitis E outbreaks have recently been reported in Iraq, the Sudan, and Chad. Hepatitis E is extremely uncommon in the United States, but endemic in other parts of the world, and thrives in conditions of social and political disruption and violence.

Hepatitis E resembles hepatitis A in transmission and disease course – people get infected through “fecal-oral” routes (contaminated food or water, as occurs with poor sanitation). There is little or no evidence for person-to-person (e.g., sexual) transmission. In the U.S., virtually all hepatitis E cases are seen in people who recently traveled to endemic (high-prevalence) areas, such as Mexico, Africa, and Asia, though a small number of cases may originate in the United States and other industrialized countries (see Clemente-Casares et al., Hepatitis E Virus Epidemiology in Industrialized Countries, Emerging Infectious Diseases vol. 9, no. 4, April 2003).

Questions about hepatitis E and other forms of viral hepatitis often come up in hepatitis C education sessions. Some people have heard (incorrectly) that the letters assigned to each virus (A, B, C, etc.) indicate severity – that if hepatitis A is bad, then hepatitis B and C are even worse, and hepatitis E must be instantly fatal. The reality is that the letters don’t correspond to any grade for how dangerous each virus is, and were assigned (roughly) in order of discovery.

Complementary and Alternative Medicine and Nutrition

Many people with hepatitis C pursue complementary or alternative approaches to treatment (herbs, supplements, acupuncture, etc.) due to the drawbacks and limitations of conventional treatment. Common complementary therapies thought to help people with hepatitis C include milk thistle (active component silymarin or silybum marianum), licorice root (active component glycyrrzhin), sho-saiko-to (a mixture of seven plants, including licorice), ginseng, thymus extract, and vitamins and antioxidants.

Some people with hepatitis C also make adjustments to their diet, given the importance of the liver in metabolizing food.

The general goals of nutrition and of complementary/alternative medicine (CAM) are to reduce the potential for liver damage from hepatitis C, and to offset symptoms and side effects. Herbs and supplements are often touted for their potential to boost the immune system, decrease inflammation or oxidative stress, and/or reduce elevated liver enzyme levels. Neither nutrition nor CAM alone can cure hepatitis C, but some approaches may help protect the liver and make it easier to live with the virus.

Right now there’s no definitive research showing that CAM or nutrition benefits people with hepatitis C. We need well-designed clinical trials to investigate the impact of CAM approaches on hepatitis C – do they really protect the liver? Are they really safe? Who do they work best for?

A lot of doctors disapprove of their patients trying CAM approaches. It’s good to keep in mind that herbs can have dangerous properties, including their own side effects. Some herbs and supplements are actually harmful to the liver. Interactions between herbs and prescription medications may increase drug side effects or lower blood levels of a drug, making it less effective. For that reason, it’s important to tell your doctor about any complementary or alternative therapies that you’re using or thinking about.

It’s also important to remember that herbs, supplements, and vitamins are a big business that’s largely unregulated by the Food and Drugs Administration (FDA; see FDA's Tips for the Savvy Supplement User: Making Informed Decisions and Evaluating Information [Spanish version]). That means that the purity and levels of active ingredients of the products you can buy in health food stores and on-line can vary a lot. It also means that you can’t believe everything that you read or hear about these products – if it sounds too good to be true, it probably is.

Share your experiences and decisions with CAM and nutrition for hepatitis C by clicking on the 'comments' link beneath this post.

Here are some resources for learning more about CAM and nutrition:

Hepatitis A and IDUs

When we think of viral hepatitis and injection drug users (IDUs), we usually think of hepatitis C. But hepatitis A also poses a significant threat to IDUs. Here's why:

Hepatitis A can be transmitted through blood, so sharing needles and injection equipment (cookers, cotton, water) could put IDUs at risk for hepatitis A

A study in Baltimore from the mid-1990s found that 66% of IDUs had been infected with hepatitis A (see PDF of article from Clinical Infectious Diseases). More recently a Vancouver study found evidence of past hepatitis A infection in 43% of IDUs (full text of article from Canadian Medical Association Journal; PDF here)

The Centers for Disease Control (CDC) reports that 5% of all new cases of hepatitis A in the United States occur among IDUs – but since half of all new cases have no reported risk, this figure may underestimate the rate of new infections in IDUs.

Hepatitis A is rarely fatal. But if you already have hepatitis C, getting hepatitis A can cause fatal liver failure (see abstract in New England Journal of Medicine).

The good news is that hepatitis A is almost totally preventable through vaccination. Injection drug users and people with hepatitis C should be vaccinated for hepatitis A.

Alcohol: How much is too much? (part 2)

Yesterday's post discussed a new study assessing the impact of different levels of drinking on hepatitis C disease progression. The results indicated that heavy drinking, particularly in men, was associated with greater fibrosis. Beyond that, there was a trend towards increased fibrosis associated with greater amounts of alcohol consumption, but that for light or moderate drinkers the association with fibrosis progression was not statistically significant.

Here are some ways to think about this research from a harm reduction perspective:

1. Research can't always give you clear, unambiguous answers: One of the lessons of this study is that alcohol's effects may be subtle and highly variable. The study could not demonstrate a safe level of drinking, nor could it unequivocably show that even light drinking is harmful for people with hepatitis C. While more research would be helpful, it's unlikely to result in a clear formula for how much it's safe to drink, and for whom. As with many other aspects of hepatitis C, we listen to the research and learn to live with the ambiguities. Clear answers can be comforting, but they're often in short supply, and it's dishonest to impose false certainties and absolutes on the messy realities of hepatitis C.

2. Everyone's body is different: Just as people respond differently to alcohol in their mood and behavior, people with hepatitis C will likely have a range of possibilities in how drinking affects their liver. As the study authors note, some people may be more susceptible to the effects of alcohol on the liver. Even heavy drinkers in this study did not invariably progress to cirrhosis.

3. There's no way of knowing how susceptible someone is to liver damage from alcohol consumption: If you have hepatitis C, you can't predict what level of drinking is "safe" or "dangerous" for your liver. Some people with advanced liver disease can feel the effects of alcohol -- their body's telling them through symptoms that alcohol is hard on the liver. But most people won't know what effect alcohol is having on their liver from symptoms.

4. Other information about liver health can help put the risk of drinking in context: In the study described yesterday, elevated ALT levels were strongly associated with risk of greater fibrosis, as was age and liver inflammation. In other studies, obesity or a high body mass index has been associated with greater fibrosis, while female sex may somewhat protect from fibrosis progression. There's no formula for predicting your risk of fibrosis, but a biopsy can tell you where things stand with your liver. People who have been infected with hepatitis C for 20 years and have little or no fibrosis may not have to change the way they drink; people who have cirrhosis may need to take the risks of alcohol more seriously.

5. Drinking may be a risk, but it's not just a risk: People have a range of reasons for drinking -- pleasure, companionship, relief from stress, etc. Even people who aren't dependent on alcohol may be reluctant to give it up. Some drug users have worked hard to quit other drugs, like heroin, cocaine, and crack, trading them for alcohol -- drinking helps them stay away from the drugs that were creating more immediate and severe problems in their lives. If you only think and talk about alcohol as a risk for liver disease, you're missing a big part of the picture -- the reasons why people drink, and the real and perceived benefits they get from continuing to drink.

In a future post, I'll talk about how educators and people with hepatitis C are grappling with these issues. In the meantime, feel free to add a comment (click at the bottom of this post) about your take on alcohol and hepatitis C.

Alcohol: How much is too much? (part 1)

The negative effects of heavy drinking on the liver health and survival of people with hepatitis C are well-documented. Heavy drinking increases damage to the liver, leading to greater risk of cirrhosis and liver cancer (hepatocellular carcinoma).

But research on the effects of light or moderate drinking on hepatitis C disease progression have been less conclusive (download full article as a PDF file here). In the absence of clear answers, many doctors, educators, and people with hepatitis C advise total abstinence from alcohol if you have hepatitis C.

Yet veterans of the War on Drugs are instinctively wary of absolute, "Just Say No" messages. Harm reduction theory and practice originated in part from a recognition that total abstinence from substances was not always possible, necessary, or even perhaps desirable for many people. Is harm reduction an appropriate model for thinking about alcohol and hepatitis C? That depends on how you interpret the research.

A new study published in the March issue of Hepatology examines how different amounts of alcohol affect the progression of hepatitis C liver disease. The study compared the biopsy results of 800 people with hepatitis C to their reported histories of alcohol consumption, measured as average grams/day (with one drink containing 10 grams of alcohol). People were divided into four categories:

Non-drinkers -- no alcohol
Light drinkers -- up to 2 drinks per day
Moderate drinkers -- between 2 and 5 drinks per day
Heavy drinkers -- greater than 5 drinks per day

As expected, heavy drinkers had more fibrosis overall. There was a general trend showing greater fibrosis with increased amounts of alcohol, but these results were only considered statistically significant for heavy drinkers -- specifically, men who consumed on average over eight drinks a day. There was a substantial range of fibrosis within each category of alcohol consumption, and nearly half of heavy drinkers had little or no fibrosis. When all factors were considered, the most significant predictors of fibrosis were age (strongly associated with duration of hepatitis C infection, which averaged over 20 years), liver inflammation (as measured on biopsy), and ALT levels.

So what does this mean for people with hepatitis C? The headlines of two articles discussing the study reflect different interpretations:

from WebMD: "Bad Mix: Alcohol and Hepatitis C -- No Safe Alcohol Levels if You're Infected"

from HIVandHepatitis.com: "Light and Moderate Alcohol Intake May Have Minimal or No Effect on Fibrosis Development in HCV Infection"

Both perspectives are valid, and supported by the research. But they only tell part of the story. It seems that the effects of alcohol on hepatitis C progression can vary considerably, and in some cases other factors may be more important in determining fibrosis.

Coming next: translating research on alcohol into harm reduction.