Community News #45 â€˘ September 2009
Hep C & Lifestyle Factors: Part 1
Introduction Welcome to the first special issue of the Hepatitis C Community News in a series that will focus on liver health. On pages 8-10 you will find a beginner’s guide to the liver and how to look after it, while on pages 2-3 you will see the latest research on smoking and how it affects liver health. 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 firstname.lastname@example.org
This focus will carry over to our next issue, with a look at nutrition and its effects on the liver (including hepatitis-friendly recipes), as well as the use of cannibis and its impact on hepatic health. This issue also continues to examine the outcomes of the South Australian Hepatitis C Action Plan, the launch of which was featured in the last issue. Take a look at pages 7, 12 and 14 for the latest developments. As always, please get in touch and tell us what you think.
STAFF Executive Officer: Kerry Paterson Administration Coordinators: Lynn Newman Megan Collier Info and Support Line Coordinator: Deborah Warneke-Arnold Info and Support Line Volunteers: Fred Lyn Will Judy Anne Debra Michele Coordinator of Education Programs: John McKiernan Educator: Maggie McCabe Peer Education Coordinator: Lola Aviles Information and Resources Coordinator: Cecilia Lim
Next issue’s copy deadline is 20 November, and the magazine will be published in December. See you then.
About the Cover Lifestyle and liver health: two extremes. Art by James Morrison, making use of photographs by Martin Eric (top) and El Alvi (bottom). Jack’s comic strip adventures written and illustrated by James Morrison. Correspondence: Please send all correspondence to The Editor at PO Box 782, Kent Town, SA 5071, or email email@example.com.
Smoking & Hepatitis C
Publications Officer: James Morrison
Hep C Education in Borneo
Librarian: Joy Sims
More Hepatitis Nurses
Launch of the eBox
Liver Health: The Basics
Info and Resources Volunteers: Bryan Gauri Karan Lyn Mark Phil Philip Yvonne
BOARD Chairperson: Arieta Papadelos
Liver Health Tips
Vice Chairperson: Catherine Ferguson
Volunteers at Monarto
Secretary: Peter Underwood
The Peer Support Program
Treasurer: Darrien Bromley
HCV Antibody Research
Senior Staff Representative: Kerry Paterson
Ordinary Members: Lisa Carter Bill Gaston Carol Holly Stefan Parsons Justine Price Kristy Schirmer
Increasing Treatment Uptake
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. We welcome contributions from Council members and the general public. “As far as I can tell, your entire enterprise is more than a solitary man with a messy apartment which may or may not contain a chicken.”
The new Equal Opportunity Act
n 26 November 2008, the South Australian Government introduced a Bill into Parliament to update our 1984 Equal Opportunity Act. The Equal Opportunity (Miscellaneous) Amendment Bill 2008 was passed on 14 July 2009. The Bill strengthens SA antidiscrimination laws, bringing them into line with those of other states and nationally, and gives South Australians better options to solve problems locally. There is more protection for: • people who care for a dependent child or a family member, • people with a mental illness, or an infection without symptoms, • domestic partners, • people discriminated against because of their spouse or partner, • contractors, and • people who have been sexually harassed. Workers have better protection, if they:
Some outdated laws have also been repealed: • clubs and associations may not turn away homosexual members, • small partnerships may not refuse to admit new members to partnership on the ground of their sexuality, and • church-run hospitals, aged-care homes and welfare agencies may not discriminate on sexuality. Of most pertinence to those living with hepatitis C are the rules regarding disabilities: “Disability now covers people with mental illness, learning difficulties or who have been infected with HIV, Hepatitis C or other organisms that can cause disease. This broader recognition of disability replaces the previous ground of impairment and mirrors the Commonwealth law.”
shops and service providers to treat someone less favourably because of their caring responsibilities. That includes refusing to employ or admit to a course of study. It will also be unlawful for them to set requirements that are particularly hard for carers to meet, unless those requirements are reasonable. A commencement date for the new law is yet to be fixed.
MAKE A NOISE!
For more information, visit www.eoc.sa.gov.au and follow the prompts from the homepage to see the law changes.
Furthermore, the new law will recognise ‘caring responsibilities’ for the first time. A ‘caring responsibility’ is a responsibility to provide care or support for a close family member. It will be unlawful for employers, schools, colleges,
• are sexually harassed and the employer has not taken reasonable steps to prevent the harassment, • are harassed by customers or clients – such as waiters harassed by patrons, and care workers harassed by residents, or • wear dress or adornments symbolic of their religion. Schools and universities must have sexual harassment policies. And, students and staff are able to lodge a complaint about sexual harassment by any student aged 16 or over. Image © Dimitri dF
The time limit for lodging a complaint is doubled, from six months to twelve months, in line with most other Australian jurisdictions.
Hepatitis C Community News September 2009 •
Puffing Smoking with hepatitis C raises liver cancer risk
ew research demonstrates that a man with hepatitis C who smokes has a significantly greater chance of getting liver cancer than those who are able to steer clear of cigarettes. In order to prevent the worsening of liver disease, those living with chronic hepatitis C often seriously consider making some lifestyle changes. Since alcoholic drinks are a known liver toxin and have been shown to accelerate liver damage from hepatitis C, alcohol abstinence is the most obvious change that can positively affect liver health. However, smoking is now believed to be one of the worst things you can do when living with the virus. New research shows that, especially in men, cigarette smoking can dramatically increase the likelihood of hepatitis C leading to liver cancer. Liver Disease Progression Only about half of those infected with the most common type of hepatitis C in America, genotype 1, can eliminate the virus with the current standard of therapy. The other 50% learn to live with hepatitis C, and hope that the health of their liver does not worsen. Positive lifestyle changes that include alcohol abstinence, quitting smoking, avoiding toxins, eating a healthy diet and regular exercise appear to significantly minimise the risks of liver damage. When it does advance, liver damage is progressive, and so may escalate from fibrosis to one of the following final stages of liver disease:
Hepatitis C Community News • September 2009
1. Cirrhosis - a worsening of fibrosis, when the liver becomes irreversibly scarred and blood can no longer flow through this organ 2. Liver Cancer - when damage to the liver alters the genes inside the liver’s cells, the cells can become cancerous Smoking and Liver Disease Progression Because cigarette smoke contains so many toxins and known carcinogens, its cessation has been advised to people with hepatitis C for many years. However, proof of liver damage from smoking has been slow to accrue. Nonetheless, several previous studies have examined the relationship between hepatitis C and cigarette smoking: • A French study published in the January 2003 edition of Gut found that smoking, independent of alcohol, could aggravate the histological activity of chronic hepatitis C. • In the June 2006 issue of Clinical Gastroenterology & Hepatology, California researchers found that smokers with chronic hepatitis C may be more likely than nonsmokers to develop liver fibrosis.
Smoking and Liver Cancer While there has been evidence pointing to cigarette smoke’s ability to injure the liver, there is now proof that it increases a man with hepatitis C’s risk for developing liver cancer. Published in the October 2008 edition of the International Journal of Cancer, researchers from Texas investigated smoking and other behaviors as risk factors for the most common type of liver cancer, hepatocellular carcinoma (HCC), with men and women who have chronic hepatitis C. The researchers found the following: • Differences between men and women were observed in smokers with hepatitis C who develop HCC.
• Women with hepatitis C who consume large amounts of alcohol have a more than 13-fold increased risk of HCC. The researchers concluded that there appears to be a significant link between smoking and hepatitis C infection in men, leading to a more than 136-fold increased risk of developing HCC. Since increasing the risk of liver cancer by over 100 times is so dramatic, there is no doubt of the risks of cigarettes. For men with hepatitis C who have the intent of preventing their liver disease from progressing to cancer, abstaining from smoking cigarettes should lie at the top of their to-do list. Of course, this is easier said than done. A good first step is to contact Quit SA’s Quitline on 13 78 48. Their website, at www. quitsa.org.au, has plenty of good advice on how to proceed.
Smoke image © Vanessa Pike-Russell Smoker image © Jim O’Connell
• Men with hepatitis C who smoke have a more than 136-fold increased risk of HCC.
More information: www.hcvadvocate.org/news/newsRev/2008/NewsRev-284.html#_ Cigarette_Smoking,_hepatitis, Cigarette Smoking, hepatitis C Virus Synergistic in Raising Liver Cancer Risk, Reuters Health, Retrieved November 23, 2008, medscape.com, hepatitis C Support Project, 2008. www.hivandhepatitis.com/hep_c/news/2006/070706_a.html, Smoking May Worsen Liver Fibrosis in Patients with Hepatitis C, Retrieved November 23, 2008, hivandhepatitis.com, July 2006. www.medicinenet.com/script/main/art.asp?articlekey=18104, Smoking With Liver Disease - A No-No, Jay W. Marks, MD, Retrieved November 23, 2008, MedicineNet Inc., 2008. www.ncbi.nlm.nih.gov/sites/entrez, Effect of different types of smoking and synergism with hepatitis C virus on risk of hepatocellular carcinoma in American men and women: case-control study, Hassan MM, et al, Retrieved November 23, 2008, International Journal of Cancer, October 2008. www.ncbi.nlm.nih.gov/sites/entrez, Impact of smoking on histological liver lesions in chronic hepatitis C, Hezode C, et al, Retrieved November 23, 2008, Gut, January 2003.
Next Issue: Cannabis use and hepatitis C
Nicole Cutler Nicole Cutler is a neuroscientist and acupuncture therapist in the US who specialises in hepatitis treatment and liver disease. See www.joyousmedicine.com for more information. This article was adapted from her article in The Hep C Review, June 2009.
Hepatitis C Community News September 2009 •
A Borneo Connection International hepatitis C education
riends of mine have been managing a national park in Borneo for a number of years and I had been wanting to visit them and the local communities for some time. Finally, in April 2009, I was able to spend five weeks in Borneo on annual leave, travelling with a dear friend, Sandy Dekker. I asked if there might be some projects we could be involved in when we came over. Maybe plant some trees or cut back noxious weeds? Or teach belly-dancing (which Sandy did, to the delight of the local women). To my surprise, they asked if we could facilitate some workshops on hepatitis C for staff and community members. They stated that intravenous drug use had been an issue in the communities and, given their geographical isolation, there is very limited knowledge of ways people can remain healthy and minimise the spread of the virus. Both Sandy and my own backgrounds as social workers have focused on working in the areas of violence and abuse, and with survivors of childhood sexual abuse. Hepatitis C was a bit out of our area of expertise!
Expanding our knowledge of hepatitis C I had a conversation with the nurses Denise Pratt and Margaret Grohs, who work with me at the Playford Primary Health Care Service. They helped me search some websites which included the Hepatitis C Council of SA. From there, I contacted John McKiernan. John was extremely helpful, meeting with Sandy and me, going through information and providing us with lots of resources. I met with Enaam Oudih, from PEACE, Relationships Australia of SA (RASA), to discuss multi-cultural aspects of working with different population groups. I also met with Cathy Healey (RASA) to talk about working with indigenous Hepatitis C Community News â€˘ September 2009
Sandy and I also have training in Narrative Therapy, so we drew on our knowledge of that practice, and the experiences of Yvonne Sliep, recorded in her articles about her community work with people in Malawi (who are addressing the impacts of HIV-AIDS on local communities), and Barb Wingard, writing on her experiences of addressing the effects of diabetes within Aboriginal communities in South Australia.
The Workshops I ran the draft of the workshops past my friends to ensure there were no glaring cultural issues which needed to be addressed. This proved to be invaluable as they know the communities very well, and I was able to make relevant changes. Sandy assisted, especially with information on diet and nutrition and with the roleplays (indicating that the virus is spread only via blood). To say that I was a bit nervous with the first workshop is a bit of an understatement. Working in a different culture, with population groups whom I didn’t know, using an interpreter, discussing quite a sensitive topic: it all had me feeling quite apprehensive. However, the audience, comprised of park staff, was genuinely interested in the topic. They were relieved to hear
All photos© Jussey Verco
communities. Both women were very helpful and giving of their time. Other people who generously shared their knowledge and resources included: SAVIVE staff Carol and Patrick; Lucia from the Communicable Disease Control Branch, SA Health; and Megan Camfferman, dietician from Playford Primary Health Care Services, providing information on diet and the importance of eating well, especially when dealing with a health issue like hepatitis C. Everyone whom I contacted was so helpful.
Malaysian sector (Sabah & Sarawak )
BORNEO Indonesian sector (Kalimantan)
that hepatitis C was blood-borne only and could not be caught through sharing meals together, or through sharing of bathrooms, toilets or swimming areas. They were surprised to learn, however, that sharing of toothbrushes, razors and hairbrushes (common practices) could be possible sources of transmission. We had some indepth discussions about ways in which they could educate the local barber (used regularly by many of the men) by taking information to him about hepatitis C and asking him to use their own personal razors and combs rather than using communal items. The interpreter was very interested in the topic as his two sons and his daughter-in-law have all been diagnosed with hepatitis C. He indicated that his family had been subject to discrimination from community members due to the fear of hepatitis C. He told us that his new wife had left when she found out that his children had hepatitis C, as she was frightened of contracting the virus and he was obviously very sad about this. He attended all but one of the workshops (a total of six in all, with about 85 people attending) as he was keen to get accurate
information. He is an Elder in the local Church (a powerful group within the community) so he will continue to spread this information. He knew the content of the workshops so well that by the last workshop, he could have facilitated this himself. When we told him this, he was quietly proud. People asked lots of questions, including whether mosquitos could carry the virus and were not convinced when I said that the research indicated this was not the case! They were curious to know where the virus had come from, how long it had been around and whether it was safe to have sex if one or both partners have hepatitis C. They were relieved to learn that, unless blood was present, this was safe. (Several smiles and embarrassed laughter spread around the room at this discussion!). We had some interesting discussions when we talked about the importance of eating well (and cutting down on eating the fat from wild boar which they view as a delicacy) and decreasing cigarette and alcohol consumption. These particular discussions were not so warmly received! (continued over page) Hepatitis C Community News September 2009 •
After the first workshop, we heard that people thought that I had said that tattooing should be stopped. This was a concern as tattooing is an important part of cultural practices within the communities. This was a lesson in me needing to be very clear about what I was saying. After that, I took greater care to acknowledge the importance of tattooing, but emphasised the need not to be sharing implements. Some tender outcomes Sandy and I met with the young couple who both have hepatitis C and talked through some very intimate details with them about ways of keeping healthy and not passing on the disease to their little daughter. They said that they had received medical help from the nearby hospital, but that noone had actually explained the implications of hepatitis C, ways in which to minimise its spread, the importance of diet, and ways of keeping healthy generally. The day we left, the young man told us that he had given up smoking and drinking alcohol and that his intention was to abstain forever as he wanted to live a long and healthy life with his wife and child. They also wished to have more children and would now consider this. The interpreter asked if I could run a workshop for community members. At the end of that session, he brought his wife over to meet us. After hearing the information from the workshops via her husband, she had returned that day to hear the information first-hand. She had decided to live again with the family. That really touched our hearts. We really enjoyed doing the workshops. It felt good to be able Hepatitis C Community News • September 2009
We encouraged people to view this as a community issue and to work together to decrease the likelihood of hepatitis C spreading throughout the area, to create healthy communities where issues like this can be openly discussed and acted on. I can see a huge need for community education and health promotion in areas like Borneo. I reflect on how lucky we are in Australia to have the dedication of staff and the resources from agencies like the Hepatitis C Council, RASA and SA Health. My friends contacted me recently to say that there continue to be comments made by community members indicating that the workshops were helpful. There have been no new reported cases in recent months. This is so good to hear! While I was surprised when my friends asked me to do the hepatitis C workshops, I am now pleased to have had the opportunity to offer them and that the communities were eager to take up the information discussed.
Thank you to all the people who helped me gather the relevant information on hepatitis C and provide the resources which could then be shared with the communities in Borneo. A special thanks to John McKiernan and the Hepatitis C Council of SA. Without the help of the people named above, the workshops would not have happened. Note: In order to respect the privacy of the communities in Borneo, the names of the specific park and area have been omitted. Jussey Verco Jussey Verco is the senior social worker with Central Northern Adelaide Health Service, Ambulatory and Primary Health Care Services, Playford site, Davoren Park. References: Sliep, Y., 1996: A spirit on its own is easily broken but together we will not break: communitites respond to HIV/AIDS, diabetes and grief. Dulwich Centre Newsletter, No 3., Dulwich Centre Publications, 1997. Wingard, B., 1996: Bringing the Work Home: the work of Barb Wingard and the Aboriginal Women’s Health and Healing Project of South Australia. Dulwich Centre Newsletter, No 3., Dulwich Centre Publications, 1997.
All photos© Jussey Verco
to do something, even in a small way, to help to diminish fears about hepatitis C and hopefully, pass on information which will enable community members to live a healthier life.
More Hepatitis Nurses Nursing support for hepatitis C treatment to increase
reatment numbers must triple to reduce cirrhosis and liver cancer.
Treatment rates for hepatitis C are low in South Australia and nationally, with only 1-1.5% of eligible patients taking it up annually. In 2005, a national estimates and projections study on hepatitis C was commissioned. It concluded that a tripling of the number of people treated in 2005 was required in order to decrease the number of people living with moderate liver disease or cirrhosis
caused by chronic hepatitis C, and to reduce the impact on the health system. Consultations for the SA Hepatitis C Action Plan 2009-2012 revealed that a key barrier to treatment uptake in SA is the lack of nursing capacity to support people through treatment. The HIV/HCV Policy and Programs section, in consultation with hepatology services provided through the Royal Adelaide Hospital, Flinders Medical Center, the Queen Elizabeth and Lyell
McEwin Hospitals, established the SA Hepatitis C Action Plan target for an additional 9 full-time-equivalent nursing positions over 3 years. Nurses will work to increase the number of patients completing treatment and facilitate treatment support and care in the community setting. The new nursing positions will be phased in over time, and provide outreach to primary care sites, including community health services and GPs interested in treatment referral and shared care for people with hepatitis C.
Image © Quite Adept
eBox! HCCSA recently delivered a boxful of resources to the Shopfront at Salisbury – not uncommon, only this time the “box” is an electronic one. eBox offers movies, slides and step through guides about hepatitis C risks and treatment. This is a 3-month trial project implemented in partnership with SAVIVE.
Left: SAVIVE worker Sue Brownbill shows off the eBox. Hepatitis C Community News September 2009 •
The Liver Protection Scheme How the liver works, and how to look after it
he liver is situated on the upper right side of the abdomen, just below the diaphragm. The liver receives 30% of the circulating blood each minute, and it acts as a giant chemical processing plant in the body. The liver cells, called hepatocytes, perform vital chemical reactions called ‘metabolism’, which are central to normal body maintenance. Metabolism of nutrients Once digested, nutrients enter the blood; they are then taken straight to the liver to be processed. How the hepatocytes deal with the nutrients depends on whether each nutrient is in abundance, or whether levels are low in the body. The liver processes carbohydrates in many ways. Carbohydrates are broken down into glucose in the gastrointestinal tract, which enters the blood and is taken to the liver. Glucose is a vital energy source for cells, and levels in the blood stream must remain constant. When the blood glucose level is within the right range, the liver converts the excess glucose into glycogen for storage. The
glucose that is not stored is used to produce energy. In between meals, during starvation, or during exercise, blood glucose levels fall. The hepatocytes detect this change, and restore glucose levels by either converting glycogen back to glucose, or by converting nonsugars such as amino-acids into glucose. The liver is involved in breaking down fat and creating compounds that include fat, such as lipoproteins, cholesterol and phospholipids. If fat is in excess, the liver joins fatty acids and glycerol together to form a storage molecule for storage in subcutaneous tissue (tissue just under the skin) and other storage depots. If energy and glucose levels are low, as one would find between meals, or as a result of exercise, stored fat is converted back into glycerol and fatty acids which are then transported to the liver for use as an alternative energy supply. Proteins are broken down to amino acids in the intestines and are transported to the liver via the blood. If proteins are in excess, amino acids can be converted into fat and stored in fat depots, or if
required, made into glucose for energy. However, before amino acids can be utilised in these ways, the nitrogen component must be removed from the compound. In the hepatocytes, nitrogen quickly changes into ammonia, which is highly toxic to the body. The liver acts fast to convert ammonia into urea which can then be excreted in the urine and eliminated from the body. Processing of toxins The liver is vital for the detoxification and destruction of substances that are harmful to the body. These substances may be byproducts of normal metabolism, or ingested/inhaled substances such as drugs and alcohol. The liver filters the blood, removing cellular debris and any invading bacteria; amino acids are broken down, and the nitrogen dealt with; some hormones are inactivated; and excess cholesterol is metabolised. Toxins and unwanted substances are released into the intestinal tract or sent to the kidneys for excretion from the body. Once alcohol is broken down, its components are used to create fat, which is subsequently stored if not burnt.
Image © Euthman
A cross-section from a liver biopsy, showing damage from alcohol consumption
Hepatitis C Community News 10 • September 2009
Exercise can be invaluable for liver health Production of bile The liver creates bile, which is needed for the absorption of fat and fat-soluble vitamins, and to provide a route for excretion of unwanted substances from the body. Bile is stored in the gall bladder, which empties the bile into the intestines when needed. Metabolic wastes and drug products may form part of the bile which can then be excreted from the body via the digestive tract in faeces. Storage of nutrients The liver plays an important role as a storage facility. The hepatocytes take up many types of vitamins and minerals from the blood and store them, such as vitamins A, B12, D, E, K and minerals like iron and copper. Glycogen, which is the storage form of glucose, is also stored in the liver, although muscle tissue can also store glycogen. The role of exercise and diet in a healthy liver Many liver problems are a result of contracted diseases (such as hepatitis C), genetic defects or substance abuse. Once damage has occurred, nutrition becomes instrumental in managing the liver damage. However, there is one important disease, known as non-
alcoholic fatty liver disease, which is associated with a poor diet and inadequate physical activity. Fatty liver disease affects around 1 in 10 Australians, and is one of the most common causes of liver problems. It is a condition where fat builds up in the liver cells, causing abnormal liver function tests and, in some people, inflammation which can lead to liver scarring (cirrhosis). Fatty liver disease is associated with being overweight. Exercising regularly and eating a healthy, low fat diet can help to achieve and/or maintain a healthy weight. A high fat diet by itself does not cause fatty liver. If something goes wrong in the processes of breaking down, building, or storing fat, fat can build up in the liver instead of being transported to other parts of the body for storage. However, it makes sense to eat a diet low in fat to reduce the processing work that the liver has to do. There is evidence that exercise itself (with or without weight loss) can prevent and reverse fatty liver disease. In a 2008 study, researchers gave obese rats access to voluntary running wheels for 16 weeks. Scientists then transitioned the rats to a sedentary lifestyle. After a week, the rats began showing signs of fatty liver disease. In the animals tested immediately at the end of 16 weeks of voluntary running, there were no signs of the disease.
Source: Hepatitis Australia (see www.loveyourliver.com.au for more)
Fatty liver disease is also associated with diabetes and heart disease. Therefore, it is important to eat a healthy diet that reduces your risk of developing these conditions, and/or help you to manage them. The dietary recommendations for these conditions are to consume only small amounts of fat, and to have the right types of fat to keep cholesterol levels under control. The healthy fats are known as unsaturated fats. Eating small, frequent meals and snacks that are high in fibre will help to reduce the workload on the pancreas and therefore help to prevent/manage diabetes. “Detox” diets Some people believe that it is possible to “detox” the liver, to make it function better. Unfortunately there is no scientific evidence to prove this. The liver is a detoxifying organ which rids the body of unwanted substances by breaking them down into non-harmful components and/or adding them to bile for excretion from the body. Toxins do not build up in liver cells, and hence there is no plausible rationale of a “detox diet”. In fact, many herbal remedies thought to cleanse the liver are actually harmful, as the liver goes into overload to metabolise them and rid them from the body. Hepatitis C Community News September 2009 • 11
10 Tips for Good Liver Health 1. Maintain a healthy weight It is estimated that approximately 60% of Australians are overweight or obese, and that approximately 30% of obese people have a fatty liver – a liver disease that may lead to cirrhosis, liver failure and liver cancer. Maintain a healthy weight by eating a diet that is low in fat, high in fibre and high in vitamins and minerals. Do some regular exercise to burn excess energy before it is stored in your body as fat. Excess weight stored around the middle is associated with a condition called ‘insulin resistance’. Insulin resistance often accompanies and contributes to fatty liver disease. If you have insulin resistance, try to decrease your waist measurement. Men should aim for a waist circumference of less than 102cm and women, less than 88cm. 2. Avoid fad diets Fad diets can cause fast and dramatic increases/decreases in your weight, which can put excessive stress on your liver. Spot fad diets by paying attention to their advertising; they often promise large amounts of weight loss in an unrealistically short period of time. Upon closer assessment, you will notice that they are usually lacking in one or more of the essential five core food groups, and hence are not nutritionally adequate. Aim to lose weight at a healthy rate of ½-1kg per week. Avoid ‘liver cleansing’ or ‘detox’ diets – contrary to popular opinion, no particular diet is liver cleansing, but a healthy one greatly aids wellbeing. Your doctor or dietitian can provide you with a well-designed, healthy and nutritious plan. 3. Limit your intake of dietary fat, especially saturated fat Hyperlipidaemia (high levels of fat in the blood) and hypercholesterolaemia (high levels Hepatitis C Community News 12 • September 2009
of cholesterol in the blood) are associated with fatty liver disease. Get your levels under control by eating a diet that is low in total fat. Of the fat you do eat, try to have more unsaturated fats (both poly- and monounsaturated fats). Try to limit your intake of saturated fats, as these have been shown to increase blood fats and cholesterol. If dietary modification is not entirely effective, speak to your doctor about medications that can help.
7. Get vaccinated against hepatitis A and B
4. Drink alcohol in moderation
Some medications require the liver to work hard to metabolise them. Taking too many medications at once can damage the liver. Be careful with certain herbal supplements that can be toxic to the liver such as kava, comfrey, chaparral, kombucha tea, pennyroyal and skullcap.
While alcoholism is more common among men, it has been demonstrated that women are more susceptible to the adverse consequences of alcohol on the liver. In fact, it takes as little as 20 grams of alcohol daily (only 2 standard drinks) for women to develop liver problems. If you can’t cut back, talk to your doctor about getting professional help to reduce your drinking. 5. Have regular blood tests Blood tests can identify abnormally high levels of fat, cholesterol, and glucose in the blood, all of which are associated with fatty liver disease. Too much glucose in the blood may mean you have Impaired Glucose Tolerance or Diabetes. If you have either of these, focus on controlling your blood sugar levels through diet, medications and/or weight loss. If you have ever experimented with intravenous drugs, or if you have had a blood transfusion or organ transplant prior to 1992, get a blood test for hepatitis C. 6. Stop smoking Smoking has been linked to the development of liver cancer, and may enhance the toxic effects of some medications, such as Tylenol (acetaminophen) on the liver. Talk to your doctor or ring Quitline to get help to stop.
Speak to your doctor about getting vaccinated. If you choose not to get vaccinated, avoid sushi or raw/partially cooked clams, oysters, mussels, and scallops, as these fish often live in hepatitis A contaminated rivers and seas. 8. Talk to your doctor before mixing herbal supplements, prescription and non-prescription drugs
9. Practice safe sex Protect yourself from hepatitis B and C. Not engaging in unprotected sex will greatly reduce the likelihood of infection with hepatitis B. While the risk of sexual transmission of hepatitis C is rare, protected sex is recommended if a person engages in anal sex, has multiple sexual partners, has frequent prostate infections, has open cuts or sores on the genitalia, or is menstruating. In addition, do not share toothbrushes, razors or other personal items with anyone. These may be routes of transmission of hepatitis B or C. 10. Don’t ignore liver problems because you feel no pain If you have ever been told that something is wrong with your liver, ask your doctor for a referral to a liver specialist (hepatologist) – even if you feel fine. Signs and symptoms of liver disease and hepatitis are not always present. More next issue, including liverfriendly recipes!
Source: Hepatitis Australia (see www.loveyourliver.com.au for more)
Monarto! A big day out to Monarto for our trusty volunteers Rhinos © Deborah Warneke-Arnold
e met early on a chilly morning at the HCCSA on Hackney Road. It was the first day of July in the very heart of winter, and the rain pelted down. It was the long-awaited big day out to Monarto open range zoo. This outing had been planned as a way to celebrate the contribution that volunteers make to this community. The food committee had been very busy indeed, preparing our picnic lunch and the hallway was lined with an amazingly large array of baskets, eskies and hampers. We were told that, as Monarto was in a rain-shadow area, the rain should, in theory, ease off once we got there. We loaded up our supplies and off we set in a minibus. There were only eleven of us, as some people were sadly not well enough to come. As we drove through the hills the rain still bucketed down and the hills were bright green and shrouded in mists. By the time we got to the gates of Monarto the rain had stopped. It was a bit of a
shock for the smokers to suddenly realize that Monarto is definitely a non-smoking area. A fire would be awful there, so the reasoning was perfectly understandable. Deborah handed out nicotine patches. We stopped at the visitor’s centre first before transferring to a minibus for a guided tour. Volunteers staff these buses. The first animals that we saw were some bison. These monumental creatures were calmly munching away on fodder, ignoring our close presence. Although absolutely huge creatures, weighing about 1 to 1.5 tons, they are surprisingly graceful with dainty little feet. They have
massive horned heads and dense shaggy coats. They seem to have a strong spiritual presence, perhaps because they were an essential part of the Native American way of life. For them they are a symbol of abundance and of following the right path in life. Next we saw the Mongolian wild horses and then the Chapman’s Zebra with, surprisingly, a trio of stripes: white, creamy beige and black. They have a cute stand-up mane too. The bongo antelopes and Barbary sheep and many, many more were all magnificent. At times it seemed as though (continued on p12) Image © Marty Kennewell
Giraffe © Cecilia Lim
Meerkat © Cecilia Lim Hepatitis C Community News September 2009 • 13
At the Adelaide Womens’ Prison
Remember: hepatitis C affects, on average, 60% of female prisoners in Australian jails. There is no vaccine and you can be infected with more than one strain. Currently there are no clean needle programs in prison, so having a considerable amount of time to discuss transmission with our Peer Support students was really beneficial for all. Increasing prevention of hep C for women in prison is a serious thing, and knowing that the women who participated in this course are enthusiastic and motivated to be involved as Peer Support is a great step forward. As a result of the women’s commitment to their learning, there are now 13 well-educated Peer Support people able to answer other prisoners’ queries about what is hep C transmission, prevention, testing (including the different types of testing, such as the PCR test and liver biopsies), as well as providing general HCVrelated support. The Peer Support team knows how to contact the Hepatitis C Council Information and Support Line (1300 437 222) to attain additional support for themselves or for another prisoner. I wish all the Peer Support graduates much success in their new roles, and I keep my fingers crossed that HCCSA will be invited to facilitate more programs like this initiative in the other SA prisons. Maggie McCabe
Megan (far left) and some of the other workers involved in the program at the AWP Hepatitis C Community News 14 • September 2009
(continued from p11)
animals had stepped out of the famous ancient cave painting of France and were walking towards us. It was quite magical. As Mark said, “The animals look happy and relaxed—not like in the small cages at old-fashioned zoos.” Next we all had a coffee break at the Visitors’ Centre. Fred said that he loved seeing the bilbies there. They were peacefully sleeping under warming lights, and he could see that they were much bigger than he had imagined them to be. They were not like little rabbits at all, and their colours are delicate pinks and greys. We went on three tours, and people had some favourite animals. Gouri said that it was a spectacular treat to see the lions so closely. The big cats, the lions and the cheetahs regarded us with serene gazes, and they were so close to us. Many of us were quite taken by the rather manic pack of African painted wild dogs. Once again they looked as if they had been rendered by those busy cave painters. The leader of the pack stood out with his lop-sided ears: one stood up at a sharp angle and the other flopped down in a jaunty fashion. He was very cool! Cecilia loved the giraffes, which we saw from an elevated platform, up at their eye level. There were 16 giraffes, and they feel safe enough to sit down—something that they can’t do in the wild because of lurking predators. The giraffes looked at us and we looked back at them.
Zebra © Deborah Warneke-Arnold
or three weeks, Megan—a Hepatitis C Council Peer Educator—and I were able to facilitate peer support training at the Adelaide Womens’ Prison (AWP) for three hours a week. Thirteen women were enrolled to do this course, and they had already completed four weeks of training with Relationships Australia SA on communication before commencing their work with us on hepatitis C. Honestly, it was one of the best education sessions I have been involved in. The information we were able to provide was really appreciated by all the participants. The AWP Peer Support students were really interested, organised and motivated to learn everything that we gave them. Furthermore, the Peer Support program is such a great idea in light of providing hepatitis C education at the AWP: the Peer Support team will help other women with their questions about hep C by providing correct information and support, particularly to women with HCV or who are at risk of hepatitis C infection, with being tested, and for women who are considering treatment or who are on treatment. We discussed hepatitis C inflammation, and what fibrosis and cirrhosis are. Hepatitis C treatment, how to support someone with the decision to commence treatment, and supporting someone if they feel they have been discriminated against because they have hep C, were also all topics of in-depth discussion.
Image © Cecilia Lim
MAKE A NOISE!
Peer Support Program
HCV Antibody Research Promising new findings announced We had lunch in one of the purpose-built picnic shelters. We shared a health gourmet feast of pumpkin soup, sushi, cold chicken and Gouri’s special fried rice, fruit and cake. It was all really delicious. The food committee had done us all proud! It had been a truly lovely, even a magical day out. Many people commented as we left Monarto on how relaxed and loose-limbed they felt at the end of this trip. Being with the animals had been calming and relaxing. Thank you everyone for helping to make it such a great day! Yvonne Doley
uilding upon a series of successful preclinical studies, researchers at the University of Massachusetts Medical School have announced the beginning of trials testing the safety and activity of a human monoclonal antibody they developed that can neutralise the Hepatitis C virus. The first volunteer received the antibody known as MBL-HCV1 on July 28, 2009, and the study is planned to involve 30 healthy subjects in a dose-escalation trial expected to conclude later this year.
Bison © Deborah Warneke-Arnold
“We are pleased that this program has now entered the clinical trial phase,” said Donna Ambrosino, MD, executive director of the research company and a professor of pediatrics at the Medical School. “This trial will test the safety of the antibody and measure its activity in the subjects. This will help us determine the useful dose and other parameters as we plan for the next step in this program, which will be a Phase 2 study in liver transplant patients.”
To close that clinical gap, the new antibody is designed to be a therapy shortly before and after transplant surgery. By giving a patient the new antibody before and during the time when the donor liver is implanted, researchers hope the HCV virus left in the bloodstream will be neutralised and rendered unable to infect the new liver. Then, because monoclonal antibodies are highly specific and typically have little or no sideeffects, additional dosages of the new antibody could, theoretically, be given immediately after transplant surgery to continue neutralising any remaining virus. It is also possible, researchers theorise, that the antibody could be used in combination with new antiviral drugs for treatment in patients with newly diagnosed HCV infection. “There is still more work to be done, but we are encouraged by the progress of this program to date,” Dr. Ambrosino noted. “And we are grateful to the people who have volunteered to participate in this Phase 1 study. These subjects’ participation will help others and advance the cause of human health.” See www.eurekalert.org/ pub_releases/2009-08/uommfhg080609.php for more.
Image © AJC1
HCV is the leading indication for liver transplantation, which can be a life-saving treatment; however, in nearly all cases the patient’s new liver is eventually infected by HCV because the virus remains in the patient’s bloodstream during surgery. The powerful antiviral drugs now used to attack HCV prior to end-stage liver failure are not routinely used during surgery due to the patients’ weakened
condition and because of the strong medication that must be used to prevent the body from rejecting the new liver. After reinfection with HCV, nearly 40% of patients suffer rapid liver failure, with markedly reduced survival rates.
Hepatitis C Community News September 2009 • 15
MAKE A NOISE!
Shared Care Hepatitis C Shared Care to expand in SA
ore GPs in private practice and community health contribute to treatment services. In South Australia, approximately 16,000 people have been infected with hepatitis C. Treatment for hepatitis C has improved dramatically in recent years, with between 50-80% of people who undergo treatment now achieving a sustained virological response, meaning they are effectively cured. Treatment consists of a 6-12 month regimen of pegylated interferon and ribavirin, and is associated with significant side effects. SA Health is building consensus on a statewide model of shared care for hepatitis C treatment to increase support for patients, to make treatment more locally accessible, and to increase General Practitioners’ hepatitis C knowledge. For the first time in SA, the model will include an accreditation system for General Practitioners to prescribe highly specialised drugs for maintaining treatment after it has been initiated by a specialist. On Friday and Saturday, 20-21 June, more than 15 GPs attended the first intensive training course as part of this new approach. The two-day course was organised by ASHM and Nunkuwarrin Yunti, which has been running a liver clinic for more than two years (for more information, see issue 37 for several in-depth features—this issue is available online at www. hepccouncilsa.asn.au/resources/ magazine/134-issue-37-september2007). The in-depth training included learning how to prescribe the S100-rated hepatitis C medications. Combination therapies Pegasys RBV and Pegatron, and monotherapies PEGIntron Redipen and Pegasys, are listed as highly specialised drugs under Section 100 of the National Health Act. These drugs can only be prescribed by specialist hospital units and
Hepatitis C Community News 16 • September 2009
dispensed through pharmacies within hospitals that participate in the Highly Specialised Drug Program. Medical practitioners must be formally associated with specialist hospitals to prescribe these drugs as pharmaceutical benefit items. This training is the first step in extending this capability to the enrolled GPs, making hepatitis C treatment more broadly available. Among those presenting at the training was Jill Benson, who we would like to congratulate for winning the annual Australian Medical Association (SA) Award, which honours the work of doctors who have given outstanding service to others, or to their chosen field. With this award, the AMA(SA) this year acknowledged Dr Jill Benson’s untiring work across diverse spheres of medical practice, incorporating rural and remote health, Indigenous health, migrant and refugee health, transcultural mental health, and doctors’ health. A depth of care for the profession and for patients has been a hallmark of Jill’s career. She has shown a willingness to “go beyond the comfort” zone to help others, whether in Adelaide, a remote Indigenous community, or overseas, and has taught and written on many topics relating to her areas of interest.
Jill Benson The Director of the Health in Human Diversity Unit of the Discipline of General Practice at the University of Adelaide , and a general practitioner for almost 30 years, she currently works with refugees at the Migrant Health Service in Adelaide, as well as in the remote Aboriginal community at Yalata, and has also worked in a teaching hospital in Dharan in rural eastern Nepal. The AMA(SA) Award was awarded to Jill Benson due to her commitment to working in difficult and often unheralded areas of medicine, as well as teaching and research. Jill Benson has long worked closely with HCCSA, and we value her tireless and extensive efforts on our behalf. Well done, Jill!
Regarding the shared care expansion, interested GPs are encouraged to contact Elissa Mortimer on 8226 7309 or elissa. firstname.lastname@example.org.
Providing Treatment A critical look at increasing treatment uptake
government, suggest that the current rate at which people are taking up hepatitis C treatment needs to triple if the burden of the disease is to be kept under control. It is in order to achieve this that the increasing decentralisation of treatment supply has been happening. One of the common alternatives is to offer hepatitis C treatment at IDU treatment centres, sometimes described as opioid pharmacotherapy treatment (OPT) centres. The researchers argue that unfortunately there is often a very low understanding of the nature
to efforts to expand the delivery of HCV treatment into non-specialist areas of medicine, such as general practice clinics and pharmacotherapy clinics (see pages 14 and 16 for the most recent South Australian developments). Treloar and her co-author, Suzanne Fraser of the Centre for Women’s Studies and Gender Research at Monash University, argue that there is a real need “for more qualitative social research if we are to understand adequately [the influences] on the potential for success of hepatitis C treatment services in new sectors.” Projections from the Ministerial Advisory Committee on Blood Borne Viruses and Sexually Transmitted Infections, which reports to the federal
and risks of hepatitis C among people attending OPT centres. Another problem appears to be that many people associate the interferon-induced ‘flu-like’ symptoms, a common side-effect of hepatitis C treatment, as being similar in nature and severity to opioid withdrawal symptoms, and so increase a person’s likelihood of returning to injecting drug use if they have given it up. Discrimination is another major problem with treatment uptake. Treloar and Fraser state that moving the treatment availability to a different setting does not make this problem go away. Some research even suggests that people with hepatitis C are treated less well than other clients at drug treatment clinics, even though injecting drug use itself is already highly stigmatised by broader society.
As the report notes, “evidently, introducing hepatitis C treatment into services where staff have not all received adequate training in hepatitis C-related issues, or have not actively chosen to work with this group, can mean patients’ experiences of support and respect are at best uneven.” Other issues such as housing problems, poverty or court proceedings and criminal records can also work against somebody successfully taking up treatment. All of these can lead to clinicians labelling a person’s life as
‘chaotic’, which disqualifies them from receiving hepatitis C treatment. Treloar and Fraser say that even attending an OPT service can be problematic, as they are often not very secure (for clients, as well as staff), exposing vulnerable people to the possibilities of violence or stress— factors which can, in turn, make the side-effects of treatment, such as depression, even worse. Because of this, the researchers claim that OPT services may well need to be reconsidered and redesigned to make them effective and appropriate places for providing treatment for hepatitis C. The full text of ‘Hepatitis C treatment in pharmacotherapy services: Increasing treatment uptake needs a critical view’ is available from the HCCSA Library. Note: For a different view of treatment in OPT centres, see page 16. Hepatitis C Community News September 2009 • 17
Image © Shortie66
arla Treloar of the National Centre in HIV Social Research recently coauthored a paper about the various initiatives planned to increase hepatitis C treatment uptake in Australia. Published in the Drug and Alcohol Review in July, ‘Hepatitis C treatment in pharmacotherapy services: Increasing treatment uptake needs a critical view’ examines the implications of this new approach to treatment delivery. The rising incidence of HCV infection, and increasing government awareness of the problem, has led
Warinilla Clinic Warinilla reopens hep C treatment clinic Expressions of Interest Hepatitis Australia Board
We are seeking nominations from people living with chronic viral hepatitis, who are financial members of one of the state or territory hepatitis organisations to join the Hepatitis Australia Board from November 2009 for a two year term. All Board Members are volunteers and are not paid by Hepatitis Australia for their services; however, the costs associated with attendance at meetings are met by the organisation. The role of the Board includes setting the strategic direction of the organisation; driving and monitoring organisational performance; selection and monitoring of the performance of the CEO; ensuring accurate financial reporting; establishing governance policies; ensuring compliance with legal obligations and controlling organisational risk. In addition, the community board members have a role in bringing a lived understanding of viral hepatitis to the work of the Board. A board induction process is in place and the executive officer of your local hepatitis organisation would provide mentorship and assistance to fulfil your board responsibilities. If you are interested in joining the Hepatitis Australia Board, please contact Kerry Paterson, Executive Officer at the Hepatitis C Council of SA on 8362 8443 to obtain copies of the nomination form and detailed role description.
he Drug and Alcohol Services of SA will be restarting its communitybased hepatitis C treatment clinic at Warinilla for DASSA clients in September. This follows a successful 18-month trial. Of the 22 people who started treatment at Warinilla in the trial period (2007 to 2009), 18 completed treatment and 13 successfully cleared the virus. One client who was successfully treated was unreserved in his recommendation. “I found all the staff, especially the doctors, to be very helpful and genuinely concerned about my health and general well being,” he said. “The treatment was carried out in a completely open and non judgemental way and any questions about the treatment and other health issues were always answered without me ever feeling like I was being talked down to. “At Warinilla you actually feel like an individual and not just the next person on the list for the day.” He added that the best things about hepatitis C treatment at Warinilla were that “you have a pretty good chance of ending up virus-free after six (or 12) months, which means that your liver will probably last as long as the rest of your body”, and that “the whole deal was both costand hassle-free”. Dr Chris Holmwood from Warinilla said the new treatment services, to be run as an outreach clinic of the Flinders Medical
Centre, will initially be available fortnightly on Tuesdays. “In the intervening weeks, we will run preparatory clinics for people about to start–or thinking about– hepatitis C treatment. Clients will be assessed and given information about what to expect, and so on. We will also do all the necessary preliminary tests,” he said. “DASSA clients who sign up for hepatitis C treatment at Warinilla will not have to worry about dispensing costs or gap costs in tests as they will all be bulkbilled.” HCCSA peer educator Fred pointed out that Warinilla provided understanding and support for people on opioid substitution therapy who would like to access hepatitis C treatment. “You will be dealing with people you know, in a familiar, supportive and non-judgemental environmental,” he said. DASSA clients who are considering treatment are encouraged to ring Warinilla (8130 7531) to make an appointment with Dr Tony Chadderton or Dr Chris Holmwood. They could also call the Hepatitis C Information and Support Line (8362 8443 or 1300 437 222) for more information about treatment. Chris also encourages those who have access to the internet to go to the Hepatitis C Council SA website to read the online fact sheets on treatment and related issues.
Nominations on the approved form must be received by Hepatitis Australia on or before Friday 16th October 2009. For general information about Hepatitis Australia please visit www.hepatitisaustralia.com Hepatitis C Community News 18 • September 2009
The clinic building in Norwood
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 Councilâ€™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) 8210 0809 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 24-hour 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) 8362 0395 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 email@example.com and let us know. We rely on volunteers for many of our vital services. The Council offers a meeting room suitable for workshops, presentations, formal and informal meetings. It is a spacious area suitable for up to 30 participants.
Meeting Room Hire at the
The room has modern, self-contained kitchen and bathroom facilities. It also contains an electronic whiteboard, and the Council offers the use of an overhead projector, data projector, TV and video (subject to availability). Fees for room hire are $33 per hour (inc GST). Bookings over three hours will be charged at $110 (inc GST). Fees will be directed into programs for people living with or affected by hepatitis C. Organisations that receive funding through the HHPP of the Department of Health will be exempt from payment.
Community members affected by hepatitis C are encouraged to use the room at no cost.
Contact us at 3 Hackney Road, Hackney PO Box 782, Kent Town SA 5071 Phone: (08) 8362 8443 Fax: (08) 8362 8559 Web: www.hepccouncilsa.asn.au Email: firstname.lastname@example.org Hepatitis C Community News September 2009 â€˘ 19
The Hepatitis C Council of South Australia provides information, education and support to the hepatitis C community and those at risk. A strong membership of people affected by the virus is essential to our work. Complete the form below and send it to us by post: PO Box 782, Kent Town SA 5071 or fax: (08) 8362 8559.
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gathering up his courage, jack finally makes the call he’s been putting off...
Hi! is that the hep c info line?
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Membership type FREE! $55
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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.
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yeah--i’ve recently been diagnosed with hep c, and i don’t know what to do next. can you help me?
The Hepatitis C Council of South Australia Inc. is aware of the need for privacy and endeavours to comply at all times with the Privacy Act 2001. As such, any information provided by you is accessed only by authorised personnel and will remain strictly confidential. To change or access any personal information we hold about you, please write to the Manager at the above address. ABN: 38 030 552 547 Tax invoice – please retain a copy for your records.
Proudly supported by: Hepatitis C Community News 20 • September 2009
to be continued!
Published on Sep 14, 2009
Published on Sep 14, 2009
Quarterly magazine of the Hepatitis C Council of South Australia. Printed copies of this resource are available from Hepatitis SA - email ad...