Infections Behind Bars Hepatitis C: A Correctional-Public Health Opportunity

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Infections Behind Bars

Hepatitis C: A Correctional-Public Health Opportunity

Anne S. De Groot, MD, Stubblefield, Joe

Bick, MD

[Medscape Infectious Diseases, 2001. © 2001 Medscape,

Inc.]

Introduction

For a variety of reasons, many diseases are present at

a higher prevalence in prisons and jails. Mental

illness, HIV, hepatitis B and C, and drug and alcohol

addiction are just a few of the conditions that are

common in prisoners entering the correctional system.

What is often seen as an overwhelming burden to

correctional healthcare systems should more

appropriately be seen as a tremendous public health

opportunity. The stark truth is that most inmates will

eventually be released from prisons and jails. Once

released, many of them either do not have access to

healthcare or fail to avail themselves of it. In

focusing healthcare resources on the incarcerated,

society has the opportunity to decrease crime rates

(mental illness, addiction), prevent transmission

(HIV, hepatitis, other sexually transmitted diseases

[sTDs]), and lower lifetime costs associated with

untreated diseases. This article will focus on the

challenges and opportunities associated with the

treatment of hepatitis C virus (HCV) in the

incarcerated.

Epidemiology of HCV in Correctional Settings

Hepatitis C infection outstrips HIV in correctional

settings in terms of sheer numbers of inmates living

with this infection (Table 1). According to a recent

analysis performed by Dr. Ted Hammett (Abt Associates,

Cambridge Massachusetts) and reported to Congress,[1]

between 1.0 and 1.25 million individuals harboring

chronic HCV infection were released from prisons and

jails in the United States in 1996, or approximately

30% (29% to 32%) of the estimated 4.5 million

individuals living with chronic HCV infection in the

United States. The prevalence of HCV infection among

US prisoners is at least 10-fold higher than the

estimated prevalence of 2% in the general

population.[2] Outside of correctional settings, 79%

of current injection drug users (IDUs) have HCV

infection.[3] In fact, young IDUs acquire HCV

infection at rates 4 times higher than the rate of

acquisition of HIV; after 5 years of continuous

injection drug use, 90% of IDUs are HCV infected.

HCV prevalence studies in correctional settings are

rare; however, some statistics have been compiled from

a number of sources by HIV and Hepatitis in Prison

Project In the Colorado state prisons, for example,

the prevalence of HCV among inmates has been reported

to be 30%.[4] A recent survey of Arizona reported a

31.3% prevalence rate among inmates (Gerard

Chamberlin, personal communication). In land, the

prevalence of HCV among state inmates has been noted

to be slightly higher, at 38%.[5] One county jail in

semi-rural Massachusetts recently reported that 20.7%

of its jail inmates had HCV infection (Hampden

County).[6] In Virginia, 30% to 40% of inmates have

been reported to have HCV infection.[7] Approximately

the same rate has been reported in Washington state

(30% to 40%).[8] The prevalence of HCV among state

inmates in Pennsylvania is slightly lower, at 13%.[9]

Reflecting their higher rate of participation in HIV

and HCV risk behaviors, incarcerated women exhibit

about a third higher HCV co-infection rate than

incarcerated men.[10] For example, in a sample of

incoming inmates in California, 54% of women inmates,

compared with only 40% of men inmates, have HCV

infection.[11] In Connecticut, 1 in 3 women (32%)

incarcerated at the only state facility for women

inmates has HCV infection.[12] In Texas, 37% of

incarcerated women and 28% of incarcerated men have

HCV infection.[3] Wisconsin reported HCV infection

rates among women inmates that are almost 2-fold

higher than the rates among men: 21% for women, 12.4%

for men, 13.2% overall.[13]

Hispanics and non-Hispanic blacks have higher rates of

HCV and HBV infection and chronic disease than whites;

most cases of HCV and HBV infections are found among

persons who are male, members of minority populations,

and 30 to 49 years of age.[3] These race- and

class-related risk factors for hepatitis infection

probably contribute to the current concentration of

HCV- and HBV-infected persons in prisons and jails.

Screening for and Treating HCV in Correctional

Facilities

The CDC lists correctional institutions, HIV

counseling and testing sites, and drug and STD

treatment programs as sites where hepatitis screening

and interventions should take place. (See Table 2 for

screening recommendations.) Correctional facilities

that screen for HCV and educate their inmates about

HCV are performing a significant public service, since

approximately 50% of persons with hepatitis are

unaware of their hepatitis infection.[1] Testing for

hepatitis infection informs the patient and physician

about the potential for and possible existence of

liver damage, and it should serve as an important

prompt for a discussion about risky behaviors and

transmission to others.[1]

Treatment of HCV

The current standard of care in community settings is

to treat chronic HCV patients who meet treatment

selection criteria with a combination of

ribavirin/interferon alpha (Table 3). Most

correctional facilities have either developed

protocols for screening and treating HCV-infected

inmates, or are in the process of developing these

protocols. However, the criteria for HCV treatment may

vary slightly from one correctional system to another.

The CDC is in the process of developing a set of

guidelines for HCV screening and treatment that may

assist correctional facilities with their

decision-making process. (A draft of the hepatitis

recommendations that are proposed for publication in

MMWR [Morbidity and Mortality Weekly Report] in the

fall of this year can be obtained by contacting Rob

Lyerla or Wientraub or by calling 404-371-5460.)

In general, eligible patients meet the following

criteria: (1) have evidence of persistent HCV

infection and inflammation based on liver function

test (LFT) abnormalities and detectable virus in the

blood stream; (2) have enough time left in their

sentence to allow for completion of treatment (6-12

months) (3) are committed to a life free from

substance and alcohol abuse; (4) are educated about

potential HCV treatment side effects and willing to

adhere to an arduous course of treatment.

Standard therapy is to provide daily treatment with

ribavirin (usually 5-6 pills divided into 2 doses) and

thrice-weekly alpha-interferon injections. (See Table

3 for dosing and side effects of treatment regimens.)

Pegylated interferon, a new form of interferon that

permits once-weekly dosing, was approved by the FDA

this year. Monotherapy is currently used only if the

patient cannot take ribavirin due to toxicities or

side effects.

Response Rates

Combination therapy consistently yields higher rates

of sustained response compared with monotherapy. (A

sustained response implies that HCV RNA remains

undetectable for 6 months or longer after therapy

stops.) With combination therapy, 40% of

treatment-naive patients respond. Patients with

genotype-1 have sustained response rates of 25% to 30%

(slightly better response rates are seen with lower

baseline HCV viral loads). Non-genotype-1 patients

achieve response rates of 60% to 65%.[14,15] Other

factors that increase the likelihood of a response to

therapy include age younger than 45, female gender,

and mild (rather than advanced) chronic inflammation

on liver biopsy. Histologic improvement occurs in 86%

of patients who achieve a sustained response and 39%

of patients who relapse after initial response to

combination therapy.[15]

Cost vs Benefits

As with many other chronic medical conditions,

morbidity and mortality attributable to HCV may not

manifest themselves until well after the end of

incarceration. Treatment is often ineffective, poorly

tolerated, and prohibitively expensive. Many

correctional systems, still reeling from the impact of

providing HIV treatment, have been slow to embrace

wide-scale treatment of hepatitis C. Additionally, the

therapy in most cases is being given to IDUs who are

in forced institutional abstinence, have not had and

will not have drug treatment, and will therefore

probably be promptly reinfected upon release.

Despite these concerns, some state medical directors

have led the way and adopted clear protocols for the

screening and treatment of HCV in their facilities.

These individuals are mindful that a year 2001 dollar

spent on treatment may reduce the eventual cost (to

society) of caring for patients who may require liver

transplants in 20-30 years.[4,16] Furthermore,

combination therapy of HCV is leading to higher rates

of cure (up to 88% in carefully selected patients);

therefore, the overall cost-effectiveness of HCV

interventions in corrections is improving.

Cost-benefit analyses have been performed. For

example, medical decision analyst J. Wong calculated

that 6 months of combination therapy resulted in net

savings in the range of $400 to $3500 over the

lifetime of each HCV-infected patient.[17] Dr. Wong's

analysis ranked combination therapy for HCV in the

same range of cost-effectiveness as stool guaiac

testing, pneumococcal vaccination, coronary bypass

surgery, and mammography.[17]

Liver Biopsy

The need for confirming the extent of damage to the

liver by HCV and chronic HBV infection is another area

of debate, since obtaining liver biopsies can be both

costly and logistically complicated in correctional

settings. LFTs can be normal in patients with rather

advanced cirrhotic features. Likewise, LFTs may be

consistently elevated in hepatitis C patients with

normal histology. Some state correctional systems do

not routinely perform liver biopsies prior to

initiating treatment, because of cost and logistical

difficulties. Other states (eg, Florida) believe

biopsies are the only real way to measure disease

progression over time and therefore have made

arrangements to do them on site at very reduced costs

($200 per biopsy). Depending on the cost of obtaining

a liver biopsy, electing to treat all incarcerated

individuals who meet the criteria for treatment may be

more cost-effective for society as a whole than

management by biopsy.[17]

The Lowest-Cost Intervention: Education

The lowest-cost intervention for the prevention of

hepatitis infection is education. Given the risk of

acquiring HCV (not to mention HIV), all bloodborne

pathogen screening events should lead to careful

discussion of the risks of acquiring HIV, HBV, and HCV

infection (for those patients who have negative

hepatitis serologies). The risk of transmitting

hepatitis should also be made very clear (see

Resources for information on educational materials).

The impact of continued drug use should also be made

very clear to patients, especially those who are not

yet HCV infected. For those inmates who are already

HCV infected, education should be provided on the

impact of alcohol abuse on HCV progression (4-fold

increase in risk of progression, risk of liver damage

directly correlated with alcohol intake) and the risk

of transmission to uninfected sexual partners. Inmates

who have HCV infection should, at the very least, be

educated about options for treatment even if they are

not eligible for treatment while incarcerated (see

Resources for information on expanded access

programs).

Additional Considerations

Another low-cost (but not no-cost) intervention is

vaccination. For HCV-infected patients, vaccination

against HBV and HAV is routinely recommended, as these

relatively inexpensive vaccines may reduce the risk of

fulminant liver failure and the need for liver

transplantation for HCV-infected patients. A new

schedule of HBV vaccination (3 shots at 0, 1, and 4

months) has received approval. The first shot provides

up to 50% protection, and the series does have

efficacy even if it is given over several years, so

the new CDC guidelines are expected to encourage

initiating HBV vaccination even in jail settings.

Management of HCV in Correctional Settings

Since the incidence of side effects to HCV combination

therapy can be relatively high and it can be difficult

for incarcerated patients to quickly gain access to

their clinician to report side effects, it is

important to:

Spend time preparing the patient for potential

treatment-related side effects

Prescribe PRN medications for symptom management

Consider following the patients in a dedicated

hepatitis clinic

Consider establishing a support group for patients

under HCV treatment

Utilize peer education programs when possible

Use a nurse or other staff person to regularly check

in with patients who are receiving HCV treatment so

that side effects can be rapidly addressed

Without a good support system, a high percentage of

patients will fail to complete therapy. Because of the

high cost of treatment, time spent preparing patients

and supporting them while on treatment is likely to be

cost-effective. Table 4 provides guidelines for

monitoring treatment.

HIV and HCV Coinfection

Analyses of the effect of HCV and HIV co-infection on

progression of either disease are often confounded by

concurrent risk factors for progression. However,

available data seem to indicate that HIV infection

accelerates HCV liver disease. Persons who are

co-infected (HIV/HCV) appear to have a 12- to 300-fold

higher risk of developing hepatocellular carcinoma

compared with noncarriers.[18] Furthermore,

antiretroviral agents can contribute to liver

inflammation, and this may be more frequent in those

who have underlying chronic hepatitis due to HCV or

HBV. Ritonavir and nevirapine appear to be the

antiretroviral therapy medications that are most

commonly associated with liver inflammation in HCV/HIV

co-infected patients.[19]

The impact of HCV infection on HIV infection is less

clear. In some studies, HCV infection does not appear

to have an effect on the progression of HIV.[20] Other

studies have reported an association between more

rapid progression to AIDS or death in HIV-infected

patients, particularly among those who were

co-infected with HCV genotypes 1a and 1b.[21,22]

However, a report by Sulkowski[23] at the 8th National

Conference on Retroviruses and Opportunistic

Infections (CROI), contraindicated these findings,

suggesting that risk of progression was more closely

linked to lack of access to medical care (for HIV) in

his cohort of African American patients who had HIV

and HCV co-infection.

Response to HCV therapy in individuals who also have

HIV infection appears to be equivalent to that of

non-HIV-infected individuals.[24] A recent study in

JAMA by Sulkowski and associates[19] indicates that

88% of co-infected patients tolerate concurrent HCV

treatment and highly active antiretroviral therapy

(HAART). Following successful HCV treatment,

co-infected patients are not more likely to relapse

after HCV treatment than are patients who do not have

concurrent HIV infection.

Currently, when exclusionary criteria are not present

(see Table 2), treatment of hepatitis C is recommended

for patients when CD4 and viral load values reflect

good response to antiretroviral treatment. Although

some controversy remains with regard to the definition

of a good response to HAART, a stable CD4+ T-cell

count greater than 200 with a stable viral load less

than 400 is generally accepted.[25]

Conclusion

The cost of HCV treatment is expected to be a major

barrier to wide implementation of the guidelines in

prisons and jails. There is a concern that treatment

could overwhelm some systems' healthcare budgets. The

high prevalence of hepatitis infections among

incarcerated individuals and the availability of

treatments with less than 100% efficacy force

difficult decision making in correctional health

facilities.

The clustering of individuals with hepatitis and other

treatable illnesses in correctional facilities creates

not only challenges but opportunities as well. With an

effective public health-correctional collaboration,

the opportunity exists to make a tremendous impact on

the health of society as a whole. Without such

initiatives, many prisoners will eventually return

untreated to the communities from which they came.

Prisons and jails are an ideal site for introducing

public health interventions that will have a positive

impact on hard-to-reach communities; this opportunity

to improve public health should not be overlooked.

It must be noted, however, that the cost savings that

may accrue from treatment of prisoners are primarily

to society as a whole. While treatment of incarcerated

individuals for hepatitis and HIV is the right thing

to do and can tremendously benefit the public health,

it is not realistic to expect correctional systems to

shoulder this financial burden without assistance.

Guidelines and standards for selecting patients who

are to be treated, while providing access to care for

HCV-infected individuals regardless of incarceration

status, are forthcoming from the CDC. Correctional

physicians eagerly anticipate further guidance from

state and federal health officials on supplemental

sources of funding for HCV treatment initiatives in

correctional settings.

Acknowledgements

This article is modified from an article by Anne S. De

Groot entitled HCV: The Correctional Conundrum,

published in HEPP News, Vol. 4 (4), April 2001.

Available at:

http://www.hivcorrections.org/archives/april01/.

Table 1. Hepatitis and HIV Disease Prevalence Inside

and Outside Correctional Facilities*

HCV HIV

Hepatitis and HIV prevalence in US populations†

Chronic Infections 4.5 million 0.8 million

New Infections per year 35,000 40,000

Deaths per year 8000 18,000

Hepatitis and HIV prevalence among inmates released

from prisons and jails‡

Number of infected inmates released 1.3-1.4 million

98,000-145,000

Percent of US population with disease 29% to 32%

13% to 19%

* Hammett and colleagues[1] noted an extreme lack of

HBV data on correctional populations. These numbers

are rough period prevalence estimates based on studies

done in California (1994) and New York (1987-1997)

correctional systems.

† CDC, Harold Margolis, Hepatitis Branch.[26]

‡ Burden of disease among releasees in 1996, CDC, NIJ,

Abt survey.[1]

Table 2. HCV/HBV Screening

Persons who should be tested routinely for hepatitis

include:

Persons residing in correctional facilities

Injection drug users (IDU), including those who

injected once or a few times and do not currently

consider themselves to be drug users

Persons with selected medical conditions, including:

Persons who received clotting factor concentrates

produced before 1987

Persons ever on chronic hemodialysis

Persons with persistently abnormal ALT levels

Persons who received blood transfusions, blood

components, or organ transplantation before July 1992

Persons diagnosed with HIV infection and sexual

partners of persons diagnosed with HIV infection

Healthcare and correctional workers after needle

sticks, sharps, or mucosal exposures to HCV-positive

blood.

Source: Modified from MMWR, 1998.[3]

Table 3A. Hepatitis C Treatment

Treatment Cost* Dose Frequency Side Effects§

Combination therapy: ribavirin and interferon

(Rebetron)†

Ribavirin + interferon

(Rebetron, Schering-Plough) Rebetron† 1200: $391

per week Rebetron: cardiac and pulmonary events

associated with anemia occurred in approximately 10%

of patients.

Rebetron† 1000: $354 per week Psychiatric events in

treatment-naive patients: insomnia (39%), depression

(34%), irritability (27%).

Rebetron 600: $290 per week

Ribavirin: oral antiviral agent† Ribavirin 200-mg

capsule: $1.25 1000 mg: $43.75/week 200-mg capsules:

1000 mg/day divided bid for < 75 kg; 1200 mg/day

divided bid for > 75 kg 2x daily Ribavirin: primary

toxicity: hemolytic anemia (reductions of hemoglobin

levels occurred within the first 1-2 weeks of therapy)

1200 mg: $52.50/week

Interferon alpha-2a,

interferon alpha-2b,

consensus interferon (see below) INF-alphas: 3

MU/injection 3x weekly SC (see below)

Consensus interferon: 9 mcg/injection

Monotherapy‡

Interferon alpha-2a

(Roferon A, Roche) $36.72 per 3 MU 3

MU/injection 3x weekly SC Flu-like symptoms; headache

(52%); dizziness (13%); nausea/vomiting (33%),

diarrhea (20%), depression (16%), irritability (15%),

insomnia (14%)

Interferon alpha-2b

(Intron A, Schering-Plough) $40.00 per 3 MU 3

MU/injection 3x weekly SC Flu-like symptoms

Peginterferon alpha-2b

(Pegintron, Schering-Plough) 100 mcg/mL: $240

1x weekly Flu-like symptoms

160 mcg/mL: $253

240 mcg/mL: $265

300 mcg/mL: $279

Interferon alphacon-1

(consensus interferon,

Infergen, Amgen) $38.76 per 9 mcg 9

mcg/injection 3x weekly Flu-like symptoms

MU: Million units; SC = subcutaneously

* The pricing shown should be considered a maximum

price. Substantially discounted pricing may be

available based on the type of pharmacy purchasing

medications (eg, institutional, retail, government

operated). In addition, quantity or market share

rebates from the manufacturer may be available. Prices

are subject to change at any time.

† Currently, ribavirin is only available from

Schering-Plough packaged with Interferon alpha-2b as

Rebetron or compounded by Fisher's Pharmacy (3904

sville Ave., Pittsburgh, PA 15214; 888-347-3416).

Rebetron contains interferon 3 MU plus 1200 mg, 1000

mg, or 600 mg ribavirin, and is packaged in 2-week

supplies.

‡ Reserve for patients who have contraindications to

ribavirin.

§ In clinical trials, most of the reported adverse

reactions were considered mild to moderate and were

manageable.

Table adapted from NIDDK.[27]

Table 3B. Hepatitis C Treatment

Treatment

(Trade Name) Cost*

(Manufacturer) Dose Frequency Side Effects

Combination Therapy

Ribavirin: oral

antiviral agent†

WITH Ribavirin: 200-mg capsule: $1.25 Ribavirin:

200-mg capsules (1000 mg/day divided bid or < 75 kg;

1200 mg/day divided bid for > 75 kg) 2x day Primary

toxicity: hemolytic anemia (reductions of hemoglobin

levels occurred within the first 1-2 weeks of

therapy).

1000 mg: $43.75/week

1200 mg: $52.50/week

(See below for

interferons.)

Rebetron† 1200 (Schering-Plough): $391/week

Rebetron† 1000: $354/week

Rebetron 600: $290/week

Interferon alpha-2a,

interferon alpha-2b,

consensus interferon Interferons: 3 MU/

injection; consensus interferon 9 mcg/ injection 3x

weekly SC Rebetron: cardiac and pulmonary events

associated with anemia occurred in approximately 10%

of patients.

Psychiatric events in treatment naive: insomnia (39%),

depression (34%), irritability (27%).

Monotherapy‡

Interferon alpha-2a

(Roferon A, Roche) $36.72 per 3MU (Roche) 3 MU

per injection 3x weekly SC Flu-like symptoms; headache

(52%); dizziness (13%); nausea/vomiting (33%),

diarrhea (20%), depression (16%), irritability (15%),

insomnia (14%)

Interferon alpha-2b

(Intron A) $40 per 3 MU (Schering-Plough) 3 MU

per injection 3x weekly SC Flu-like symptoms

Peginterferon alpha-2b

(Pegintron) 100 mcg/mL: $240 1x weekly

Flu-like symptoms

160 mcg/mL: $253

240 mcg/mL: $265

300mcg.ml : $279.00

(Schering-Plough)

Interferon alphacon-1

(Infergen) $38.76 per 9 mcg (Amgen) Consensus

interferon 9 mcg/injection. 3x weekly Flu-like

symptoms

MU: Million units; SC = subcutaneously

* The pricing shown should be considered a maximum

price. Substantially discounted pricing may be

available based on the type of pharmacy purchasing

medications (eg, institutional, retail, government

operated). In addition, quantity or market share

rebates from the manufacturer may be available. Prices

are subject to change at any time.

† Currently, ribavirin is only available from

Schering-Plough packaged with interferon alpha-2b as

Rebetron or compounded by Fisher's Pharmacy (3904

sville Ave., Pittsburgh, PA 15214; 888-347-3416).

Rebetron contains interferon 3 MU plus 1200 mg, 1000

mg, or 600 mg ribavirin, and is packaged in 2-week

supplies.

‡ Reserve for patients who have contraindications to

ribavirin.

§ In clinical trials, most of the reported adverse

reactions were considered mild to moderate and were

manageable.

Table adapted from NIDDK.[27]

Table 4. Monitoring HCV Treatment (Table also applies

to HCV patients co-infected with HIV)

Baseline

HIV viral load, CD4, CBC, LFTs, Chem panel, HCV load,

genotype

Screen for comorbid disease

Depression screen (consider antidepressant

prophylaxis)

Week 2

CBC

If anemic, give erythropoeitin

4-week intervals

CBC, LFTs, Chem panel

Evaluate mood, adverse effects

12-week intervals

HCV VL, HIV VL, CD4

Evaluate for drug-drug interactions

Screen for IFN-associated thyroid dysfunction (TSH)

Check HCV VL weeks 12 and 24

Week 12: HCV RNA > 1 log reduction

Week 24: HCV RNA undetectable

If genotype 1, continue TX for 48 weeks. If

nongenotype 1, stop therapy after 24 weeks.

CBC = complete blood count; Chem panel = chemistry

panel; LFTs = liver function tests; TSH = thyroid

stimulating hormone; VL = viral load

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Hepatotoxicity associated with antiretroviral therapy

in adults infected with human immunodeficiency virus

and the role of hepatitis C or B virus infection.

JAMA. 2000;283:74-80. Abstract Available at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=1\

0632283 & dopt=Abstract.

Staples CT, Rimland D, Dudas D. Hepatitis in the HIV

Atlanta VA Cohort Study (HAVACS): the effect of

coinfection on survival. Clin Infect Dis.

1999;29:150-154. Abstract Available at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=1\

0433578 & dopt=Abstract.

Sabin CA, Telfer P, AN, Bhagani S, Lee CA.

The association between hepatitis C virus genotype and

HIV disease progression in a cohort of hemophilic men.

J Infect Dis. 1997;175:164-168. Abstract Available at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=8\

985212 & dopt=Abstract.

Soriano V, -ldo R, -Samaniego J.

Management of chronic hepatitis C in HIV-infected

patients. AIDS. 1999;13:539-546. Abstract Available

at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=1\

0203378 & dopt=Abstract.

Sulkowski M, R, Mehta S, D. Effect of HCV

coinfection on HIV disease progression and survival in

HIV-infected adults [abstract 34]. Program and

abstracts of the 8th National Conference on

Retroviruses and Opportunistic Infections; February

4-8, 2001; Chicago, Illinois. Available at:

http://www.retroconference.org/2001/abstracts/abstracts/abstracts/34.htm.

Soriano V, -Samaniego J, Bravo R, et al.

Interferon alpha for the treatment of chronic

hepatitis C in patients infected with human

immunodeficiency virus. Clin Infect Dis.

1996;23:585-591. Abstract Available at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=8\

879784 & dopt=Abstract.

Carpenter CC, DA, Fischl MA, et al. Antiviral

therapy in adults; updated recommendations of the

International AIDS Society-USA Panel. JAMA.

2000;283:381-391. Abstract Available at:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=1\

0647802 & dopt=Abstract.

Harold Margolis, Hepatitis Branch NCID, CDC.

Prevention and Control of Viral Hepatitis in the

Community; CDC Consultants' Meeting; March 5-7, 2001;

Atlanta, Georgia.

National Institute of Diabetes & Digestive & Kidney

Diseases. Chronic Hepatitis C: Current Disease

Management. NIH Publication No. 99-4230, May 1999.

Available at:

http://www.niddk.nih.gov/health/digest/pubs/chrnhepc/chrnhepc.htm.

__________________________________________________

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NOTE: To view the article with Web enhancements, go

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--------------------------------------------------------------------------------

Infections Behind Bars

Hepatitis C: A Correctional-Public Health Opportunity

Anne S. De Groot, MD, Stubblefield, Joe

Bick, MD

[Medscape Infectious Diseases, 2001. © 2001 Medscape,

Inc.]

Introduction

For a variety of reasons, many diseases are present at

a higher prevalence in prisons and jails. Mental

illness, HIV, hepatitis B and C, and drug and alcohol

addiction are just a few of the conditions that are

common in prisoners entering the correctional system.

What is often seen as an overwhelming burden to

correctional healthcare systems should more

appropriately be seen as a tremendous public health

opportunity. The stark truth is that most inmates will

eventually be released from prisons and jails. Once

released, many of them either do not have access to

healthcare or fail to avail themselves of it. In

focusing healthcare resources on the incarcerated,

society has the opportunity to decrease crime rates

(mental illness, addiction), prevent transmission

(HIV, hepatitis, other sexually transmitted diseases

[sTDs]), and lower lifetime costs associated with

untreated diseases. This article will focus on the

challenges and opportunities associated with the

treatment of hepatitis C virus (HCV) in the

incarcerated.

Epidemiology of HCV in Correctional Settings

Hepatitis C infection outstrips HIV in correctional

settings in terms of sheer numbers of inmates living

with this infection (Table 1). According to a recent

analysis performed by Dr. Ted Hammett (Abt Associates,

Cambridge Massachusetts) and reported to Congress,[1]

between 1.0 and 1.25 million individuals harboring

chronic HCV infection were released from prisons and

jails in the United States in 1996, or approximately

30% (29% to 32%) of the estimated 4.5 million

individuals living with chronic HCV infection in the

United States. The prevalence of HCV infection among

US prisoners is at least 10-fold higher than the

estimated prevalence of 2% in the general

population.[2] Outside of correctional settings, 79%

of current injection drug users (IDUs) have HCV

infection.[3] In fact, young IDUs acquire HCV

infection at rates 4 times higher than the rate of

acquisition of HIV; after 5 years of continuous

injection drug use, 90% of IDUs are HCV infected.

HCV prevalence studies in correctional settings are

rare; however, some statistics have been compiled from

a number of sources by HIV and Hepatitis in Prison

Project In the Colorado state prisons, for example,

the prevalence of HCV among inmates has been reported

to be 30%.[4] A recent survey of Arizona reported a

31.3% prevalence rate among inmates (Gerard

Chamberlin, personal communication). In land, the

prevalence of HCV among state inmates has been noted

to be slightly higher, at 38%.[5] One county jail in

semi-rural Massachusetts recently reported that 20.7%

of its jail inmates had HCV infection (Hampden

County).[6] In Virginia, 30% to 40% of inmates have

been reported to have HCV infection.[7] Approximately

the same rate has been reported in Washington state

(30% to 40%).[8] The prevalence of HCV among state

inmates in Pennsylvania is slightly lower, at 13%.[9]

Reflecting their higher rate of participation in HIV

and HCV risk behaviors, incarcerated women exhibit

about a third higher HCV co-infection rate than

incarcerated men.[10] For example, in a sample of

incoming inmates in California, 54% of women inmates,

compared with only 40% of men inmates, have HCV

infection.[11] In Connecticut, 1 in 3 women (32%)

incarcerated at the only state facility for women

inmates has HCV infection.[12] In Texas, 37% of

incarcerated women and 28% of incarcerated men have

HCV infection.[3] Wisconsin reported HCV infection

rates among women inmates that are almost 2-fold

higher than the rates among men: 21% for women, 12.4%

for men, 13.2% overall.[13]

Hispanics and non-Hispanic blacks have higher rates of

HCV and HBV infection and chronic disease than whites;

most cases of HCV and HBV infections are found among

persons who are male, members of minority populations,

and 30 to 49 years of age.[3] These race- and

class-related risk factors for hepatitis infection

probably contribute to the current concentration of

HCV- and HBV-infected persons in prisons and jails.

Screening for and Treating HCV in Correctional

Facilities

The CDC lists correctional institutions, HIV

counseling and testing sites, and drug and STD

treatment programs as sites where hepatitis screening

and interventions should take place. (See Table 2 for

screening recommendations.) Correctional facilities

that screen for HCV and educate their inmates about

HCV are performing a significant public service, since

approximately 50% of persons with hepatitis are

unaware of their hepatitis infection.[1] Testing for

hepatitis infection informs the patient and physician

about the potential for and possible existence of

liver damage, and it should serve as an important

prompt for a discussion about risky behaviors and

transmission to others.[1]

Treatment of HCV

The current standard of care in community settings is

to treat chronic HCV patients who meet treatment

selection criteria with a combination of

ribavirin/interferon alpha (Table 3). Most

correctional facilities have either developed

protocols for screening and treating HCV-infected

inmates, or are in the process of developing these

protocols. However, the criteria for HCV treatment may

vary slightly from one correctional system to another.

The CDC is in the process of developing a set of

guidelines for HCV screening and treatment that may

assist correctional facilities with their

decision-making process. (A draft of the hepatitis

recommendations that are proposed for publication in

MMWR [Morbidity and Mortality Weekly Report] in the

fall of this year can be obtained by contacting Rob

Lyerla or Wientraub or by calling 404-371-5460.)

In general, eligible patients meet the following

criteria: (1) have evidence of persistent HCV

infection and inflammation based on liver function

test (LFT) abnormalities and detectable virus in the

blood stream; (2) have enough time left in their

sentence to allow for completion of treatment (6-12

months) (3) are committed to a life free from

substance and alcohol abuse; (4) are educated about

potential HCV treatment side effects and willing to

adhere to an arduous course of treatment.

Standard therapy is to provide daily treatment with

ribavirin (usually 5-6 pills divided into 2 doses) and

thrice-weekly alpha-interferon injections. (See Table

3 for dosing and side effects of treatment regimens.)

Pegylated interferon, a new form of interferon that

permits once-weekly dosing, was approved by the FDA

this year. Monotherapy is currently used only if the

patient cannot take ribavirin due to toxicities or

side effects.

Response Rates

Combination therapy consistently yields higher rates

of sustained response compared with monotherapy. (A

sustained response implies that HCV RNA remains

undetectable for 6 months or longer after therapy

stops.) With combination therapy, 40% of

treatment-naive patients respond. Patients with

genotype-1 have sustained response rates of 25% to 30%

(slightly better response rates are seen with lower

baseline HCV viral loads). Non-genotype-1 patients

achieve response rates of 60% to 65%.[14,15] Other

factors that increase the likelihood of a response to

therapy include age younger than 45, female gender,

and mild (rather than advanced) chronic inflammation

on liver biopsy. Histologic improvement occurs in 86%

of patients who achieve a sustained response and 39%

of patients who relapse after initial response to

combination therapy.[15]

Cost vs Benefits

As with many other chronic medical conditions,

morbidity and mortality attributable to HCV may not

manifest themselves until well after the end of

incarceration. Treatment is often ineffective, poorly

tolerated, and prohibitively expensive. Many

correctional systems, still reeling from the impact of

providing HIV treatment, have been slow to embrace

wide-scale treatment of hepatitis C. Additionally, the

therapy in most cases is being given to IDUs who are

in forced institutional abstinence, have not had and

will not have drug treatment, and will therefore

probably be promptly reinfected upon release.

Despite these concerns, some state medical directors

have led the way and adopted clear protocols for the

screening and treatment of HCV in their facilities.

These individuals are mindful that a year 2001 dollar

spent on treatment may reduce the eventual cost (to

society) of caring for patients who may require liver

transplants in 20-30 years.[4,16] Furthermore,

combination therapy of HCV is leading to higher rates

of cure (up to 88% in carefully selected patients);

therefore, the overall cost-effectiveness of HCV

interventions in corrections is improving.

Cost-benefit analyses have been performed. For

example, medical decision analyst J. Wong calculated

that 6 months of combination therapy resulted in net

savings in the range of $400 to $3500 over the

lifetime of each HCV-infected patient.[17] Dr. Wong's

analysis ranked combination therapy for HCV in the

same range of cost-effectiveness as stool guaiac

testing, pneumococcal vaccination, coronary bypass

surgery, and mammography.[17]

Liver Biopsy

The need for confirming the extent of damage to the

liver by HCV and chronic HBV infection is another area

of debate, since obtaining liver biopsies can be both

costly and logistically complicated in correctional

settings. LFTs can be normal in patients with rather

advanced cirrhotic features. Likewise, LFTs may be

consistently elevated in hepatitis C patients with

normal histology. Some state correctional systems do

not routinely perform liver biopsies prior to

initiating treatment, because of cost and logistical

difficulties. Other states (eg, Florida) believe

biopsies are the only real way to measure disease

progression over time and therefore have made

arrangements to do them on site at very reduced costs

($200 per biopsy). Depending on the cost of obtaining

a liver biopsy, electing to treat all incarcerated

individuals who meet the criteria for treatment may be

more cost-effective for society as a whole than

management by biopsy.[17]

The Lowest-Cost Intervention: Education

The lowest-cost intervention for the prevention of

hepatitis infection is education. Given the risk of

acquiring HCV (not to mention HIV), all bloodborne

pathogen screening events should lead to careful

discussion of the risks of acquiring HIV, HBV, and HCV

infection (for those patients who have negative

hepatitis serologies). The risk of transmitting

hepatitis should also be made very clear (see

Resources for information on educational materials).

The impact of continued drug use should also be made

very clear to patients, especially those who are not

yet HCV infected. For those inmates who are already

HCV infected, education should be provided on the

impact of alcohol abuse on HCV progression (4-fold

increase in risk of progression, risk of liver damage

directly correlated with alcohol intake) and the risk

of transmission to uninfected sexual partners. Inmates

who have HCV infection should, at the very least, be

educated about options for treatment even if they are

not eligible for treatment while incarcerated (see

Resources for information on expanded access

programs).

Additional Considerations

Another low-cost (but not no-cost) intervention is

vaccination. For HCV-infected patients, vaccination

against HBV and HAV is routinely recommended, as these

relatively inexpensive vaccines may reduce the risk of

fulminant liver failure and the need for liver

transplantation for HCV-infected patients. A new

schedule of HBV vaccination (3 shots at 0, 1, and 4

months) has received approval. The first shot provides

up to 50% protection, and the series does have

efficacy even if it is given over several years, so

the new CDC guidelines are expected to encourage

initiating HBV vaccination even in jail settings.

Management of HCV in Correctional Settings

Since the incidence of side effects to HCV combination

therapy can be relatively high and it can be difficult

for incarcerated patients to quickly gain access to

their clinician to report side effects, it is

important to:

Spend time preparing the patient for potential

treatment-related side effects

Prescribe PRN medications for symptom management

Consider following the patients in a dedicated

hepatitis clinic

Consider establishing a support group for patients

under HCV treatment

Utilize peer education programs when possible

Use a nurse or other staff person to regularly check

in with patients who are receiving HCV treatment so

that side effects can be rapidly addressed

Without a good support system, a high percentage of

patients will fail to complete therapy. Because of the

high cost of treatment, time spent preparing patients

and supporting them while on treatment is likely to be

cost-effective. Table 4 provides guidelines for

monitoring treatment.

HIV and HCV Coinfection

Analyses of the effect of HCV and HIV co-infection on

progression of either disease are often confounded by

concurrent risk factors for progression. However,

available data seem to indicate that HIV infection

accelerates HCV liver disease. Persons who are

co-infected (HIV/HCV) appear to have a 12- to 300-fold

higher risk of developing hepatocellular carcinoma

compared with noncarriers.[18] Furthermore,

antiretroviral agents can contribute to liver

inflammation, and this may be more frequent in those

who have underlying chronic hepatitis due to HCV or

HBV. Ritonavir and nevirapine appear to be the

antiretroviral therapy medications that are most

commonly associated with liver inflammation in HCV/HIV

co-infected patients.[19]

The impact of HCV infection on HIV infection is less

clear. In some studies, HCV infection does not appear

to have an effect on the progression of HIV.[20] Other

studies have reported an association between more

rapid progression to AIDS or death in HIV-infected

patients, particularly among those who were

co-infected with HCV genotypes 1a and 1b.[21,22]

However, a report by Sulkowski[23] at the 8th National

Conference on Retroviruses and Opportunistic

Infections (CROI), contraindicated these findings,

suggesting that risk of progression was more closely

linked to lack of access to medical care (for HIV) in

his cohort of African American patients who had HIV

and HCV co-infection.

Response to HCV therapy in individuals who also have

HIV infection appears to be equivalent to that of

non-HIV-infected individuals.[24] A recent study in

JAMA by Sulkowski and associates[19] indicates that

88% of co-infected patients tolerate concurrent HCV

treatment and highly active antiretroviral therapy

(HAART). Following successful HCV treatment,

co-infected patients are not more likely to relapse

after HCV treatment than are patients who do not have

concurrent HIV infection.

Currently, when exclusionary criteria are not present

(see Table 2), treatment of hepatitis C is recommended

for patients when CD4 and viral load values reflect

good response to antiretroviral treatment. Although

some controversy remains with regard to the definition

of a good response to HAART, a stable CD4+ T-cell

count greater than 200 with a stable viral load less

than 400 is generally accepted.[25]

Conclusion

The cost of HCV treatment is expected to be a major

barrier to wide implementation of the guidelines in

prisons and jails. There is a concern that treatment

could overwhelm some systems' healthcare budgets. The

high prevalence of hepatitis infections among

incarcerated individuals and the availability of

treatments with less than 100% efficacy force

difficult decision making in correctional health

facilities.

The clustering of individuals with hepatitis and other

treatable illnesses in correctional facilities creates

not only challenges but opportunities as well. With an

effective public health-correctional collaboration,

the opportunity exists to make a tremendous impact on

the health of society as a whole. Without such

initiatives, many prisoners will eventually return

untreated to the communities from which they came.

Prisons and jails are an ideal site for introducing

public health interventions that will have a positive

impact on hard-to-reach communities; this opportunity

to improve public health should not be overlooked.

It must be noted, however, that the cost savings that

may accrue from treatment of prisoners are primarily

to society as a whole. While treatment of incarcerated

individuals for hepatitis and HIV is the right thing

to do and can tremendously benefit the public health,

it is not realistic to expect correctional systems to

shoulder this financial burden without assistance.

Guidelines and standards for selecting patients who

are to be treated, while providing access to care for

HCV-infected individuals regardless of incarceration

status, are forthcoming from the CDC. Correctional

physicians eagerly anticipate further guidance from

state and federal health officials on supplemental

sources of funding for HCV treatment initiatives in

correctional settings.

Acknowledgements

This article is modified from an article by Anne S. De

Groot entitled HCV: The Correctional Conundrum,

published in HEPP News, Vol. 4 (4), April 2001.

Available at:

http://www.hivcorrections.org/archives/april01/.

Table 1. Hepatitis and HIV Disease Prevalence Inside

and Outside Correctional Facilities*

HCV HIV

Hepatitis and HIV prevalence in US populations†

Chronic Infections 4.5 million 0.8 million

New Infections per year 35,000 40,000

Deaths per year 8000 18,000

Hepatitis and HIV prevalence among inmates released

from prisons and jails‡

Number of infected inmates released 1.3-1.4 million

98,000-145,000

Percent of US population with disease 29% to 32%

13% to 19%

* Hammett and colleagues[1] noted an extreme lack of

HBV data on correctional populations. These numbers

are rough period prevalence estimates based on studies

done in California (1994) and New York (1987-1997)

correctional systems.

† CDC, Harold Margolis, Hepatitis Branch.[26]

‡ Burden of disease among releasees in 1996, CDC, NIJ,

Abt survey.[1]

Table 2. HCV/HBV Screening

Persons who should be tested routinely for hepatitis

include:

Persons residing in correctional facilities

Injection drug users (IDU), including those who

injected once or a few times and do not currently

consider themselves to be drug users

Persons with selected medical conditions, including:

Persons who received clotting factor concentrates

produced before 1987

Persons ever on chronic hemodialysis

Persons with persistently abnormal ALT levels

Persons who received blood transfusions, blood

components, or organ transplantation before July 1992

Persons diagnosed with HIV infection and sexual

partners of persons diagnosed with HIV infection

Healthcare and correctional workers after needle

sticks, sharps, or mucosal exposures to HCV-positive

blood.

Source: Modified from MMWR, 1998.[3]

Table 3A. Hepatitis C Treatment

Treatment Cost* Dose Frequency Side Effects§

Combination therapy: ribavirin and interferon

(Rebetron)†

Ribavirin + interferon

(Rebetron, Schering-Plough) Rebetron† 1200: $391

per week Rebetron: cardiac and pulmonary events

associated with anemia occurred in approximately 10%

of patients.

Rebetron† 1000: $354 per week Psychiatric events in

treatment-naive patients: insomnia (39%), depression

(34%), irritability (27%).

Rebetron 600: $290 per week

Ribavirin: oral antiviral agent† Ribavirin 200-mg

capsule: $1.25 1000 mg: $43.75/week 200-mg capsules:

1000 mg/day divided bid for < 75 kg; 1200 mg/day

divided bid for > 75 kg 2x daily Ribavirin: primary

toxicity: hemolytic anemia (reductions of hemoglobin

levels occurred within the first 1-2 weeks of therapy)

1200 mg: $52.50/week

Interferon alpha-2a,

interferon alpha-2b,

consensus interferon (see below) INF-alphas: 3

MU/injection 3x weekly SC (see below)

Consensus interferon: 9 mcg/injection

Monotherapy‡

Interferon alpha-2a

(Roferon A, Roche) $36.72 per 3 MU 3

MU/injection 3x weekly SC Flu-like symptoms; headache

(52%); dizziness (13%); nausea/vomiting (33%),

diarrhea (20%), depression (16%), irritability (15%),

insomnia (14%)

Interferon alpha-2b

(Intron A, Schering-Plough) $40.00 per 3 MU 3

MU/injection 3x weekly SC Flu-like symptoms

Peginterferon alpha-2b

(Pegintron, Schering-Plough) 100 mcg/mL: $240

1x weekly Flu-like symptoms

160 mcg/mL: $253

240 mcg/mL: $265

300 mcg/mL: $279

Interferon alphacon-1

(consensus interferon,

Infergen, Amgen) $38.76 per 9 mcg 9

mcg/injection 3x weekly Flu-like symptoms

MU: Million units; SC = subcutaneously

* The pricing shown should be considered a maximum

price. Substantially discounted pricing may be

available based on the type of pharmacy purchasing

medications (eg, institutional, retail, government

operated). In addition, quantity or market share

rebates from the manufacturer may be available. Prices

are subject to change at any time.

† Currently, ribavirin is only available from

Schering-Plough packaged with Interferon alpha-2b as

Rebetron or compounded by Fisher's Pharmacy (3904

sville Ave., Pittsburgh, PA 15214; 888-347-3416).

Rebetron contains interferon 3 MU plus 1200 mg, 1000

mg, or 600 mg ribavirin, and is packaged in 2-week

supplies.

‡ Reserve for patients who have contraindications to

ribavirin.

§ In clinical trials, most of the reported adverse

reactions were considered mild to moderate and were

manageable.

Table adapted from NIDDK.[27]

Table 3B. Hepatitis C Treatment

Treatment

(Trade Name) Cost*

(Manufacturer) Dose Frequency Side Effects

Combination Therapy

Ribavirin: oral

antiviral agent†

WITH Ribavirin: 200-mg capsule: $1.25 Ribavirin:

200-mg capsules (1000 mg/day divided bid or < 75 kg;

1200 mg/day divided bid for > 75 kg) 2x day Primary

toxicity: hemolytic anemia (reductions of hemoglobin

levels occurred within the first 1-2 weeks of

therapy).

1000 mg: $43.75/week

1200 mg: $52.50/week

(See below for

interferons.)

Rebetron† 1200 (Schering-Plough): $391/week

Rebetron† 1000: $354/week

Rebetron 600: $290/week

Interferon alpha-2a,

interferon alpha-2b,

consensus interferon Interferons: 3 MU/

injection; consensus interferon 9 mcg/ injection 3x

weekly SC Rebetron: cardiac and pulmonary events

associated with anemia occurred in approximately 10%

of patients.

Psychiatric events in treatment naive: insomnia (39%),

depression (34%), irritability (27%).

Monotherapy‡

Interferon alpha-2a

(Roferon A, Roche) $36.72 per 3MU (Roche) 3 MU

per injection 3x weekly SC Flu-like symptoms; headache

(52%); dizziness (13%); nausea/vomiting (33%),

diarrhea (20%), depression (16%), irritability (15%),

insomnia (14%)

Interferon alpha-2b

(Intron A) $40 per 3 MU (Schering-Plough) 3 MU

per injection 3x weekly SC Flu-like symptoms

Peginterferon alpha-2b

(Pegintron) 100 mcg/mL: $240 1x weekly

Flu-like symptoms

160 mcg/mL: $253

240 mcg/mL: $265

300mcg.ml : $279.00

(Schering-Plough)

Interferon alphacon-1

(Infergen) $38.76 per 9 mcg (Amgen) Consensus

interferon 9 mcg/injection. 3x weekly Flu-like

symptoms

MU: Million units; SC = subcutaneously

* The pricing shown should be considered a maximum

price. Substantially discounted pricing may be

available based on the type of pharmacy purchasing

medications (eg, institutional, retail, government

operated). In addition, quantity or market share

rebates from the manufacturer may be available. Prices

are subject to change at any time.

† Currently, ribavirin is only available from

Schering-Plough packaged with interferon alpha-2b as

Rebetron or compounded by Fisher's Pharmacy (3904

sville Ave., Pittsburgh, PA 15214; 888-347-3416).

Rebetron contains interferon 3 MU plus 1200 mg, 1000

mg, or 600 mg ribavirin, and is packaged in 2-week

supplies.

‡ Reserve for patients who have contraindications to

ribavirin.

§ In clinical trials, most of the reported adverse

reactions were considered mild to moderate and were

manageable.

Table adapted from NIDDK.[27]

Table 4. Monitoring HCV Treatment (Table also applies

to HCV patients co-infected with HIV)

Baseline

HIV viral load, CD4, CBC, LFTs, Chem panel, HCV load,

genotype

Screen for comorbid disease

Depression screen (consider antidepressant

prophylaxis)

Week 2

CBC

If anemic, give erythropoeitin

4-week intervals

CBC, LFTs, Chem panel

Evaluate mood, adverse effects

12-week intervals

HCV VL, HIV VL, CD4

Evaluate for drug-drug interactions

Screen for IFN-associated thyroid dysfunction (TSH)

Check HCV VL weeks 12 and 24

Week 12: HCV RNA > 1 log reduction

Week 24: HCV RNA undetectable

If genotype 1, continue TX for 48 weeks. If

nongenotype 1, stop therapy after 24 weeks.

CBC = complete blood count; Chem panel = chemistry

panel; LFTs = liver function tests; TSH = thyroid

stimulating hormone; VL = viral load

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__________________________________________________

[Guest guest]

Claudine...I am finding your info to be very helpful....I am saving most of your

emails in a special

folder to be printed out. Thanks so much for this.

Does anyone know what the difference is between AST level and ALT level. I was

told my AST was twice as

much as normal but the rest of the levels were within the normal range. Since

Canada doesn't

automatically do biopsys, I'd like to know at least what this means.

Carol

[Guest guest]

Claudine...I am finding your info to be very helpful....I am saving most of your

emails in a special

folder to be printed out. Thanks so much for this.

Does anyone know what the difference is between AST level and ALT level. I was

told my AST was twice as

much as normal but the rest of the levels were within the normal range. Since

Canada doesn't

automatically do biopsys, I'd like to know at least what this means.

Carol

[Guest guest]

Claudine...I am finding your info to be very helpful....I am saving most of your

emails in a special

folder to be printed out. Thanks so much for this.

Does anyone know what the difference is between AST level and ALT level. I was

told my AST was twice as

much as normal but the rest of the levels were within the normal range. Since

Canada doesn't

automatically do biopsys, I'd like to know at least what this means.

Carol

[Guest guest]

Claudine...I am finding your info to be very helpful....I am saving most of your

emails in a special

folder to be printed out. Thanks so much for this.

Does anyone know what the difference is between AST level and ALT level. I was

told my AST was twice as

much as normal but the rest of the levels were within the normal range. Since

Canada doesn't

automatically do biopsys, I'd like to know at least what this means.

Carol