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Addressing Viral Hepatitis
Based in part on SAMHSA TIP 53
Dr. Dawn-Elise Snipes Executive Director,

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– Overview of viral hepatitis
– Screening and evaluation
– Counseling Approaches for People Who Have Viral Hepatitis
– Ensuring Safety
– Providing Reliable Information
– Building the Therapeutic Relationship
– Helping Clients Understand Their Diagnoses
– Incorporating Client Needs in Substance Abuse Treatment Planning
– Developing a Prevention Plan
– Using Motivational Approaches
– Confronting the Social Factors of Hepatitis
– Addressing Relapse
– Building Support Systems
– Providing Effective Case Management
Overview of Viral Hepatitis
– 3.5–5.3 million people in the United States live with chronic viral hepatitis
– Symptoms can take decades to manifest, so many people who are infected do not seek timely treatment
– SUD does not cause, but can exacerbate Viral Hepatitis
– As many as 90 percent of people who have HIV infection have been infected with HBV
– 33 percent of people who are infected with HIV are co-infected with HCV
– Chronic hepatitis infection affects approximately 5% of psychiatric inpatients

Overview of Viral Hepatitis
– More than 90% of infants that are infected will develop a chronic hepatitis B infection
– Up to 50% of young children between 1 and 5 years who are infected will develop a chronic hepatitis B infection
– 90% of healthy adults over the age of 19 will recover from a Hep B exposure
– HCV will spontaneously clear in 25% of the population
Love Your Liver
– Breaks down toxins found in the blood and excretes them as harmless byproducts either in the stool or the kidneys
– Metabolizes drugs, alcohol, and prescription and over-the-counter medications
– Makes cholesterol and clotting factors
– Stores sugar (as glycogen –> glucose), fats, and vitamins
• Fever
• Fatigue
• Loss of appetite
• Nausea
• Vomiting
• Abdominal pain
• Dark urine
• Clay-colored bowel movements
• Joint pain
• Jaundice (yellow color in the skin or the eyes)

Hepatitis A Transmission
– An estimated one-third of U.S. residents have had HAV which is down 92% since the discovery of a vaccine.
– HAV is spread by the oral transmission of fecal matter (stool) of a person who is infected with HAV and it is extremely contagious.
– HAV can survive outside the body for several days and in water for several months.
– People are most infectious during the 2 weeks before the onset of symptoms.
Hepatitis B Transmission
– Hepatitis B is spread when blood or body fluid infected with the hepatitis B virus enters the body of someone who is not infected.
• Birth (spread from an infected mother to her baby during birth)
• Sex with an infected partner
• Sharing needles, syringes, or drug preparation equipment
• Sharing items such as toothbrushes, razors, or medical equipment (like a glucose monitor) with an infected person
• Direct contact with the blood or open sores of an infected person
– Hepatitis B is not spread through food, sharing utensils, breastfeeding, kissing, hand holding, coughing, or sneezing.
– Many people with hepatitis B don’t feel or look sick. However, they can still spread the virus to others.
– The hepatitis B virus can survive outside the body (even in dried blood) and cause infection for at least 7 days.
Hepatitis C Transmission
– Hep C is commonly spread by:
• Sharing drug needles or accidental needlestick injuries
• Being born to a mother who has hep C
– Less commonly, Hep C is spread by:
• Contact with someone's blood via razors or toothbrushes
• Sex
• Getting a tattoo or body piercing in an unregulated setting
– Hep C CANNOT be spread by:
• Food, water, or sharing eating utensils
• Hugging, kissing, holding hands, coughing, or sneezing

Who Should Be Regularly Tested
– People at risk for infection by sexual exposure
– People who inject drugs
– People with HIV
– Household and sexual contacts of people with hepatitis B
– People requiring immunosuppressive therapy
– Hemodialysis patients
– People with hemophilia who receive blood clotting factors
– People with another form of viral hepatitis
– Pregnant women
– Infants born to infected mothers
Who Should Get Vaccinated (A & B)
• All infants
• People at risk for infection by sexual exposure
• People whose sex partners have hepatitis B
• Sexually active people who are not in a long-term, mutually monogamous relationship
• People at risk for infection by exposure to blood
• People who inject drugs
• People who live with someone who has hepatitis B
• Health-care and public-safety workers at risk for exposure to blood or blood-contaminated body fluids
• People who receive hemodialysis or, prior to 1992, blood or organ transplants
• People with diabetes who are 19–59 years of age
Who Should Get Vaccinated (A & B)
• International travelers to countries where hepatitis B is common
• People with hepatitis C virus infection
• People with chronic liver disease
• People with HIV infection
• People who are in jail or prison
• All pregnant women during each pregnancy
Screening and Evaluation
– Verbal screening at intake for all people
– Those who are at risk should be counseled to seek medical screening.
– Screening is an opportunity to educate about hepatitis.
– Note: Some people confuse hepatitis (HBV/HCV with HIV) CLARIFY!
– Antibody vs. antigen
– Antigens (virus) –contagious
– Antibody (indicates prior exposure)
– A “positive” HCV antibody test could mean the person is a chronic carrier of HCV (75 percent to 85 percent), has been infected but has resolved infection (15 percent to 25 percent), or is one of the few recently (acutely) infected
– Follow-up to a positive: A qualitative HCV RNA test determines whether the virus is present in the blood.
Counseling Approaches
– Providing Reliable Information
– Liver Foundation
– Know More Hepatitis
– Locations
– Posters in the lobby
– Reading material in your office
– Posters in bathroom stalls

Counseling Approaches
– Ensuring Safety
– Confidentiality
– Establish rapport
– Discuss overlapping symptoms to prevent defensiveness

Counseling Approaches
– Helping Clients Understand Their Diagnoses
– Acute vs Chronic (> 6 months)
– A, B, C
– Among those who develop chronic HCV or HBV infection, an estimated 20 to 30% will develop cirrhosis
– Progresses faster in those infected after 40
– Increased risk of developing Type 2 Diabetes
– Abdominal swelling (Ascites) indicates treatments are no longer working.
– Hepatic encephalopathy will occur in approximately 30 to 40% of individuals with cirrhosis is the illness becomes more severe.
– Neurologic and psychiatric manifestations including apathy, irritability, decreased energy level, impaired sleep-wake cycle, impaired cognition, diminished consciousness, or loss of motor control

Counseling Approaches
– Helping Clients Understand Their Diagnoses
– Interventions (Consult with physician)
– Medication to slow progression of cure the disease
– Get screened for liver cancer annually
– Avoid or limit alcohol and smoking since both cause a lot of stress to your liver
– Eat a healthy diet with lots of vegetables since fried, greasy foods are hard on your liver
– Control blood sugar and prevent diabetes
– Limit sodium intake to less than 2000 mg per day
– Maintain a healthy weight to prevent fatty liver
– Drink coffee-
– Individuals with chronic HCV who do not have cirrhosis can often take acetaminophen, aspirin or NSAIDs at low or standard recommended dosages.
– Persons with chronic HCV infection and cirrhosis should, in general, avoid taking acetaminophen, NSAIDs or aspirin
– Those with chronic HCV are often told to avoid taking iron supplements or a daily multivitamin that contains iron
– Vitamin D deficiency is common with chronic HCV infection (and depression)

Counseling Approaches: Motivation
– Readiness
– Precontemplation
– Contemplation
– Preparation
– Action (testing)
– Maintenance (treatment/prevention)
Counseling Approaches: Motivation
– For Testing or Treatment
– Physical (relieve symptoms)
– Affective (anxiety/depression)
– Cognitive (provide direction and clarity)
– Environmental/Relational (know they are not putting anyone else at risk or how to mitigate risk)
– OARS: Open-ended questions, Affirmation, Reflection, Summarizing
– FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Support
Counseling Approaches
– Developing a Prevention Plan
– Prevent self and loved ones from infection
– Prevent additional infections or development of confounding issues
– Prevent infecting others if infected
Counseling Approaches
– Building Support Systems
– Educate about prevention and to reduce stigma
– Family counseling
– Community education
– Support groups
– For the patient
– For the family
– For each stage: New Dx, Chronic Illness, Terminal Conditions

– Encourage development of synchronous support groups in your community (hospitals, churches, libraries)
– Online support groups

Case Management (Disease and Tx)
– Physical
– Pain management
– Disability income- /Lost wages
– Nutrition
– Medication maintenance (patient assistance programs)
– Clinical trials

– Affective/Cognitive
– Anger
– Anxiety
– Depression
– Grief
– Brain fog / concentration
– Environmental/Relational
– Housing
– Stigma and discrimination (Advocacy/Education)
– Enhance support for both the individual and SOs
– Hepatitis impacts millions of people physically, affectively, cognitively, financially and relationally
– Several symptoms of hepatitis overlap with that of depression or cognitive impairment including
– Fatigue
– Difficulty concentrating
– Loss of appetite
– Dark colored urine* (if dehydrated)
– Achiness (joint pain)
– Hepatitis, like other blood borne pathogens carries a stigma and is highly contagious
– Clinicians have an obligation to educate the public about hepatitis to destigmatize and advocate for health prevention activities

– Counseling should focus on where the person is (testing/treatment) and their level of readiness for change.
– Counseling goals should be to
– Reduce risk of infection/complications or infecting others
– Improve health literacy regarding hepatitis
– Encourage social support
– Assist the person in connecting with needed biopsychosocial resources