Note: Pictures and graph at websource. ~PSL
Sunday, June 4, 2006
By Dorsey Griffith -- Bee Medical Writer
It's been three years since Kristina Taylor tried to end it all, asking two men to unload full syringes of methamphetamine into her arms simultaneously. And it's been eight months since she's taken a drop of alcohol.
Now, clean and sober, the 38-year-old Rancho Cordova woman wants to slay a different beast, one that has her in the grip of another fight for her life: liver disease caused by hepatitis C.
"I don't want to die no more," Taylor says. "I want to live."
Although the sometimes fatal viral illness is rampant -- affecting more than 25,000 people in Sacramento County alone -- its treatment has been unattainable for most, especially those most vulnerable to the disease: low-income men and women with a history of injection drug use.
"Very few people are willing to undertake these cases," explained Dr. Diana Sylvestre, the gutsy executive director of the O.A.S.I.S. Clinic in Oakland, which provides care to hundreds of patients with addiction, hepatitis C and other health problems. "They are very challenging patients."
By taking on the difficult cases, holding rallies, hounding legislators for support and educating anyone who will listen, Sylvestre and a growing cadre of activists are working to fill the void. Their goal: to stanch an epidemic that affects an estimated 4 million to 5 million Americans and kills about 8,000 of them every year.
"The working principle is that all patients with hepatitis C are potential candidates for therapy," said Barbara Sigler, a nurse practitioner with the California Pacific Medical Center in San Francisco. Sigler is one of several medical specialists who is training front-line nurses and doctors determined to confront hepatitis C -- and all the complications that go with it.
Her audience on a recent Tuesday was a Sacramento group that calls itself Moving Mountains, aptly named for medical practitioners from the region who have decided to join the uphill battle against the disease. Fortunately, Sigler explained, new drug combinations -- pegylated interferon and ribavirin -- can eliminate the virus in 50 percent to 80 percent of those treated, depending on the type of hepatitis C and the patients' genetic makeup.
But there are caveats. As Sigler said, the drugs -- daily pills and weekly injections taken for up to 18 months -- can produce miserable side effects. Among them: fatigue, depression, headache, anemia, fever, anxiety, nausea, heartburn, loss of appetite, hair loss, gastric reflux disease and itching. "One of our patients recently waved a gun around in his neighborhood and was arrested," Sigler told the group. "We've had two suicides. One drank herself to death."
About 40 percent of Sacramento County's indigent adults are infected with hepatitis C, which is spread through contact with infected blood. In just a couple of weeks recently, county staff compiled a list of 80 patients who tested positive for the virus and were interested in treatment, said Dr. Dorothy Pitman, county clinics director. But finding a gastroenterologist -- much less one who specializes in liver disease -- can be an exercise in frustration. Waiting times can last as long as a year, she said.
"They all believe they are going to die," Pitman said. "Then, when they are put on waiting lists or told there is no treatment, it is very discouraging."
Part of the problem is that many people with hepatitis C also struggle with drug or alcohol addiction or other ailments, such as mental illness, making their treatment even more complex.
The rate of new hepatitis C infections actually has dropped in recent years because blood banks screen for the virus and because drug users are more aware of the hazards of needle-sharing.
Nevertheless, the need for medical care has never been more acute. That's because people who became infected decades ago -- many from experimental drug use -- only now are beginning to get sick. Hepatitis C can wreak havoc on the liver for years before it's detected, said Dr. John Vierling, a liver specialist at Baylor College of Medicine.
"The death rate is increasing, rates of liver (cirrhosis) and liver cancer are increasing," said Vierling, president of the American Association for the Study of Liver Diseases. "Hepatitis C-cirrhosis is the leading indication for liver transplants in the United States."
Sacramento County held its first hepatitis C clinic last month. Nineteen patients assembled at Sacramento County's Primary Care Center on Stockton Boulevard.
"Everyone in here has a different story," said Pitman, the county clinics director. "Not everybody will be a good candidate for treatment."
After viewing videos aimed at busting hepatitis C myths, patients asked their own questions:
"Will I have to have a biopsy before treatment?" asked one.
"Can I get treatment while I'm taking narcotic drugs for pain?" asked another.
"If I bleed into the food I am preparing, can I infect someone?" wondered another.
Taylor asked if her 10-year-old daughter, who was born with antibodies to hepatitis C, actually has the disease itself. Pitman explained that 20 percent of children exposed to the virus at birth will fight off the infection on their own.
Later, in an exam room with Pitman, Taylor described how she regularly injected methamphetamine in her early 20s, how she has been treated for mental illness and how she once tried to kill herself with an overdose, distraught over her father's death and loss of custody of her two children.
"I'm ready," she said of her drive to treat her disease. "I want to get better."
Pitman reviewed Taylor's medical chart, noting high blood sugar levels and signs of liver disease from previous blood tests. Treatment for hepatitis C, Pitman told her, "is no walk in the park." The drugs can exacerbate depression, so controlling the mental illness is essential before starting medication.
"They say I have cirrhosis," Taylor said, her eyes filling with tears. "They say my liver is a cobblestone."
Sacramento County's outreach to indigent adults with hepatitis C represents part of a fledgling national movement to tackle the problem early, from the trenches of medicine. The federal Department of Veterans Affairs has led the way, and other medical personnel dedicated to society's disenfranchised now are taking on the emerging epidemic. The National Association of Community Health Centers, for example, launched pilot projects last year that trained providers in six clinics to treat hepatitis C. In just nine months, more than 800 cases were detected.
UC Davis liver specialist Lorenzo Rossaro, who works with Sacramento County providers treating hepatitis C patients, also consults electronically with doctors at 65 clinics throughout Northern California.
And, starting in July, the Bi-Valley Medical Clinics in Sacramento County, which provide methadone treatment for heroin and other opiate addicts, will begin treating hepatitis C.
Bi-Valley program director Garrett Stenson said hepatitis C is the leading cause of death among his patients. Yet many are refused medical treatment for the disease, even after kicking heroin addiction.
"We are sick of watching our patients die," Stenson said.
Of the first 19 hepatitis C patients who came through the county primary care clinic, nine were deemed good candidates for therapy and will return later this month to get started.
Pitman said a blood test proved that one patient no longer had the virus; eight others will be re-evaluated periodically for possible treatment down the line.
Two weeks after her first visit, Taylor returned to the clinic feeling both giddy and anxious.
The news was mixed. Taylor let out a whoop upon learning that she is not diabetic. But she winced when Pitman told her that tests showed low supplies of white blood cells and platelets due to her liver disease. Treatment for hepatitis C, which can by itself cause anemia, could worsen that condition, she said.
"We have a gastroenterologist at UCD who is helping us," Pitman said, referring to Rossaro. "I want to talk to him about your treatment. I'm not comfortable proceeding ahead."
Psychiatrist John Onate added that Taylor needs to understand that hepatitis C drug treatment also could worsen her mental state.
"I'm going to have a strong will about me," Taylor assured him. "I'll tell myself every day, 'This is for the good.' "
About the writer:
The Bee's Dorsey Griffith can be reached at (916) 321-1089 or firstname.lastname@example.org
Hepatitis C links
Hepatitis Foundation International: www.hepfi.org
American Liver Foundation: www.liverfoundation.org
Hepatitis C Support Project: www.hcvadvocate.org