Dr. Diana Sylvestre is not an alarmist. But when it comes to the hepatitis C virus (HCV) — the country's number one blood-borne pathogen — she says we are in the midst of a grave public health crisis with Oakland as an epicenter. And that's inexcusable, she believes, because hepatitis C can be beaten through treatment. Many of the infected experience no symptoms, and those requiring care have a good chance of clearing the virus with medication. But even as awareness of the problem has grown, the already-scant resources devoted to it have been slashed.
More than four million Americans have been exposed to the virus and nearly 3 million are thought to be chronically infected. Hepatitis C is the country's leading cause of liver failure and liver transplantation, accounting for about 12,000 deaths a year, according to the Centers for Disease Control and Prevention. Liver transplant lists are accumulating names at a startling rate, and donors can't keep up.
And yet, hepatitis C is growing in scope. "It's something that can lead to death and debility, and it's not being addressed," said Sylvestre, who encounters the virus on a regular basis at her Oakland-based OASIS clinic, which has detected more than 3,500 cases of hepatitis C since it began screening for it ten years ago.
In fact, hep C is several times more common than HIV, but awareness by health care professionals and citizens is strikingly low. Why? For one thing, a majority of hep C sufferers use intravenous drugs. Then again, about half the people infected don't even know they have it. Even among the afflicted, there is often a lack of urgency. "The word is on the street, you know, 'Everyone's got that shit; I don't have to do anything about it,'" Sylvestre lamented. "The truth is it can kill you, but it doesn't have to."
Interferon and ribavirin combination treatment, a form of chemotherapy, has proven successful in eliminating the virus in about half of those who take it. But getting patients to that stage is a huge obstacle. Inadequate access to health care is partly to blame, but so is the failure of doctors to recognize the need for testing. Highland Hospital, the default hospital for the poor and uninsured in Alameda County, hasn't offered treatment in several years. When the doctor running the internal clinic left, the hospital never hired someone else. Instead, doctors there refer patients sick with hep C to specialists like those connected with Sylvestre's clinic.
The virus lives in the liver. It's not HCV that destroys the body, but the immune system's reaction to it. If the immune system declares war on the liver, it can lead to cirrhosis or liver cancer. Persons with HIV are now more likely to die from hep C-related liver disease than any other condition. And alcohol accelerates liver damage and makes treatment ineffective. "Alcohol and hep C are like gasoline and fire," Sylvestre said.
Intravenous drugs are closely linked to the disease. According to people on the front lines, if you use intravenous drugs in Alameda County, you have a 97 percent chance of being exposed to the virus. "In most places, if a test turns up positive for HCV they confirm it with another test," Sylvestre said. "Here, if I get a negative test I go to confirm it. That's how unusual a negative test is."
While drug use is responsible for the majority of new cases, it's not merely a junkie disease. "People who say, 'Well, I don't use needles so I don't need to worry about it' are kidding themselves," she said. About one third of the roughly three million Americans infected with hep C acquired it in some other manner. Failure to implement strategies to stop the illness can risk a serious outbreak, even for people who don't use IV drugs and aren't in prison — it can be passed on by sharing a toothbrush or razor, or having unprotected sex.
"It's ridiculous to call it an addiction disease," Sylvestre said. "Before screening began in 1992, one in ten units of blood were infected. There were 200,000 cases a year back then, so there are a lot of people cruising around with hep C who got it through a blood transfusion." Studies estimate that 15 percent of people with the virus contracted it sexually — a large number when you consider the millions currently infected.
Prison populations are dense with hep C and hard to monitor. "Drug use is rampant in prisons," Sylvestre noted. "Who knows? Tattoos, sex, lots of things." These populations leave prison and bring it back to the street. And in the days before HCV screening began, people incarcerated for drug offenses were sometimes offered sentence reduction for blood donations.
The relative ignorance about this epidemic highlights the health-care discrepancies in poor neighborhoods. Poverty and substance abuse are linked inextricably in this country, and when a virus also is linked to drugs, clinical trials and a national campaign to stop it tend to take longer. "Addiction doesn't elicit much sympathy from the public," noted Orlando Chavez, a coordinator of HepTev, the Berkeley Free Clinic's Hepatitis Testing, Education, and Vaccination program. "Once HIV crossed over to the mainstream people paid attention, but hep C hasn't yet had that 'crossover effect.'"
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