CURING HCV in prison: The new Community Standard of Care.

"Q: Will we be able to wipe out hepatitis C entirely?

A: In contrast to HIV, we do have the capability of doing that - essentially curing everyone who got infected. While we have made tremendous progress against HIV, we still don't have a cure, we still don't have a vaccine. The situation for HCV is dramatically different. A cure is achievable. Someday soon, the cure using an interferon-free cocktail is going to be routine...."

 ----------

Until now, I thought it was likely that this disease would kill not only my imprisoned friend Davon, sick as a dog on interferon right now, but also my big brother, who hasn't been able to get treatment - both I feared would die very painfully, at an early age. 

This news gives me hope, though. We have the capability to wipe out this disease and cure those who are ill right now - the question remains: do we have the collective will? That much, I still don't know.

Nearly 6,000 AZ state prisoners have tested positive for the Hepatitis C virus, but only a fraction are deemed eligible for a miserable course of interferon treatment because it costs so much and takes such a toll on body and mind. Many drop out from the side effects, having to face debilitating and fatal liver disease instead. Most public health estimates put the jail/prison population at being over 50% HCV+. Imagine how hard it is already to see loved one do time and maybe even make amends for their crimes in prison, and come home only to find that they were sentenced to die from an infectious disease, as well. 


For those who don't care about prisoners, though, think about this: since 95% of then return to the free world eventually, that means there's already an epidemic in communities with high rates of poverty, unemployment, homelessness, felonization, incarceration, uninsured persons, IV drug addiction, HIV/AIDS, and other compromised populations. It also disproportionately affects people of color, the LGBTQ communities, and Baby Boomers. That's a huge public health problem that no one in Arizona likes talking about - why are they so silent now, I wonder? Surely they've heard this by now.

It sounds like it's time for the AZ DOC and Wexford to re-write their Hep C treatment protocols, in any case, in order to assure that the standard of care they provide to prisoners with the virus (HCV) is consistent with the community's new standard. Otherwise, they can both expect to be named in a new class action lawsuit soon, I'm sure. I'd think the public at large could even sue the state for having an infected population unleashed on us - uneducated, untreated, unsupported, uninsured, and unwell.

remembering those we have already lost...

  

we must accelerate the fight for the living.

Fight the spread of HEP C today: 

support PHRO (Phoenix Harm Reduction Organization)

Phoenix Art Museum: Art of Resistance

Prisoners' Justice Day Guerilla Installation

August 10, 2012

--------from the San Francisco Chronicle----------

Hepatitis C fight - 'watershed moment'

Erin Allday / San Francisco Chronicle

Tuesday, September 11, 2012

Earlier this year, an editorial in the New England Journal of Medicine declared that the world was in a "watershed moment" in the history of treatment for hepatitis C, a virus that is believed to infect roughly 180 million people globally. Dr. Warner Greene, director of the Gladstone Institute of Virology and Immunology in San Francisco, agrees wholeheartedly - and believes that with recent advances in treatments and a cure, the world could be on the cusp of nearly wiping out the virus.

Q: What does the hepatitis C virus do to the body?

A: This is an RNA virus that infects hepatocytes, cells in the liver. That's why you ultimately get hepatitis, or inflammation in the liver, and that can progress on to cirrhosis. About 20 percent of people spontaneously clear the hepatitis C virus, and of the rest, about 20 to 25 percent will progress to cirrhosis, and eventually end-stage liver disease. Hepatitis C is the leading reason behind liver transplants in the United States.

Q: For many years, hepatitis C has been treated with interferon. What is interferon?

A: Interferon is a type of protein called cytokine. It normally triggers an antiviral response in the body. It inhibits key steps in the (hepatitis C) virus life cycle that allow it to replicate. But it's doing it at a cost. Cytokine is pretty toxic. It makes patients very sick.

Q: Last year the Food and Drug Administration approved new drugs to treat hepatitis C. How do they work?

A: It's just like with HIV - you're attacking multiple, key proteins needed for the hepatitis C virus lifecycle. Now you have these small molecules that are attacking the virus itself, as opposed to trying to induce an antiviral response, like with interferon.

These drugs are proving to be just dynamite. We're very close to being able to cure everybody of hepatitis C. The natural history of hepatitis C virus infection has been fundamentally changed.

Q: Why has hepatitis C been so hard to treat historically?

A: One thing that limited progress was the lack of an infectious molecular clone to use in the laboratory to test drugs. It was only in the last few years that an infectious molecular clone came out of Japan. Before that, none of them fully replicated (in the lab). When the molecular clones came along progress just took off at light speed.

Then the blueprint for working on HIV became very informative - protease inhibitors, polymerase inhibitors, they were all targeted very quickly, by multiple pharmaceuticals. Many of the pharmaceuticals just moved their HIV discovery teams into HCV. Progress has been made so rapidly here because the trail had been blazed by all of the HIV drugs.

Q: Will we be able to wipe out hepatitis C entirely?

A: In contrast to HIV, we do have the capability of doing that - essentially curing everyone who got infected. While we have made tremendous progress against HIV, we still don't have a cure, we still don't have a vaccine. The situation for HCV is dramatically different. A cure is achievable. Someday soon, the cure using an interferon-free cocktail is going to be routine.

Then it becomes more of an implementation issue - how you distribute these drugs, what you charge for them. There are 180 million people infected worldwide, five to six times the size of the HIV epidemic, and many are living in resource-poor settings. We're going to have to figure out how to deal with the developing world.

Hepatitis C drugs offer hope for cure

Erin Allday / San Francisco Chronicle

Updated 4:09 p.m., Wednesday, September 12, 2012

Scientific breakthroughs, one piled on top of another at breakneck speed over the past few years, have put medical researchers on the cusp of curing almost everyone who suffers from hepatitis C, if not wiping out the disease entirely.With 180 million people in the world thought to be infected with the virus - 12,000 of them in San Francisco alone - that's potentially a huge public health coup, doctors and scientists say.

In a little more than a decade, a virus that was once almost untreatable could be made nearly extinct.
"It is just a remarkable moment in the history of hepatitis C," said Dr. Warner Greene, director of the virology and immunology division at the Gladstone Institute in San Francisco. "I think hepatitis C and its sequela - liver cancer, cirrhosis, liver transplants - can largely be gone in the future. We just won't have to worry about it."

In the past year, new treatments have come out that already have doubled the number of people who can be cured of hepatitis C. Now the race is on among drug developers to market the first medical cocktails that would cure almost everyone on the planet, and do it safer and faster than the best treatments currently available.

New treatments - both those already available and those expected to be approved in the next five or so years - were a large part of the reason the U.S. Centers for Disease Control and Prevention recommended this summer that all Baby Boomers get screened for hepatitis C.

That generation is thought to have the largest number of undiagnosed cases of the disease, with so many of them potentially exposed to the virus in the wild, drug-friendly hippie years of the '60s and '70s. Until recently it wasn't practical to screen millions of people for possible cases of hepatitis C because few good treatments were available.

Hepatitis C's spread

Hepatitis C is a virus transmitted through the blood, similar to HIV. It's often spread through shared needles used by intravenous drug abusers. Decades ago, and even still in some developing parts of the world, people were exposed to hepatitis C through unsterilized equipment used for tattoos or surgical procedures. Also, the U.S. blood supply wasn't screened for hepatitis C until the early 1990s, so people sometimes became infected from a blood transfusion or organ transplant.

In roughly 20 percent of hepatitis C cases, the body's immune system fights off the virus without any medical intervention and probably without the individual ever being aware of having it. The remaining cases develop into chronic hepatitis C.

In some of those cases, the virus may lie dormant for decades, or even a lifetime, but in about 1 in 5 chronic cases, the virus will attack the liver, scarring it and causing cirrhosis, and potentially leading to liver cancer and liver failure. The infection causes about 10,000 deaths a year in the United States, and it's the leading reason for liver transplants. Hepatitis C is especially prevalent in people who also have HIV infections; in fact, HIV-positive patients are more likely to die of hepatitis-caused liver disease than of AIDS or HIV.

Antiviral drugs

It's only in the past seven years or so that doctors and scientists discovered the first antiviral drugs that can stop the virus, giving the body's natural immune system a chance to fight it off. The cure rate with those drugs is 75 to 80 percent, but they require that patients also take interferon, a toxic medication that can cause disabling side effects for a year.

In the next five years, researchers expect to develop even more potent antiviral medications - drugs that will cure more than 90 percent of patients, and do it in half the time and without the interferon.

"There's no question that with these new treatments, cure is going to be the rule and not the exception," said Dr. Brad Hare, medical director of the HIV/AIDS ward at San Francisco General Hospital, who studies HIV and hepatitis C co-infections. "It's more important than ever to identify people with hepatitis C, because we have something even better to offer them."

That said, Hare added, it's unlikely that the virus will ever be eradicated. There will always remain a pocket of people who don't respond to drug therapy or aren't able to take it for some reason. Those who have been cured can be reinfected.

And getting new medications to the tens of millions of people affected by hepatitis C won't be easy, especially because the drugs will almost definitely be expensive.

Strains on the system

Just screening the millions of Baby Boomers in the United States, and getting those who test positive for hepatitis C into treatment, could be an overwhelming strain on the health care system, public health experts say. Drugs in development could ease some of that burden if they're easier to take and more effective than the current treatments.

Hepatitis C was discovered in the late 1980s, although scientists had known for years that a virus existed that was causing inflammation in the liver and that wasn't the hepatitis A or B viruses.

The U.S. Food and Drug Administration approved the first treatment for hepatitis C - the chemotherapy drug interferon - in 1991, and added a second drug, ribavirin, in 1998. Those two medications were considered a breakthrough therapy for a virus that had previously been untreatable, but the treatment itself was rough and not all that effective.

The ribavirin comes in pill form, but the interferon has to be given intravenously three times a week for 48 weeks. Both drugs, especially the interferon, often come with awful side effects - major depression and, sometimes, suicidal thoughts, plus fatigue, nausea and flu-like symptoms.

And the worst of it is that the treatments lead to a cure only roughly half the time - less than half for patients with the most common strain of hepatitis C.

"A lot of us didn't have bad symptoms before we went on treatment," said Daniel Berrner, a San Francisco resident who was diagnosed with both HIV and hepatitis C in 2005, and underwent successful treatment for the latter in 2009. "People maybe feel some fatigue, but that's it. So to convince them to feel awful for a year when they're not feeling that bad to begin with is a really hard thing to do."

Because treatment was, for many people, tougher to endure than the virus itself, many doctors over the years have "triaged" patients by performing liver biopsies or blood tests to determine if hepatitis C was causing severe enough damage to treat even at the risk of failure. If patients weren't experiencing acute symptoms and their livers seemed relatively healthy, they'd often postpone treatment.

More seek treatment

Whether to get treatment for hepatitis C is still a personal decision and best made after a thoughtful conversation with a primary care doctor or a liver expert, doctors said. But increasingly patients are being encouraged to get treatment, even if their infection isn't particularly virulent.

"I still try to triage based on the risk of end-stage liver disease. But now more patients are willing to be treated," said Dr. Natalie Bzowej, a liver disease specialist at California Pacific Medical Center.

Bzowej helped lead national research into one of the first antiviral treatments that targeted hepatitis C, a protease inhibitor called telaprevir made by Vertex Pharmaceuticals, which was approved by the FDA in June 2011. A similar drug, boceprevir from Merck, also won FDA approval last year.

Remarkable success

In clinical trials, about 80 percent of patients with the most common strain of hepatitis C who took one of those drugs, plus the usual interferon and ribavirin combination, were cured. That was a remarkable improvement over the previous 40 to 50 percent cure rate.

Also encouraging: Most of the patients who were cured were able to stop taking the medications after just 24 weeks, cutting the treatment time in half.

The reason for the difference is that the new drugs single out the hepatitis C virus specifically, whereas the interferon and the ribavirin essentially just give a boost to the body's natural immune system. For many people, the immune system is not strong or fast enough on its own to fight off the virus.

Protease inhibitors are best known as a class of drugs used to treat HIV infection. They work by attacking specific enzymes, or proteases, in a virus that are a key part of the replication process. By inhibiting those enzymes, the virus is unable to reproduce and eventually dies off.

Now, scientists are looking for the next line of drugs to attack other points of the hepatitis life cycle. The pharmaceutical industry is racing toward clinical trials - companies battling to be the first to get new drugs, especially those that would make interferon obsolete, to the market.

Multidrug attack

Doctors and scientists alike expect the first of the new wave of drugs to be available in four or five years. Part of the reason not everyone can be cured of hepatitis C is that, like many viruses, it mutates so quickly and becomes immune to drugs. So ideally, doctors will have at their disposal several drugs - maybe dozens - that will attack the virus on several fronts at once.

If those drugs are strong and fast enough, they could cure patients without the need for interferon. Protease inhibitors and other antiviral drugs aren't without side effects, but the symptoms are much less severe than those from interferon, and the newest classes of drugs may work in as little as 12 weeks, or about half the time it takes telaprevir, the protease inhibitor, to do the job.

"I feel like we are glimpsing the beginning of the end for hepatitis C," said Dr. Cami Graham, vice president of global medical affairs at Vertex. "We really are beginning to see what that path to eradication is going to look like."

Long incubation period

Both drug developers and doctors alike said they are advising patients not to raise their hopes too high. Almost all of the clinical trials are in their earliest stages, and for the Baby Boomers especially, patients with decades-old infections may not have even a few years to wait for new treatments.

"What we have now is better than anything we've had in a long time," said Dr. Joanna Ready, chief of gastroenterology at Kaiser Santa Clara. "What will be even better is interferon-free therapies, and the early studies have been very, very, very promising. But the disease has such a long incubation period and damages the liver over decades, so we really need to be following people over time.
Still, Ready said, she's hopeful.

"If we don't wipe out hepatitis C entirely, we can probably make it go away like polio, where you haven't gotten rid of it but you've really beaten it down," she said. "The science behind these treatments is improving every day. And the more we know, the better we are at treating it."

Erin Allday is a San Francisco Chronicle staff writer. E-mail: eallday@sfchronicle.com 

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

FIGHT THE SPREAD OF HEP C TODAY. 

 Phoenix Harm Reduction Organization (PHRO)

Terminating harm reduction hope in CALI.

Very disappointing news from Stopthedrugwar.org. This man just condemned countless more people to die unnecessarily from Hep C - and to infect others until they do. I think he's pandering to the conservative communities who don't want to allow needle sales - they don't really seem to care much if a bunch more addicts die...until the one that gets Hep C or HIV from a dirty needle ends up being their kid.


I'd love to set up a needle exchange program in Phoenix. Since Sheriff Joe doesn't run the county health department he really shouldn't get the final word on that. The legislature and Governor will need to support it, though. I'm not sure what it would take to win them over. It won't be easy.

Schwarzenegger also vetoed a bill that the legislature passed unanimously that would have prohibited the shackling of pregnant prisoners - particularly during labor - even those in on non-violent offenses. I don't understand that one at all, except that he has absolutely no concept of what a woman goes through. How are we a threat to public safety when giving birth?

There are far too many ignorant people in power in this nation today.

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

California Governor Vetoes Needle Access Bill

By psmith

Created 2010/10/06 - 8:27pm

by Phillip Smith [1], October 06, 2010, 08:27pm, (Issue #652 [2])

California Gov. Schwarzenegger could have made syringe sales to adults legal throughout the state in a bid to reduce the transmission of HIV and Hep C. Instead, he chose to extend a program leaving it up to cities and counties. 

 

Gov. Arnold Schwarzenegger (R) last Thursday vetoed a bill that would have allowed pharmacies all over California sell syringes to adults without a prescription. The bill was touted by health experts as a key step in reducing the transmission of HIV/AIDS, hepatitis, and other blood-borne diseases.

mobile needle exchange/clinic site, Fresno

 

The state Department of Public Health estimates that approximately 3,000 California residents contract hepatitis C through syringe sharing every year and another 750 cases of HIV are caused by syringe sharing. Sharing dirty needles is the leading cause of new hepatitis C infections in the state and the second leading cause of new HIV infections.

"When I signed legislation my first year in office allowing for a pilot program to allow the sale of syringes through participating counties and registered pharmacies, I was seeking to balance the competing public health, law enforcement and local control issues that this issue requires," the governor wrote in his veto message [8]. "I believe this balance was achieved and SB 1029 [9] would remove the ability of local officials to best determine policies in their jurisdiction. Some counties have not sought to implement this pilot program, citing competing priorities, lack of pharmacy interest and law enforcement opposition. I respect these local decisions and while I appreciate the author’s hard work and dedication to this issue, I cannot sign this bill," Schwarzenegger wrote.

Instead, Schwarzenegger signed AB 1701 [10], which extends the existing Disease Prevention Demonstration Project for another eight years. That gives cities and counties the option of opting out of the program and not allowing syringe sales without a prescription.

The veto angered SB 1029 author Sen. Leland Yee (D-San Francisco), who in a statement last Friday said Schwarzenegger apparently "was not interested in an effective public health measure that would reduce health care costs to taxpayers. Not only did he ignore the recommendation of doctors and other health experts, but he ignored the fact that HIV-AIDS and hepatitis do not recognize county borders. Such epidemics are certain to continue without implementing these comprehensive strategies."

SB 1029's approach "has been evaluated extensively throughout the world and has been found to significantly reduce rates of HIV and hepatitis without contributing to any increase in drug use, drug injection, crime or unsafe discard of syringes," Yee continued. "In fact, there is not one credible study that refutes these findings. The governor’s veto is a moral and fiscal dilemma."

The veto was "tragic and infuriating," said Laura Thomas of the Drug Policy Alliance [11], which supported Yee's bill. "It is an irrational attachment to drug war hysteria, at the expense of human life and fiscal responsibility to the California taxpayer," she said. "Nothing would have worked better and cost less in reducing the spread of HIV and hepatitis C than SB 1029."

 

StoptheDrugWar.org • 1623 Connecticut Ave., NW, 3rd Floor • Washington DC 20009
Phone (202) 293-8340 • Fax (202) 293-8344 • Email • Privacy Policy

---

Source URL: http://stopthedrugwar.org/chronicle/2010/oct/06/california_governor_vetoes_needl

Harm Reductionists denied "medical necessity" defense for needle exchange.

These two courageous activists trying to stop the spread of Hep C and HIV in the community through an unauthorized needle exchange program have already been hit with sanctions by employers and licensing boards, and are now facing up to a year in jail. I believe their trial has been set for February 2011. This is actually an update - see the previous post on this story for more background

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

URL: http://www.mapinc.org/drugnews/v10/n368/a11.html
Newshawk: Syringe Exchange Facts www.drugwarfacts.org/cms/node/66
Votes: 1
Webpage: http://mapinc.org/url/8LwY8ths
Pubdate: Tue, 18 May 2010
Source: Modesto Bee, The (CA)
Copyright: 2010 The Modesto Bee
Contact: letters@modbee.com
Website: http://www.modbee.com/
Details: http://www.mapinc.org/media/271
Author: Merrill Balassone
Bookmark: http://www.mapinc.org/find?137 (Needle Exchange)

RULING HURTS IN MODESTO NEEDLE EXCHANGE CASE

A judge ruled Monday that two people arrested for handing out clean syringes to drug users and collecting dirty ones will be barred from telling a jury they did so to help prevent a public health emergency.

Kristy Tribuzio, 36, and Brian Robinson, 38, face up to a year in jail after undercover officers said they caught the two operating an unauthorized needle exchange in a south Modesto park in April 2009.

Stanislaus County Superior Court Judge Ricardo Cordova said the pair had other options that were legal, such as lobbying local officials to change the law. In September 2008, the county Board of Supervisors voted against legalizing needle exchange programs over the recommendation of county health officials.

"Frankly, this is a political decision with which the defendants disagreed," Cordova said.

Tribuzio called Cordova's decision "insulting."

"This doesn't have anything to do with politics," she said. "It's a public health issue."

During a nearly two-hour hearing, Tribuzio and Robinson's defense team argued their clients were acting out of medical necessity: that conducting a needle exchange program was a justified act aimed at saving lives and preventing such diseases as HIV and hepatitis C among drug users.

Nearly two dozen needle exchange activists from Oakland, Sacramento, Fresno and Modesto were in court for the ruling.

Tribuzio's attorney, Alonzo Gradford, likened the rate of new hepatitis C cases in Stanislaus County -- nearly 12 per week -- to a ticking bomb.

"People are dying every day as a result of dirty needles," Gradford said. "That's an imminent emergency."

Prosecutor Merrill Hoult said the defendants knew what they were doing was illegal and operated the needle exchange as an act of civil disobedience.

"We have a systematic breaking of the law," Hoult said. "Needle exchanges may have been legal in other counties, but it's illegal here."

In California, there are more than 40 needle exchange programs, but the Central Valley has just three, according to the state Department of Public Health. Fresno County approved a needle exchange pilot program in December 2008.

Robinson's attorney, Ruben Villalobos, described the scene in Mono Park on a recent afternoon. He said he and an investigator found four dirty needles left in the park, nicknamed "Needle Park" and "Heroin Park."

"If we were in another county, what Mr. Robinson did would be perfectly legal," Villalobos said. "We as a society have decided you can't do it."

Tribuzio and Robinson will be back in court Aug. 2 for the setting of their trial date.

Scottland Prisons to Consider Tattoo Parlors.

This would go so far to stem the spread of Hep C and HIV in prison. Leave it to Europe to set the trends in harm reduction - America could take years to catch up, by which time thousands more will die...

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

Call for prison tattoo parlours

• 
• Lucy Adams

12 Aug 2010

Scottish prisoners would have access to their own tattoo parlour under proposals being considered by officials.


A report commissioned by the prison service has found widespread problems with infections such as Hepatitis C partly because inmates are tattooing each other without the appropriate equipment.


The study – which depicts a diagram of how to make a tattoo gun from materials available to prisoners such as toothbrush handles, pens, glue, guitar strings and lighters – recommends the “piloting of a tattoo studio within one of the long-stay prisons”.


Dona Milne, the author who was seconded to the Scottish Government at the time, suggests there is a need to increase prisoner education on tattooing risks, make available clean materials and where possible consider introducing tattooing parlours. The prison service is still considering the proposal.


According to the report, Hepatitis C affects 16% to 20% of Scottish inmates and 45% to 54% of prisoners who have been, or currently are, intravenous drug users.


In 2008, some 54% of Scotland’s 8000 prisoners said they had a tattoo and 18% of them said they had it done while in prison. In long-stay prisons such as Shotts the proportion who received their tattoo while in jail was 28%.


Most staff said stopping illicit tattooing would be very difficult. Five out of 10 of the prison officers interviewed for the study recognised the “benefits of having a professional tattoo service available” run by prisoners or someone externally, according to the research. However, there was concern about allowing needles into prison.


One prisoner interviewed for the study had received 18 different tattoos while behind bars.


The report states: “The main reasons for getting a tattoo whilst in prison were boredom, cheaper than outside prison, others were getting one and that they had seen the work of the tattooist on someone else.


“Prisoners were asked if they had paid for the tattoo. If the tattoo was done by a friend it was usually for free. However, there was a charge if it was done by another prisoner.


“Where payment was made it was usually in the form of tobacco, although some did involve small amounts of cash payments.”


Inmates had completed up to 200 tattoos on other inmates while in prison – despite the fact the practice is illegal in jail.


Many said they were conscious of the risks of infections such as HIV and most said they took precautions – such as decanting ink into a toothpaste tube lid to avoid sharing ink.


Inmates said they also tried to sterilise equipment – sometimes using prison cleaning fluids – but most thought injecting was much riskier than having a tattoo.


Of the prisoners interviewed most wanted to see an official body art service within prison but they pointed out that for those who could not pay illicit tattooing would continue.


The report states: “Prisoners reported a high level of tattooing activity undertaken with homemade tattoo guns made from a range of components available in the prison setting.


“Prisoners also reported attempts at cleaning equipment and avoiding infection through changing equipment and not sharing ink. There was a good level of understanding of the risks of blood borne virus infection and how this could be prevented, although this knowledge was not always applied in practice.”


A spokesman for the prison service said: “The Scottish Prison Service has a duty of care to the prisoners it holds.


“This research reflects the concern for the practice of tattooing in prison and the potential risks this presents.


“The research and its conclusions will be considered by SPS as part of its ongoing general programme to maintain the health of the prison population.”

Harm Reduction, the Vienna Declaration, and the US War on Drugs

A note of much-needed Hope.

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

HIV and the U.S.-led war on drugs

By Evan Wood
Los Angeles Times
(As printed in the Denver Post)

Posted: 07/30/2010

Last week, thousands of scientists, physicians and activists fighting the HIV and AIDS pandemic around the world gathered in Vienna to discuss the latest breakthroughs — and frustrations.

There were reports on several landmark studies describing the crucial role that treatments can play in reducing the infectiousness of HIV-positive individuals. And there was encouraging news from Africa, where a study found that an intra-vaginal anti-viral gel could reduce the risk of HIV infection among women who used it by 40 percent.

But there was also sobering news at the 18th International AIDS Conference, including stark evidence of how the HIV epidemic is raging unchecked among some populations of illicit drug users.

Vienna was selected to host the biannual meeting of HIV experts because it is the gateway to one of the world's most rapidly growing HIV epidemics: that among heroin users in Eastern Europe. Outside sub-Saharan Africa, about one in three new HIV infections stems from injecting illegal drugs, and in some parts of Eastern Europe and Central Asia, 70 percent of those who inject illicit drugs are infected with the virus.

In response to these alarming statistics, this year's conference endorsed as its official statement the Vienna Declaration, a document I helped draft to draw widespread attention to how the U.S.-led war on drugs has played a central role in driving the HIV epidemic around the world.

Writing in the medical journal the Lancet, where the Vienna Declaration was also published, Michel Sidibe, the executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS) and other prominent scientific leaders stated the situation succinctly: "The war on drugs has failed."

Criminalizing drug abuse drives addicts deeper underground and into the kinds of unsafe practices such as needle-sharing that spread infection. We have seen clearly that countries with the most draconian drug laws also have the highest rates of HIV infection among users.

In Russia, for example, where one in 100 adults is now estimated to be HIV-infected, a fierce drug war has outlawed basic harm reduction tools, such as methadone maintenance treatment. Methadone is on the World Health Organization's list of essential medicines, but Russian physicians cannot even openly discuss the need to prescribe the treatment without fear of reprisals.

The mass incarceration of drug users is particularly alarming, given the spread of HIV in prisons. A Pew Trusts analysis of U.S. Department of Justice data noted that one in nine black males age 20 to 34 is in prison, many of them as a result of drug law enforcement.

Given the link between prisons and HIV, it is not surprising that in places such as Washington more than 80 percent of HIV cases identified between 2001 and 2006 were among blacks.

Beyond HIV and AIDS, the declaration also notes that the war on drugs is ineffective.

"National and international drug surveillance systems have demonstrated a general pattern of falling drug prices and increasing drug purity — despite massive investments in drug law enforcement." In just a few short weeks since being made public, the Vienna Declaration has been endorsed by more than 13,600 individuals, including five Nobel laureates and various other global leaders in science, medicine and public health.

There also have been signs that the world may be heading toward more reasoned drug policies. Just before the Vienna conference, the Obama administration announced overdue and welcome steps to help fight the HIV epidemic among drug users. Most important, given the strong support for syringe exchange programs from the U.S. Institute of Medicine and WHO, the administration has reversed a longtime ban on funding clean syringe programs.

But there is still much that needs to be done. The Vienna Declaration calls for governments to "implement and evaluate a science-based public health approach to address the individual and community harms stemming from illicit drug use."

Not surprisingly, considering that strident special-interest groups have long misled U.S. voters into believing that the drug war is an essential crime-reduction tool, most government delegations at AIDS 2010, including the U.S. government delegation, remained largely silent on the Vienna Declaration.

Decades of worldwide drug-related violence have made clear that drug prohibition enriches organized crime and causes bloodshed. But the devastating public health consequences of the drug war have been less recognized, and government acknowledgement of the link between the war on drugs and the HIV epidemic is urgently needed. The next International AIDS Conference will be in Washington in 2012. Before that meeting, governments around the world will be asked to state a formal position regarding the declaration.

In the meantime, the declaration also asks for several noncontroversial steps, including that governments "undertake a transparent review of the effectiveness of current drug policies." Given the international public health emergency presented by HIV among drug users and the estimated $2.5 trillion in tax dollars wasted on the drug war over the last 40 years, the U.S. should move forward with this simple call.

——— ABOUT THE WRITER Evan Wood, a physician and associate professor of medicine at the University of British Columbia, directs the Urban Health Research Initiative at the BC Centre for Excellence in HIV/AIDS. He wrote this for the Los Angeles Times.

Prison Health is Public Health: UN

Got this from the UNSHACKLE list-serve - join it if you haven't already and are serious about these issues. This argument also applies to Hepatitis C - only it's even more infectious and prevalent than HIV/AIDS...

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

UN warning on AIDS in prisons

By VERONIKA OLEKSYN

Associated Press Writer

VIENNA (AP) -- The U.N.'s top investigator on torture and punishment warned Friday that overcrowded prisons are breeding grounds for AIDS.

Often, inmates are held in inhumane conditions in which the HIV virus is spread through the use of non-sterile drug injection equipment, sexual contacts, tattooing and sharing of razors, Manfred Nowak said.

"There is a global prison crisis," he told an international AIDS conference.

Nowak, who has visited detention facilities around the world, urged authorities to inform prisoners of the risk of HIV transmission and to offer them free condoms, HIV testing and counseling. He also pressed prisons to offer needle and syringe programs, opiate substitution therapies and methadone treatments.

"Science tells us exactly what we have to do, it's just a question of political will to implement it," Nowak said.

In addition, prison guards should live up to their obligation to prevent rape and other forms of coercion that thrive in packed environments.

"One of the most important measures to prevent HIV transmission would be the reduction of overcrowding," since it leads to violence and conditions that are conducive to the spread of the virus, he added.

Nowak said that, although reliable figures are hard to come by, the prevalence of HIV in prisons is generally much higher than in a country's wider population.

In Ukraine, for example, the prevalence of HIV in prison is at least 10 times that of the overall population, he said.

Dmytro Shermebey of the All-Ukrainian Network of People Living with HIV/AIDS - who was diagnosed with HIV, tuberculosis and hepatitis after spending nine years in a Ukrainian jail - stressed that inmates have a right to both treatment and protection from the disease.

"They have the right because they are human," Shermebey said.

While about 10 million people are incarcerated every year, some 30 million enter and leave prisons annually - making it a public health problem for society, according to Nowak.

"Prison health is public health," he said.

Victorian Harm Reduction: prison needle exchange.

Prisoners should have needle exchange

Sydney Morning Herald
June 22, 2010

AAP

Needle exchange programs should be introduced in Victoria's prisons to reduce the transmission of blood-borne viruses, the Australian Medical Association's Victorian president says.

Dr Harry Hemley said needle exchange programs in the wider community had significantly reduced the spread of Hepatitis C and other blood-borne viruses.

About 35 per cent of prisoners tested positive to Hepatitis C but intravenous drug users in prisons were still denied access to safe injecting equipment, Dr Hemley said.

"Prisoners deserve the same rights to access and quality of health care as the wider community, this includes access to a needle exchange program while in detention," Dr Hemley said in a statement on Tuesday.

"Illicit intravenous drug use is harmful and risky but unfortunately is common in Victorian prisons," he said.

"What we need to focus on, from a health perspective, is reducing the risks to detainees, prison staff and the public by reducing the spread of blood-borne viruses through sharing contaminated injecting equipment.

"Most prisoners will join the wider community on release, so reducing the spread of blood borne viruses in prisons will also impact on transmission in the wider population."

Dr Hemley said detoxification facilities should also be available to prisoners to manage substance abuse problems.

Harm Reduction in Prison: Under the Skin

We need to be organizing more programs like this here, too. Pretty cool that they went around interviewing the prisoners instead of letting all the "experts" speak for them...

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

Under the Skin: A People’s Case for Prison Needle and Syringe Programs

What do people in prison have to say about the Canadian government’s unwillingness to permit the distribution of clean needles in prison?

Between 2008 and 2009, interviews were conducted in person and over the phone in British Columbia, Alberta, Manitoba, Ontario, Quebec, New Brunswick and Nova Scotia, resulting in sworn affidavits or testimonials from 50 individuals who have used drugs or shared needles in a federal prison. The hope is that their stories will strengthen the case for change, which governments continue to ignore even as a growing body of evidence highlights the need.

The Legal Network is not alone in calling on the federal government to implement needle and syringe programs in Canada’s prison. Our position is supported by the Canadian Medical Association, the Ontario Medical Associations, the World Health Organization, UNAIDS, the UN Office on Drugs and Crime, the Correctional Investigator of Canada and the Canadian Human Rights Commission. Furthermore, a 2006 review of the scientific evidence by the Public Health Agency of Canada concluded that prison-based needle and syringe programs have largely positive outcomes for the health of people in prison.

www.aidslaw.ca/
undertheskin

Published On	2010-02-02
Author	Canadian HIV/AIDS Legal Network
Topics	Prisons, Drug Policy and Harm Reduction
Document Type	Reports
Language	English
Doc Id	1594

World Hepatitis Day: Pushing Harm Reduction

Few of you know that I've had a family crisis of late, and thus I haven't posted or even begun to write about last week's candlelight vigil at the AZ Department of Corrections. I've been kind of homeless since that night, living out of a storage unit and hotel room with my brother; before we run out of money we're heading off to camp along the Mogollion Rim. 

I'll try to write and post on May 19 before then ( here's some photos, at least) - I know that timing is important but this is just a blog and I'm only human. Besides, content matters, too, and the event really deserves better focus than I can give it under the conditions. Actually, I'm recovering from an assault perpetrated by an intoxicated friend. There are quire a few things going on, really - life is so complicated, is it not?

Here's my awesome display, by the way - it's got all sorts of Spanish language literature and promotes harm reduction. I was counting on our friens across the street coming over.

What I can say about the vigil at this point though, is that I was a lot more open to what a gathering of resistance at the ADC could be like this time, and amazed at what actually happened. People started telling their stories after Julie told hers. Somehow she just manages to mke those connections.

There were blessings exchanged between our usual suspects and the Indigenous and Latino groups who came over to join our protest, people embracing each other across language and cultural differences and connecting on a common understanding of what constitutes human rights - which includes medical treatment for prisoners. There was even sage and incense - we were both blessed ad smudged.

We gave them some literature (I had some printed up in Spanish) and expressed our solidarity with their cause (Repeal ALL that hateful AZ legislation). A good number of the folks who joined us are the hard core activists who have been keeping the 24/7 vigil at the capitol for the group.

The great thing about that whole night was that my big brother was narrating and interviewing people through the crowd over the course of the evening. Even when I'm in heated protest and he's my cameraman, he's busy looking for the light in people, catching them smile the moment they realize how good it felt to do the right thing - like drop me a few quarters when I was panhandling. I expected pictures of the people who turned their heads that day in irritation - Bill gives me the ones full of grace or love. 

I need to figure out how to edit the tape from Hepatitis Day for you so you can see it yourselves, and hear these stories... 

Anyway, once I saw it through my brother's eyes, I knew what magic had happened that night.That's what this vigil was all about - showing our ability to be there for each other, letting other folks with Hep C, families of prisoners, and potential victims of the state know that others are out here, care about what's happening, and that we're in it for the long haul - even if they're unable to be public. 

 
I guess enough said on that for now. We prayed and laughed and hugged and cried. And we simmered. Here's the more coherent press releases from SF and DC about what they did.

- Peg 

A welcome home hug from Julie.

-------------------------------------------------from www.hivandhepatitis.com---------------------------------

Advocates Rally in San Francisco and Washington to Raise Awareness and Demand Funding for Hepatitis B and C

		SUMMARY: Hepatitis advocates gathered in San Francisco and Washington, DC, on May 19 -- World Hepatitis Day -- to bring attention to chronic hepatitis B and C and to call for increased funding for public education, testing, treatment, and care. Speakers described their experiences with stigma, difficulty accessing treatment, and side effects and suboptimal effectiveness of current hepatitis C therapies, while expressing hope for new directing-acting HCV drugs that are expected to start becoming available in the next couple years.

By Liz Highleyman

Nick Panagopoulos (at podium) presents mayoral proclamation recognizing World Hepatitis Day to SF Hepatitis C Task Force co-chairs Randy Allgaier (left of podium) and Dominique Leslie. (Photo: Liz Highleyman)

"We're here to give a voice and a face to a disease that remains in the shadows," said Randy Allgaier, co-chair of the [San Francisco Hepatitis C Task Force[http://www.hepcsf.org], speaking from the steps of City Hall. "San Francisco must move out of the shadows of this silent epidemic, because as we learned with HIV, silence equals death."

The local rally brought out about 50 activists under an unseasonable light rain.

Nick Panagopoulos from the office of Mayor Gavin Newsom -- who spearheaded the creation of the task force -- and Alex Randolph, aide to Supervisor Bevan Dufty, both presented proclamations recognizing World Hepatitis Day.
While the rally focused on hepatitis C, Allgaier applauded the new Hep B Free campaign which aims to raise awareness among the city's large Asian community, a group at especially high risk for hepatitis B.

Task force co-chair Dominique Leslie related her journey with hepatitis C, reflecting issues faced by many people with the disease. Leslie was diagnosed with non-A/non-B hepatitis in 1988, the year before the hepatitis C virus (HCV) was discovered. At the time, she was told not to worry and that she didn't need to do anything. By 2000, she began to develop symptoms of liver disease, but was told they were not due to HCV. Since then, she said she has been denied treatment twice because she is transgender, and she is now on the liver transplant waiting list.

"I joined the task force so other people don't have to go through what I face," she said. "I've been clean and sober for more than 20 years, but active drug users are being denied treatment and access to clinical trials."

Other speakers represented the diverse face of hepatitis C. Todd is an HIV positive former methamphetamine user who never used needles and believes he got HCV through sex. Today he is clean and sober, and both his HIV and HCV are undetectable, but "it was no picnic getting there," he said. 

Robin, an older woman who was diagnosed with hepatitis C years ago, has been free of the virus for 8 years with the help of holistic therapy including acupuncture. "HCV is the first virus for which we have a cure, but unfortunately the treatments are very difficult and they don't work for everyone," she said.

Jack and Havoc are 2 young men involved with UCSF's UFO Project for young injection drug users. Jack started interferon, but lasted only 3 months due to side effects; against all odds, however, he managed to clear HCV anyway. But Havoc, a member of San Francisco's new Drug Users Union, lacks permanent housing, has not been able to get on interferon treatment, and his liver disease is progressing.

Finally, Karen Aziz compared her experiences as a woman dually diagnosed with hepatitis C and breast cancer. When she learned she had breast cancer, she recalled, she was told about all the available treatment options and referred to a support group. 

"Companies sponsor walks for research, you see uplifting commercials, patients are lauded as heroes, and everyone shows compassion," she said. "It's quite the opposite for hepatitis C. "No company wants to sponsor a race for the cure for this disease. Our struggles are secret, silent, and lonely. We need funding for full medical care for everyone who needs it so a diagnosis of hepatitis C need not be a death sentence."

---

Below is a press release from the National Viral Hepatitis Roundtable about the Washington rally.

On World Hepatitis Day 2010, NVHR Capitol Hill Rally Attracts
Hundreds of Americans & Five Members of Congress to
Support Increased Federal Funding for Viral Hepatitis

Washington, DC -- May 19 -- Surrounded by a diverse group of 500 Americans from the viral hepatitis B and C communities united in common purpose on World Hepatitis Day 2010, the National Viral Hepatitis Roundtable (NVHR) today hosted a Capitol Hill rally urging swift action to fix the federal funding crisis for 5 million Americans afflicted with chronic viral hepatitis. With the support of a boisterous crowd, NVHR was joined by five Members of Congress, Congressmen Hank Johnson (D-Ga.), Mike Honda (D-Calif.), Charles Dent (R-Pa.), Anh "Joseph" Cao (R-La.), and Mike Cassidy, M.D. (R-La.), whom all pledged to make the promise of increased federal funding a reality this year and to address the viral hepatitis funding problem once and for all.

"NVHR has a simple and direct message for Washington: we are not going away and we will no longer be ignored. Until Congress and the Administration act once and for all to fix the funding crisis, we will be unrelenting in demanding adequate federal funding for viral hepatitis screening, education, and intervention programs for 5 million Americans," vowed Ms. Lorren Sandt, NVHR Chair and Executive Director of Caring Ambassadors Program, based in Portland, OR. "In the absence of federal leadership, the annual costs of viral hepatitis to Medicare and Medicaid could reach $85 billion in the coming decade. Swift federal action now will help millions of Americans and help mitigate an otherwise inevitable fiscal disaster. The time for action is now. Our community and our nation cannot afford any more delays."

Today's rally featured 500 Americans from all walks of life united in their cause to urge Washington to act. Representing 11 states and the District of Columbia, the rally featured speakers representing NVHR, the National Alliance of State and Territorial AIDS Directors, the District of Columbia Department of Health, Veterans Aimed towards Awareness, the Association of Asian Pacific Community Health Organizations, Community AIDS National Network, Hepatitis B Foundation, Greater Washington Viral Hepatitis Support Group, Harm Reduction Coalition, North General Hospital, Hepatitis Education Program, Chinese American Medical Society, Hepatitis B Initiative-DC, National AIDS Treatment Advocacy Project, Hepatitis C Support Project, Hepatitis C Association, and many others. The rally also featured a Silent Vigil in tribute to those individuals lost to hepatitis B or C.

Approximately 1 in 50 Americans are afflicted with chronic viral hepatitis B or C -- with most unaware they are infected, especially African Americans and Asian Americans. Without detection and treatment, chronic viral hepatitis leads to liver cancer, cirrhosis, or liver failure. In the absence of federal leadership, the research firm Milliman estimates that public and private payers' cost of treating chronic viral hepatitis C alone will more than triple by 2024 to $85 billion annually. Medicare and Medicaid would absorb a disproportionate share of these added costs.

Earlier this year, the Institute of Medicine (IOM) released a landmark report blasting the federal government for its inadequate response to this crisis. Since the January 2010 release of the IOM report, the Administration has done little to help assuage the viral hepatitis community. The Administration's budget proposal for 2011 would fund the Division of Viral Hepatitis at a level actually lower than allocated a decade ago during the Clinton Administration.

Bipartisan legislation, HR 3974, "The Viral Hepatitis and Liver Cancer Control and Prevention Act," sponsored by Representatives Mike Honda (D-Calif.), Charles Dent (R-Pa.) and 36 other House Members would correct this shortfall. The Honda-Dent legislation would increase the ability of the CDC to support state health departments in their prevention, immunization and surveillance, and referral to care efforts. Much of the Honda-Dent legislation tracks with the IoM's recommendations.

NVHR is a coalition of more than 150 public, private, and voluntary organizations dedicated to reducing the incidence of infection, morbidity, and mortality from chronic viral hepatitis that afflicts more than 5 million Americans. For more information, visit www.nvhr.org.
5/21/10

Source

National Viral Hepatitis Roundtable. On World Hepatitis Day 2010, NVHR Capitol Hill Rally Attracts Hundreds of Americans & Five Members of Congress To Support Increased Federal Funding for Viral Hepatitis. Press release. May 19, 2010.

Down Under: Working with what you've got.

And the Australians, again. I think we have a lot to learn from them. This is from the Hepatitis Australia website, http://www.hepedu.org.au/  which is designed specifically with health care professionals in mind.

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

Considerations for working with people in custodial settings

Set realistic goals in education about safe injecting practices

While people in custodial settings are in principle entitled to the same level of health care and information as the general community, in practice they are unable to adequately protect their own health due to the current constraints of the prison environment. Research indicates that the prevalence of injecting drug use in custodial settings is very high. In the general community around one percent of people inject, while in custody approximately 25% of inmates continue to inject in extremely hazardous circumstances. Prison inmates have limited access to the means of preventing hepatitis C transmission. Needle and Syringe Programs (NSPs) have not been implemented in any Australian prison. Other harm reduction measures such as peer based drug education and bleach provision are available in some jurisdictions but not all. Therefore, it is unrealistic for educators to provide detailed instruction to inmates on safe injecting practices when there are limited provisions to ensure inmates have the opportunity to implement safe practice.

Due to the fact that safe injecting practices are nearly impossible to achieve in custodial settings, alternative methods of administration should be explored such as smoking, snorting, swallowing or shafting (rectal administration). However, another deterrent to effective harm reduction strategies is the discrepancy in the type of sanctions imposed for injected as opposed to non-injected illicit drug use in custodial settings. It has been suggested that the efficacy in detecting cannabis as opposed to heroin may cause some inmates to switch to injecting routes of drug administration. 

There are some provisions to encourage safe injecting in custodial settings such as the provision of bleach and instructions about washing syringes with soapy water.

Inmates with hepatitis C also need to be provided with information on the risks associated with unsafe injecting practices and the potential for re-infection with different hepatitis C genotypes.

Evidence suggests that people with hepatitis C who are exposed to potential infectious blood can be infected with more than one genotype at a time, which can impact on the natural history of disease progression and treatment efficacy.

Considering the barriers in custodial settings, it is important that inmates are provided with information on safe injecting in the context of access to NSPs in the post release setting.

Set realistic goals in education about health maintenance

Educators need to be aware of the relevance and applicability of information provided to inmates on health maintenance activities, for example, healthy diet, exercise and managing stress. Inmates will have limited control over the food they eat and therefore, need to be provided with information that allows them to make healthy choices from the available food. Discussions about regular exercise and stress management need to be adapted to the context of custodial settings and could provide inmates with useful and tangible health maintenance advice. For example, developing an exercise program that accounts for limited space such as the inmate’s cell or at the gym could be useful.

Education programs need to be tailored to the custodial setting and take into account the resources that are available to inmates. However, people living in custodial settings still need to be equipped with relevant health maintenance information for their return into the community.

Provide practical advice about infection control principles

Tattooing and body piercing pose a particular problem in custodial settings where these procedures are often performed by untrained operators without access to sterile equipment. In addition, other potential sources of blood to blood contact include using blunt hair clippers, sharing razors injury, self harm, fighting and physical and sexual assaults. Spread of hepatitis C through sexual transmission in the context of sexual assault where blood and skin trauma both occur is a possibility.

Education programs which include practical information about the principles of infection control and all the potential sources of hepatitis C transmission could provide inmates with the ability to reduce the risk associated with blood to blood contact in custodial settings. 

People who work in custodial settings may not be interested in learning about hepatitis C beyond worksafe issues. Occupational health and safety is the responsibility of the employee’s organisation, however, hepatitis C educators may be contracted to provide specific training about hepatitis C transmission and prevention and infection control. 

Acknowledge structural barriers that may prevent access to specialist health care

Structural barriers may prevent or inhibit inmates from accessing health care including hepatitis C treatment and related specialists services such as testing and monitoring. Availability of antiviral therapy for hepatitis C is variable between the states and territories and between custodial settings in the same jurisdiction. The number of inmates treated in all Australian jurisdictions remains low. Hepatitis C treatment availability is restricted by limited correctional health budgets because the costs of hepatitis C treatment must be carried by State and Territory governments. It is also a policy issue that requires concerted lobbying to improve access to treatment for inmates.

Testing for hepatitis C using PCR technology is also limited for inmates due to financial restrictions, therefore, confirmation of a hepatitis C diagnosis may not be possible in custodial settings. Therefore, educators must consider these barriers when providing inmates with information on accessing hepatitis C treatment. At the same time, it is vital that educators provide inmates with information and guidance on accessing hepatitis C services post release from prison.

While it is important to acknowledge the structural barriers, it is vital that educators advocate for inmates to have access to health care including hepatitis C treatment, hepatitis A and B vaccination and monitoring tests such as PCR and liver function tests whilst incarcerated.

Provide adequate information for release from custodial settings

Although it is important to consider the barriers to hepatitis C education in custodial settings and to focus providing relevant information in the context of inmates’ limited access to resources and supports, it is equally as important to provide inmates with information on all aspects of hepatitis C including access to specialist treatment services, NSPs and information and support services for their release into the community. Developing specific education programs that target inmates due for release is one method of ensuring the information is provided to those that need it.

Overcoming hepatitis C education fatigue among inmates

Some inmates may experience hepatitis C education fatigue or overload, believing that they have “heard it all before” and believe they are well informed about hepatitis C. Acknowledging that some inmates are informed about hepatitis C is crucial to avoid fuelling the fatigue and subsequently turning them away from the safety message. At the same time using creative and interactive education strategies such as games, videos and knowledge quiz activities could make learning about hepatitis C more interesting.

---

National Centre in HIV Epidemiology and Clinical Research. (2006). Hepatitis C Virus Projections Working Group: Estimates and projections of the Hepatitis C virus epidemic in Australia 2006.
Ibid.

Hellard, M., Crofts, N. and Hocking, J. for the Burnet Institute: Epidemiology & Social Research Unit. (2004). Hepatitis C virus among inmates in Victorian correctional facilities: report of the prevalence of hepatitis C virus and the risk behaviours associated with the transmission of hepatitis C virus in Victorian correctional facilities.

Hellard, M., Hocking, J.S. and Crofts, N. (2004), ‘The prevalence and risk behaviours associated with the transmission of hepatitis C virus in Australian correctional facilities’, Epidemiology and Infection 132, pp. 409-415.

Anti-Discrimination Board of New South Wales (ADBNSW). C-Change - Report of the enquiry into hepatitis C related discrimination. 2001; Sydney: Anti-Discrimination Board of New South Wales.
Dolan, K. (2000). The epidemiology of hepatitis C in prison populations. In: Commonwealth Department of Health and Aged Care (Ed.), Hepatitis C: Informing Australia's National Response, 61-94. Canberra: Commonwealth of Australia.

Bowden, S., McCaw, R., White, P.A., Crofts, N. & Aitken, C.K. (2005). Detection of multiple hepatitis C virus genotypes in a cohort of injecting drug users. Journal of Viral Hepatitis; 12(3): 322-324.