Counseling and Support

Successful HCV care programs offer education and counseling, beginning at the initial screening for HCV antibodies.55-57,67-70 Counseling and education must be an ongoing part of care, regardless of whether HCV treatment is initiated. In the context of HCV treatment, these valuable services support adherence to HCV treatment and remain beneficial after treatment has been completed (see box, Essential Elements of HCV Education and Support).

HCV counseling must include an alcohol abuse component, because in some cases, abstaining from alcohol may be the most important intervention for HCV. A safe amount of alcohol intake for people with chronic HCV has not been identified.71-72 Thus, it is particularly important for providers to assess alcohol use in coinfected patients, and then offer information, resources, and support on reducing or abstaining from alcohol. Alcohol consumption, particularly more than 50 g per day (approximately four mixed drinks or glasses of wine or beer) causes and accelerates liver damage in people with HCV and increases HCV viral load, which may compromise the efficacy of HCV treatment.23,73-75 Options to help patients reduce or eliminate alcohol intake include referral to counseling, 12-step programs, alcohol treatment programs, and pharmacotherapy with naltrexone or acamprosate.76-78

Alameda County Medical Center’s coinfection clinic is an example of a successful program. One component is a weekly education and support group, which began in February 2002. Each 2-hour meeting includes lunch and an educational session, which is followed by an opportunity for members to share experiences and socialize. Initially, mono- and coinfected patients treated for HCV at other sites were recruited as mentors. After the first group participant initiated HCV treatment without serious side effects, a “snowball effect” was reported: Within a few months, six participants had started HCV treatment. Although demographically diverse, the group is quite cohesive. Participants call one another between meetings, offer each other transportation to medical appointments, and continue to visit long after they have completed HCV treatment.57-68

For reasons ranging from the nature of HCV progression to the efficacy of available treatments, as well as the cost of treatments, most people living with HCV, regardless of HIV status, will never undergo HCV drug treatment. In fact, the U.S. Department of Veterans Affairs has identified 270,000 HCV-infected veterans since implementing HCV screening and testing, yet between 1996 and 2003, just 8 percent were ever treated.79

HIV/HCV Coinfection, Pregnancy, and Perinatal Transmission People with HIV/HCV coinfection have higher serum HCV viral loads than those with HCV infection alone.80 HCV has been detected in the semen of HIV/HCV-coinfected men81,82 and in the genital tracts of coinfected women.83 Thus, HIV-positive female partners of men with HCV infection should be tested for HCV and counseled about the risk of sexual and perinatal transmission of the virus. Among coinfected women, the risk of perinatal transmission of HCV is approximately 17 percent, or four to five times greater than that among women with HCV monoinfection.84,85 Although treatment for chronic HCV infection is contraindicated during pregnancy, coinfected mothers can reduce the risk of vertical transmission of HIV and HCV with antiretroviral therapy and cesarean delivery. A recent study reported that either elective or urgent cesarean delivery reduced the rate of perinatal transmission of HCV among coinfected women from 17.3 to 8.3 percent.86 Because infants may carry maternal antibodies for up to 18 months, HCV viral load testing should be used to diagnose HCV infection in children under 18 months old.