1. Hepatitis C Overview Updated 9/20/2017
This basic overview of hepatitis C that can be presented in minutes. Remember to leave enough time for question and answers.
If you only have a short period of time to give your presentation than it might be a good idea to pick some of the important slides that will give basic information you want to present. For example:
A presentation on transmission/prevention can be given in minutes depending on the amount of information a presenter wants to give to the participants and how many questions come up during the presentation.
A presentation on symptoms can be given in minutes
One of the best ways to determine the amount time of the presentation is to practice it in front of a mirror. Once you feel comfortable with the pace and have run through the presentation a couple of times - write down how much time it. After you have established the timing – allow some extra time for audience questions. Also generally if you are giving a presentation on a particular topic for the first time – nerves can make you speed up the presentation. Take deep breathes and try to pace yourself.
Updated 9/20/2017

2. Introduction Self-Advocacy through Education!
The information in this presentation is designed to help you understand and manage HCV and is not intended as medical advice. HCV medical care is a partnership between patients and their medical providers
Below are a couple of statements that are important to talk about before or during your presentation.
It is our belief that education is power, and that education will give the patient and advocate the necessary tools to be the best self-advocate possible in order to receive or help people to receive the best possible medical care available.
But it should be pointed out that the information in this presentation is to help you understand and manage hepatitis C, and that it is not intended as medical advice. HCV medical care should always be a partnership between patients and their medical providers.

3. The Liver – A Chemical Factory
Largest internal organ
Size of a football
Approximately 3 lbs in the average sized male
1.5 quarts of blood flow through it every minute
The Liver – the liver is a chemical factory
It’s the largest internal organ – about the size of a football.
It weighs approximately 3 pounds in the average sized man.
And about a 1.5 quarts of blood flows through the liver every minute.
A good educational tool to use is a bag of rice or beans that weigh 3 lbs. Also point out where the liver is located (upper right hand quadrant behind the ribcage)

4. Liver Functions Chemical Factory- >500 chemical functions Bile
Immune System
Detoxifies or Filters
Clotting Factors
Hormones
We call the liver a chemical factory because of all of the chemical processes performed by the liver – in fact there are over 500 chemical functions that the liver performs to keep us all healthy.
One of the things that the liver does is make cholesterol which in turn makes bile----a greenish yellow fluid that aids in digestion.
The liver also makes immune factors that keep us healthy.
The liver filters or detoxifies all the substances that we breathe, eat or that come into contact with our skin.
It also makes clotting factors so that when we are cut or bleed we are able to heal.
The liver also makes male and female hormones including estrogen and testosterone.
Probably the most amazing thing about the liver is that it can regenerate itself. For example, if you take half of the liver out it will actually grow or expand back to its original size within 2-3 weeks! Because the liver regenerates, sometimes people can donate part of their liver to a person that needs a new liver and these types of transplants have been very successful.
Regenerates Itself!

5. Keep the Liver Healthy! If you have HCV – Avoid Alcohol
Avoid mixing drugs – prescription, over the counter, herbs/supplements and street drugs
Eat a healthy, balanced diet based on the food
Keep the Liver Healthy
So how do you keep the liver healthy? One of the best strategies if you have hepatitis C is to avoid alcohol. If you can’t stop drinking right now, cut back as much as you can.
You also want to avoid mixing drugs especially with alcohol. But this also includes mixing prescription drugs, over the counter drugs, (for example, Tylenol), herbs, supplements and street drugs.
The basic nutrition message is to eat a healthy well balanced diet based on sound nutritional guidelines. If possible consult with a registered dietician or a nutritionist.

6. Keep the liver healthy! Get vaccinated! Avoid toxic substances / fumes
HAV and HBV vaccines
Avoid toxic substances / fumes
Other ways to keep the liver healthy is to get vaccinated against hepatitis A and hepatitis B if you have not been previously exposed. If someone has hepatitis C and they get hepatitis A or hepatitis B it is more likely that there will be serious consequences for the liver. It is important to be tested for hepatitis B BEFORE being vaccinated.
You also want to avoid any toxic substances or fumes that you can – so if possible stay away from any situations that could put you at risk. You can also protect yourself by wearing safety equipment like gloves and face masks and make sure that if there are chemical fumes that the area is well ventilated.

7. Hepatitis C Statistics
U.S. Population
3.5 Million Americans Chronically Infected
Hepatitis C Statistics
It is estimated that 3.5 million Americans are chronically infected with hepatitis C. Some experts believe this number is underestimated.
The rate of infection is much higher in African Americans—at least twice as high.

8. Twin Epidemics Baby Boomers born 1945 to 1965 Current Epidemic
Highest Prevalence in Ages 20 to 29years old – but even in teens

9. HCV Antibody tests HCV Elisa II or III
Most common antibody test
A positive antibody test indicates exposure
It does not indicate current hepatitis C infection
HCV viral load (HCV RNA) test performed to indicate active HCV infection
HCV Antibody Tests (blood test)
The HCV antibody test is a blood test.
Antibodies are substances (proteins) produced by the body to fight off foreign invaders such as viruses.
There are two types of antibody tests that are used to detect the HCV antibody. The most commonly used antibody test is the HCV Elisa III.
It is very important to remember that a positive antibody test indicates exposure to hepatitis C or an infection at one time, but it does not mean that someone is currently or actively infected with the hepatitis C virus. In order to find out if someone is currently infected with hepatitis C an HCV RNA or HCV viral load test must be performed.

10. Viral Load Tests Viral Load tests Why Is a Viral Load Test Important?
Hepatitis C RNA by PCR - >10 IU/mL
HCV RNA by branched DNA Assay – > 650 IU/mL
TMA – > 5-10 IU/mL
Why Is a Viral Load Test Important?
To confirm active infection
Indication that treatment is working
** Viral load does not correlate with disease progression**
HCV RNA or Viral Load Test
The viral load test is a blood test.
Viral load tests are blood tests that can measure the amount of the hepatitis C virus in the blood. The measurements are reported in international units – a standardized form for measuring the amount of the hepatitis C virus.
There are three kinds or types of HCV viral load tests:
The hepatitis C RNA by PCR which can measure viral loads as few as 10 international units
The HCV RNA by branched DNA Assay can measure viral loads as few as 650 international units.
The TMA test which can measure as few as 5 to 10 international units.
Now, why is the viral load test important?
The viral load test is used to confirm active infection – that means that it will report if the hepatitis C virus is actively replicating—this means that the person is actively infected with hepatitis C.
The viral load test is used to find out if HCV medical treatment is working.
But it is very important to note that the amount or number of virus in the viral load does not correlate with disease progression. For instance, if someone has a high viral load it does not necessarily mean they have a more severe disease progression than someone with a low viral load and vice-visa.

11. Genotype Test Genotype (1,2,3,4,5,6 and 7)
U.S. population
~70% genotype 1
~30% genotypes 2 & 3
Why Is a Genotype Test Important?
Medication and treatment duration for some medications
The genotype test is another blood test which will tell you what strain of hepatitis C you are infected with.
There are 7 genotypes numbered 1 through 7. In the United States the most common genotype is genotype 1 which accounts for approximately 70% of the total population infected with hepatitis C in the United States. This is followed by genotypes 2 and 3 which account for about 30% of the total population infected with hepatitis C in the United States.
Why is it important to know the genotype information? The genotype information is used for deciding which hepatitis C medications to use and the period of time to treat. This is changing as some HCV medications are being prescribed the same regardless of genotype.

12. Measuring Liver Damage
Liver Biopsy
Fibroscan
Various Blood Tests, Liver Enzymes
The Liver Biopsy is being replaced by the Fibroscan and various blood tests:
Fibroscan
The Fibroscan is a machine that uses a wand to send radio waves through the liver. The machine will measure and interpret the sound waves to give an approximate measure of the scarring of the liver. It is not a perfect test, but when combined with other blood tests is a pretty accurate way to gauge the health of the liver. It is replacing the liver biopsy because it is painless and has no complications.
Liver Biopsy
Many experts believe that the liver biopsy is the “gold standard” for assessing the health of the liver. The biopsy will measure the amount of inflammation in the liver and the extent of any scarring. The liver biopsy can also be used to rule out any other diseases.
The liver biopsy is usually performed in an outpatient facility. Some physicians will order an ultrasound before the procedure to pinpoint exactly where the sample of the liver tissue is to be removed. The area around where the needle is inserted will be numbed with medication. The biopsy needle will be inserted very quickly, and a very small amount of the liver tissue will be removed. This takes only a couple of seconds. Once the procedure is completed the patient will be asked to lay on the right side of the body for about 2-3 hours for observation just in case there are any complications. For most people the pain is mild to moderate but for some people the pain can be severe. Complications are rare, occurring in only in about 1% of people who have the procedure.
It should be noted that damage to the liver occurs at somewhat the same rate throughout the liver so that the tissue sample taken will tell the extent of damage throughout the entire liver. Although subsequent biopsies will be taken from a different area of the liver.
Blood Tests
There are also various blood tests that are used in clinical practice to gauge the health of the liver.

13. Transmission- Prevention
Direct blood-to-blood transmission route
Not spread casually
Transmission/Prevents - It is important to know that the transmission of hepatitis C is by direct blood to blood contact. That means that the blood of someone infected with hepatitis C has to go directly into the blood of someone else in order for that person to become infected.
It is also important to know that hepatitis C is not easily transmitted – again it is “direct blood –to-blood transmission”.

14. Transmission Shared Needles All Drug Paraphernalia
Blood Before transfused, products, procedures
Sexual Transmission
(1-3%)*
Healthcare Workers – needle sticks
Shared House-hold items – razors & toothbrushes
Mother to Child ~5%
Tattoos /
Piercing
<10% of routes can not be identified
The most common transmission route of hepatitis C is from sharing hepatitis C infected needles and any drug paraphernalia or tools such as needles, cookers, cottons, tourniquets or any thing that comes into contact with HCV infected blood.
If someone received blood or blood products or medical procedures involving blood before 1992 is another common transmission route.
Sexual transmission among long term stable monogamous heterosexual couples appears to be low – only about 1-3% prevalence has been found in studies. It should be noted that there have not been large studies in other groups, so the risk of sexual transmission in people with multiple sexual partners, people with sexually transmitted diseases, men who have sex with men, or women who have sex with women is unknown. There have been studies that have shown that sexual transmission rates among HIV positive men who have sex with men who have multiple sexual partners.
Healthcare workers are at risk for getting hepatitis C in situations where HCV infected blood is involved. This mostly happens with needle-sticks from large hollow-bore needles.
Shared household items such as hygiene items which include razors and toothbrushes can put people at risk – but we believe this type of transmission is very rare.
Mother to child transmission is uncommon. There is about a 4-6% chance the HCV infected mother will pass the hepatitis C virus to the unborn infant, but it is higher in women who are coinfected with HIV.
Transmission of hepatitis C by tattoos/piercing in a commercial tattoo or piercing parlor appears uncommon unless standard safety precautions are not followed carefully. Transmission is higher in settings such as in prison or on the streets where safety precautions are not followed carefully.
It is estimated that less than 10% of the transmission routes can not be identified.

15. Prevention Tips Injection and Non-Injection Drugs
Do not share needles, cookers, cottons, straws, pipes, water or any items that might come into contact with blood
Use bleach to clean
People in Stable Long-Term Monogamous Sexual Relationships
Most experts recommend - no need to change current sexual practices – but there is a risk
Prevention – do not share any tools or works – such as needles, cookers, cottons, straws, pipes and even water that may have come into contact with blood. If you don’t have a needle exchange site in the area, use bleach to clean the needles and works. Users should try to only use their own needles and works. The hepatitis C virus is so small that you may not even be able to see it. It can be present in small particles of blood that remain invisible to the naked eye.
The Centers for Disease Control does not recommend that heterosexual couples in a long term stable relationship change their sexual practices. But it is very important that people realize there is still a small chance of getting or giving hepatitis C to their sexual partner. If one of the people in the relationship is uncomfortable with the low risk, the use of barriers such as male and female condoms will help reduce the risk even more. It is also advised that if there is any blood during sex then safer sex practices should be followed.
There have been reports of higher rates of sexual transmission of hepatitis C among men who have sex with men who have unprotected anal sex with multiple sexual partners.

16. Prevention Tips Safer Sex For so called “high risk groups”
Multiple sexual partners, people with sexually transmitted diseases, coinfection with HIV or HBV
Any situation where blood is present
As mentioned before, studies on sexual transmission in other groups has not been well studied. But in other situations or people in so called ‘high risk groups’ including people with multiple sexual partners, people with sexually transmitted diseases and people who are co-infected with HIV or HBV, it is recommended that they follow safer sex practices such as using male and female condoms or other barrier methods that will protect people for getting or giving hepatitis C to their sexual partner. It is also important to remember that hepatitis C is spread by direct blood contact so avoid any situations during sex where there is blood.

17. Prevention Tips Mother to Child Transmission Health-Care Settings
Low risk – about 4-6% chance of hepatitis being transmitted to infant
Most recommend treatment first
Health-Care Settings
Follow standard precautions
The chances of passing the hepatitis C virus from a mother to an unborn infant is uncommon, but there is about a 4-6% chance this could happen, and higher if the woman is coinfected with HIV. Given that the transmission rate is so low most physicians would tell a woman that it is ‘ok’ to become pregnant. It is however, important to remember that there is a small chance that the hepatitis C virus can be transmitted to the unborn infant.
Unfortunately, there are no medications that can help lessen the chance of passing the virus from the mother to the unborn infant.
In health care situations the practice of universal or standard safety precautions will prevent the transmission of hepatitis C.

18. Prevention Tips Tattoos & Piercing
Considered a low/no risk in commercial setting
Make sure disposable needles and separate ink pot are used and that general safety precautions are followed
Considered a higher risk in other settings
Non-commercial settings such as in prison or on the streets
Tattoos – Tattooing in a setting of a commercial tattoo parlor is generally considered safe. However, it is important that people make sure that the tattoo artist is following standard safety precautions. These safety precautions include making sure that only new tattoo needles are used and that they use separate ink pots for every person. They should also be wearing safety gloves. It is a good strategy to visit the tattoo parlor before getting the tattoo to make sure that safety precautions are being carefully followed. It has been our experience that tattoo and piercing professionals take safety very seriously and welcome inquiries about their practices.
However, in other situations such as in prison and on the streets the risk of getting hepatitis C is much higher because the needle and the ink are reused and standard safety precautions are not followed.

19. Shared Personal Items Household Professional Personal Care Settings
Cover cuts or sores
Do not share personal hygiene items (toothbrushes, razors, etc.)
Professional Personal Care Settings
Standard precautions
Disposable equipment
Bring own equipment
Transmission of hepatitis C in a personal or household environment is uncommon. To protect yourself and others always make sure that personal hygiene items are never shared. It is also a good idea to cover razors and toothbrushes so that they are not accidentally picked up by someone else and used.
In commercial personal care settings, such as nail salons and beauty shops, the risk of getting hepatitis C is also uncommon but possible. To prevent getting hepatitis C in these environments, make sure standard safety precautions are being followed. Some people bring their own personal manicure tools with them or have them stored at the salon.

20. HCV CAN NOT BE SPREAD BY:
BREASTFEEDING
SNEEZING
HUGGING
COUGHING
FOOD OR WATER
SHARING EATING UTENSILS OR DRINKING GLASSES
CASUAL CONTACT
The good news is that hepatitis C is not spread by casual contact.
It is not spread by breastfeeding, sharing food, water, eating utensils or drinking glasses. Hepatitis C is also not spread by sneezing, hugging, coughing or any other type of casual contact.
Remember – Hepatitis C is spread through direct blood to blood contact.

21. Chronic Symptoms Fatigue – mild to severe
Flu-like symptoms (muscle/joint/fever)
‘Brain Fog’
Liver pain
Loss of appetite
Headaches
Gastro problems
There are many symptoms of chronic hepatitis C. The most common symptoms people with hepatitis C report are :
Fatigue, mild to severe
Some people also experience mild flu-like symptoms which can include muscle and joint pain, fever, night sweats.
People with hepatitis C also experience brain fog which is characterized by forgetfulness, feeling ‘spaced-out,” trouble concentrating and difficulty retaining information.
People with hepatitis C may feel pain in the area of the body where the liver is located, as well as referred pain which is pain generally felt in the area around the right shoulder blade.
Loss of appetite
Headaches
Gastrointestinal problems
And many more symptoms.
and more……

22. Disease Progression
10-25% of HCV positive people progress on to serious disease over years
Fibrosis
Light scarring to severe
Cirrhosis
Compensated vs. decompensated
Steatosis
Fatty deposits in the liver
The good news is that only about 10-25% of people with chronic hepatitis C progress on to serious liver disease progression and this usually over many years. The process starts with inflammation of the liver which over time causes the liver to become scarred. This process is referred to as fibrogenesis, and the condition is called fibrosis. As the fibrosis worsens over time the scar tissue starts to connect and becomes severe. When the scarring becomes very severe and really starts to develop throughout the entire liver, changing its basic architecture, then it is termed cirrhosis. Cirrhosis is classified into two levels: compensated and decompensated cirrhosis. Compensated cirrhosis refers to a liver that is heavily scarred, but can still perform many of its functions. Decompensated cirrhosis refers to a liver that is so scarred that it cannot perform many of its important functions.
Another factor that can speed up the disease process in the liver is steatosis (fatty liver) in which there are fatty deposits in the liver. Steatosis for many people with hepatitis C is the result of an unhealthy diet and lack of exercise, but most experts also believe that the hepatitis C virus may induce or increase the risk of developing steatosis.

23. Treatment Recommendations
AASLD / IDSA:
The panel continues to recommend treatment for all patients with chronic HCV infection, except those with short life expectancies that cannot be remediated by treating HCV, by transplantation, or by other directed therapy
HCV Medical Treatment Decisions
Guidance: American Association for the Study of Liver Disease; Infectious Disease Society of America - HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C

24. Treatment What are direct-acting antivirals? What is ribavirin?
Inhibit the hepatitis C Virus – protease, polymease and NS5A inhibitors from replicating
What is ribavirin?
Antiviral
Used only in combination with some direct-acting antivirals pills
Treatment consists of pills that are direct-acting antivirals that inhibit the hepatitis C Virus from replicating. The current medications used to treat hepatitis C are protease, polymease and NS5A inhibitors. They may be combined and some are used with ribavirin, a type of drug called a nucleoside analog. Ribavirin is considered a broad antiviral and is only approved to treat hepatitis C. It is a pill that is only taken in combination with a HCV direct-acting antiviral.

25. Approved Medications
Brand Name
Genotype(s)
Cure Rates
Mavyret
1-6
Up to 100%
Epclusa
Harvoni
1,4,5,6
Zepatier
1 - 6
Medications approved to treat hepatitis C – these are the most prescribed drugs to treat hepatitis C.
These are the current direct-acting antiviral medications approved by the Food and Drug Administration (FDA) to treat chronic hepatitis C. There are other medications that are less frequently used. Check out Hep C Medications Blog at for more information on all of the direct-acting antiviral medications approved to treat chronic hepatitis C.
Visit for more information on all of the direct-acting antiviral medications including costs

26. Side-effects Ribavirin Direct-Acting Antivirals headache fatigue
seems to make side effects worse – especially fatigue – Anemia
**(both men & women must use birth control)
Direct-Acting Antivirals
headache
fatigue
Nausea
Itching
Insomnia
*depends on the medication
For a complete listing of side effects please refer to the product package inserts that list the reported side effects and the frequency of these side effects. These are listed on the HCV Advocate Website.
It is very important to note that ribavirin combination therapy can cause birth defects; so it is important that women of childbearing age, their partners and female partners of male patients taking ribavirin practice two forms of contraception during therapy to 6 months after the completion of therapy. The direct-acting antiviral medications have not been studied in pregnant women.

27. Managing Side-Effects
Always report any serious side effects to the medical provider
Light exercise
Daily moisturizing
Rest when tired
Frequent small meals
Stay hydrated
Low doses of ibuprofen or acetaminophen for aches and pains
Managing Side-Effects
There are many simple steps people can take to help manage their side effects, but the most important advice to remember is to report any side effects to your medical provider as soon as possible so that they can be medically managed before they become severe.
But there are also some basic strategies that people can use to minimize or help reduce some of the side effects of treatment. These include:
Stay hydrated – this is one of the best tips that patients describe that makes a difference in how they feel while on therapy.
Your medical provider may prescribe low doses of ibuprofen or acetaminophen (also known as Tylenol) for muscle aches and pains
Your medical provider may also prescribe some pain medications to help with some of the more severe muscle & joint pain
Light exercise will help to relieve some of the fatigue and will help to keep your spirits up.
Moisturize your skin at least once daily
Plenty of rest helps with the fatigue
And eating small frequent meals helps to control nausea and keeps you healthy by eating well.
Probably the best advice is to be prepared for the possible treatment side effects by getting as much support as possible from every area of your life including your medical provider, family, friends, and any other support that will help you to get through the course as therapy as comfortably as possible. It is also highly recommended that you join a support group.
Key: support from medical providers, family, friends, work – all areas of life

28. Experimental Therapies
There are many drugs understudy to treat hepatitis C. Visit our Hepatitis C Reference Guide:
New or experimental therapies
Our Hepatitis C Reference Guide contains hepatitis C and HIV / HCV coinfection clinical trials that are currently recruiting patients.

29. Complementary Medicine
Herbs – milk thistle, licorice root, etc.
Always check with your doctor and herbalist – some herbs are unsafe especially with the hepatitis C drugs
Acupuncture / Acupressure
Traditional Chinese Medicine
There are many herbs that people take for hepatitis C. The most common herb used by people with hepatitis C is milk thistle. The most important piece of information about herbs is to make sure that you are seen by a reputable herbalist and that you tell your medical provider what herbs you are taking. It is also important to remember that some herbs are unsafe and caution should always be used when taking any medication including herbs.
Acupuncture is based on the idea that “qi” flows through the body in channels called meridians; each organ system has a set of channels. An acupuncturist inserts very thin needles into defined acupuncture points to stimulate the flow of blocked “qi.” A word of caution – make sure that the acupuncturist uses disposable needles.
Acupuncture is particularly effective for relieving pain, deceasing fatigue, and overcoming addictions. Acupressure is based on the same principle of acupuncture but points are stimulated with fingers rather than needles.
Traditional Chinese medicine is a complete healing system that is based on the premise that various treatments can restore harmony and help the body heal itself—the philosophy emphasizes treating the whole person rather than specific symptoms.

30. Lifestyle Changes That Help!
Alcohol – Avoid or reduce
Get vaccinated – Hep A & Hep B
Healthy balanced diet
Exercise
Stress Reduction
Support Groups
Lifestyle Changes that Help with Hepatitis C.
People with hepatitis C can be greatly helped by following some basic lifestyle changes.
One of the most important strategies people with hepatitis C can incorporate into their lives is to avoid or reduce alcohol intake. Vaccination against hepatitis A and hepatitis B – if you have not been previously exposed – because getting hepatitis A or hepatitis B on top of having hepatitis C can damage the liver even further.
Eating a healthy balanced diet will keep you and your liver healthy.
Mild to moderate exercise will help people stay healthy both physically and emotionally.
Reduce as much stress in your life as possible. Many people with hepatitis C report that during periods of stress, they develop more symptoms.
One of the best things that people with hepatitis C can do for themselves is to join a support group. Support groups can provide much needed emotional support and information so that people can live well with hepatitis C.

31. Advocate for Yourself! Educate yourself
Establish a good relationship with your doctor
Bring an advocate for doctor’s visits
Ask questions
Keep copies of all medical tests
Keep a diary
Keep an open mind
Advocate for Yourself.
There are many ways that people with hepatitis C can take charge of their health to live healthier and happier lives. One of the most important ways to take charge is by educating themselves about hepatitis C. An educated patient will be much better equipped to develop effective strategies to deal with the difficulties of living with hepatitis C.
One strategy is to build a good working relationship with your medical provider based on mutual respect, making management of hepatitis C a partnership between the patient and the medical provider.
At times, it may be beneficial to bring a member of the family, a friend or an advocate with you to a doctor’s visit. The advocate will be able to help you stay focused during the visit and to remember what was discussed during the appointment.
It is important to always ask questions if you are not sure what a particular term means or what the benefits or risks of any procedure are. It is also important to report any of the symptoms or side effects you are experiencing.
Keep a file with all of your medical records so that you can review them before the doctor’s appointment.
Keep a health diary so that you can report any symptoms or side effects to your provider. Make sure that your medical providers lists any symptoms or side effects in your medical records.
Keep an open mind. Try to be open to any suggestions that your medical provider offers, but ask questions and weigh the pros and cons out loud so that you and your medical provider can make the best possible healthcare decision.

32. Resources – www.hcvadvocate.org
HCV Advocate Newsletter
Fact Sheets in English, Spanish,
National Support Group Listing
Recommended links
Information on hepatitis C and hepatitis B, HIV/HCV Coinfection