Hep B Blog

Tag Archives: Coinfection

HBV, Living with Hepatitis B

Hep B & HIV CoInfection: Get Tested Today!

Each year, World AIDS Day is held on December 1st to raise awareness about HIV and AIDS.  HIV/AIDS still remains a large problem, with nearly 40 million people living with the infection. Hepatitis B (HBV) remains a large issue as well, with 292 million people living with the chronic infection. Despite the inadequate amount of resources or attention that hepatitis B receives, it is important to talk about it whenever we discuss HIV/AIDS.  Why? Any individual already living with hepatitis B or HIV can also contract the other infection. This is called a coinfection, and it can have serious consequences if not addressed. Let’s look at HIV/HBV coinfection by the numbers: 

  • Globally, 10% of those living with HIV are also living hepatitis B 

    Courtesy of New England Journal of Medicine’s article titled: HIV–HBV Coinfection — A Global Challenge
  • Coinfection rates can be as high as 25% in countries where both infections are common
  • Up to 50% of injection drug users have an HBV/HIV coinfection 
  • Chronic hepatitis B progression can be up to 5 times faster in coinfected individuals compared to those living with just hepatitis B 

HIV vs Hep B: What’s the Difference? 

Hepatitis B is a viral infection of the liver that can increase one’s chances of liver disease and liver cancer.  HIV is a virus that attacks the immune system and kills the cells that are needed to fight off disease and infection. Though they are two different viruses, they can be spread in similar fashions: direct contact with infected blood, via sexual transmission, injection drug use, and through mother to child transmission during childbirth. Hepatitis B is primarily spread through mother-to-child transmission, HIV is most commonly spread by unprotected sex. Among those living with a coinfection, sexual transmission and injection drug use are the most common modes of transmission. Because of the similar transmission routes, it is recommended that people living with HIV be tested for hepatitis B and hepatitis C and those living with hepatitis B should be tested for HIV. 

Hepatitis B may be up to 100 times more infectious than HIV, but it also has a highly effective vaccine! Family members and sexual partners of people living with hepatitis B who have not been infected can protect themselves in just 2 or 3 doses. HIV does not have a vaccine, but people can take precautions to prevent transmission –  like not sharing sharp personal items – such as razors, needles, or toothbrushes – and practicing safe sex (use a condom), or through HIV pre-exposure prophylaxis (PRep). Those precautions can also prevent the spread of hepatitis B. While HIV and hepatitis B do not have cures, they both have highly effective treatments. You can learn more about HIV and hepatitis B treatments by clicking the links. 

HIV/HBV Coinfection 

If you are living with hepatitis B, it is important to get tested for HIV as well. Coinfections are very serious, and can sometimes complicate treatment. Worldwide, HIV/HBV coinfection has become an increased priority because research has shown that conditions associated with hepatitis B and C are now among the leading causes of hospital admission and death in people living with HIV. 

Left untreated and unmanaged, HIV/HBV coinfections can cause rapid progression of liver disease and liver damage, leading to serious complications at younger ages. There is also a higher risk of liver damage from anti-retroviral therapy (HIV treatment) in individuals living with hepatitis B than in those living with just HIV. Though some HIV treatments may also help treat hepatitis B, treatment options can vary based upon the person and the progression of the infections, so it is very important to discuss your options with your healthcare provider. Those living with hepatitis B, HIV, or HIV/HBV coinfection should always be closely monitored by a knowledgeable doctor.

Living with a coinfection can be scary, but with proper management and care, you can lead a healthy life! Check out this video from Jason –  one of our #justB storytellers – on successfully living with an HIV/HBV coinfection, and how he has learned to overcome challenges.  

About Hepatitis B, Living with Hepatitis B

What’s the Difference: Hepatitis B vs Hepatitis C?

With five different types of viral hepatitis, it can be difficult to understand the differences between them. Some forms of hepatitis get more attention than others, but it is still important to know how they are transmitted, what they do, and the steps that you can take to protect yourself and your liver!

This is part one in a three-part series.

What is Hepatitis?

Hepatitis means “inflammation of the liver”. A liver can become inflamed for many reasons, such as too much alcohol, physical injury, autoimmune response, or a reaction to bacteria or a virus. The five most common hepatitis viruses are A, B, C, D, and E. Some hepatitis viruses can lead to fibrosis, cirrhosis, liver failure, or even liver cancer. Damage to the liver reduces its ability to function and makes it harder for your body to filter out toxins.

Both hepatitis B and C are blood-borne pathogens, which means that their primary mode of transmission is through direct blood-to-blood contact with an infected person. Also, both hepatitis B and C can cause chronic, lifelong infections that can lead to serious liver disease. Hepatitis B is most commonly spread from mother-to-child during birth while hepatitis C is more commonly spread through the use of unclean needles used to inject drugs.

 

Hepatitis B vs. Hepatitis C

Despite having an effective vaccine, hepatitis B is the world’s most common liver infection; over 292 million people around the world are estimated to be living with chronic hepatitis B. While hepatitis C tends to get more attention and research funding, hepatitis B is considerably more common and causes more liver-related cancer and death worldwide than hepatitis C. Combined, chronic hepatitis B and C account for approximately 80% of the world’s liver cancer cases. However, studies show that those with chronic hepatitis B are more likely to die from liver-related complications than those who are infected with hepatitis C. With hepatitis C, most people develop cirrhosis, or scarring of the liver, before liver cancer. In certain cases of hepatitis B, liver cancer can develop without any signs of cirrhosis, which makes it extremely difficult to predict the virus’ impacts on the body, and makes screening for liver cancer more complicated.

The hepatitis B virus is also approximately 5-10 times more infectious than hepatitis C, and far more stable. It can survive – and remain highly contagious – on surfaces outside of the body for at least seven days if it is not properly cleaned with a disinfectant or a simple bleach solution. A new study suggests that the hepatitis B virus has the ability to survive in extreme temperatures, whereas the hepatitis C virus has been known to survive outside of the body for a short period of time on room-temperature surfaces. However, more research will need to be done on the topic.

Another major difference between the two forms of hepatitis is how the virus attacks a cell. The hepatitis C virus operates like other viruses; it enters a healthy cell and produces copies of itself that

Hepatitis C Virus
Courtesy of Google Images

go on to infect other healthy cells. The hepatitis B virus reproduces in a similar fashion, but with one large difference – covalently closed circular DNA. Covalently closed circular DNA (cccDNA) is a structure that is unique to only a few viruses. Unlike a typical virus, hepatitis B’s cccDNA permanently integrates itself into a healthy cell’s DNA – a component of the cell that allows it to function properly and produce more healthy cells. The cccDNA resides within an essential area of the cell called the nucleus and can remain there even if an infected person’s hepatitis B surface antigen (HBsAg) levels are undetectable. Its presence means that a person with chronic hepatitis B may have a risk of reactivation even if the HBsAg levels have been undetectable for a long period of time. The complex nature and integration process of cccDNA contributes to the difficulties of finding a cure for hepatitis B. The cccDNA’s location inside of the nucleus is especially troublesome because it makes it difficult to isolate and destroy the cccDNA without harming the rest of the cell.

Hepatitis C, on the other hand, has a cure! Approved by the FDA in 2013, the cure is in the form of an antiviral pill that is taken once a day over the course of 8-12 weeks. For hepatitis C, a cure is defined as a sustained virologic response (SVR), which means that the virus is not detected in a person’s blood 3 months after treatment has been completed. In the United States, an affordable, generic version of the hepatitis C cure is set to be released by Gilead Sciences, Inc. in January 2019.

People living with chronic hepatitis B are susceptible to hepatitis Delta. Only people with hepatitis B can contract hepatitis D as well. Hepatitis Delta is considered to be the most severe form of hepatitis because of its potential to quickly lead to more serious liver disease than hepatitis B alone. Of the 292 million people living with chronic hepatitis B, approximately 15-20 million are also living with hepatitis D. Unlike HIV and hepatitis C coinfections, there are currently no FDA approved treatments for hepatitis Delta. However, there are ongoing clinical trials that are researching potential treatments!

Hepatitis B/C Coinfection

It is possible to have both hepatitis B and C at the same time. The hepatitis C virus may appear more dominant and reduce hepatitis B to low or undetectable levels in the bloodstream. Prior to curative treatment for hepatitis C, it is important for people to get tested for hepatitis B using the three-part blood test (HBsAg, anti-HBc total and anti-HBs). People currently infected with hepatitis B (HBsAg positive) or those who have recovered from past infection (HBsAg negative and anti-HBc positive) should be carefully managed according to the American Association for the Study of Liver Diseases (AASLD) treatment guidelines in order to avoid dangerous elevation of liver enzymes resulting in liver damage.

How to Protect Yourself   

The hepatitis B vaccine is the best way to protect yourself and your family against hepatitis B. Although there is no vaccine for hepatitis C, you can protect yourself from both liver infections by following simple precautions! Simple steps such as not sharing personal items such as razors or toothbrushes, thoroughly washing your hands, and disinfecting surfaces that have been in contact with blood, can keep your liver healthy!

 

Hepatitis B Diagnosis & Monitoring, Hepatitis B Prevention, Hepatitis B Treatment, Living with Hepatitis B

HIV/HBV Co-Infection

World AIDS Day was last Friday, December 1st. It is a day dedicated to raising awareness about HIV and AIDS. However, it is also a great opportunity to discuss the possibility of coinfection with hepatitis B virus, HBV.

 Dr. John Ward, MD, Director, Division of Viral Hepatitis, CDC talks about hepatitis B, hepatitis C, and HIV epidemics in the United States.

Hepatitis B (HBV) and HIV/AIDs have similar modes of transmission. They can be transmitted through direct contact with blood, or sexual transmission (both heterosexual and MSM). Unfortunately, people who are high risk for HIV are also at risk for HBV, though hepatitis B is 50-100 times more infectious than HIV. Fortunately hepatitis B is a vaccine preventable disease and the vaccine is recommended for individuals living with chronic HIV.

Nearly one third of people who are infected with HIV are also infected with hepatitis B or hepatitis C (HCV).2 To break down the numbers further, about 10% of people with HIV also have hepatitis B, and about  25% of people with HIV also have hepatitis C.2 Liver complications due to HBV and HCV infections have become the most common non-AIDS-related cause of death for people who are HIV-positive.3

Who is at risk of HIV and HBV co-infection? Because both infections have similar transmission routes, injection drug use and unprotected sex (sex without condoms) are risk factors for both infections.4 However, there are additional risk factors for HIV and  for HBV that put people at risk4

It is important that people who are at risk of both diseases are tested! HIV-positive people who are exposed to HBV are more likely to develop a chronic HBV infection and other liver associated complications, such as liver-related morbidity and mortality if they are infected with HBV.1

If a person is co-infected with both HBV and HIV, management of both diseases can be complicated, so a visit to the appropriate specialists is vital.3 Some anti-retrovirals, which are usually prescribed to treat HIV, can eventually lead to antiviral resistance or liver-associated problems.3 One or both infections will require treatment and must be carefully managed.  Treatment differs from person to person .4

It is also important to hear about the perspectives of those who are living with co-infections. As a part of our #justB: Real People Sharing their Stories of Hepatitis B storytelling campaign, Jason shares his experience of living with both hepatitis B and HIV/AIDs.

To learn more about HIV and viral hepatitis coinfection, go here. For more #justB videos, go here.

References:

  1. Centers for Disease Control and Prevention (CDC). (2017, Sept). HIV/AIDS and Viral Hepatitis. Retrieved from: https://www.cdc.gov/hepatitis/populations/hiv.htm
  2. Centers for Disease Control and Prevention (CDC). (2017, June). HIV and Viral Hepatitis. Retrieved from: https://www.cdc.gov/hiv/pdf/library/factsheets/hiv-viral-hepatitis.pdf
  3. Weibaum, C.M., Williams, I., Mast, E.E., Wang, S.A., Finelli, L., Wasley, A., Neitzel, S.M, & Ward, J.W. (2008). Recommendations forMorbidity and Mortality Weekly Report (MMWR), 57(RR08), 1-20. Retrieved from: Identification and Public Health Management of Persons with Chronic Hepatitis B Infection. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm

Hepatitis B Diagnosis & Monitoring, Living with Hepatitis B

The Medical Community Wakes Up to a Dangerous Threat to People with Hepatitis B – Coinfection with Hepatitis D

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hep DBy Christine Kukka

In the U.S. and around the world, the medical community is finally acknowledging a hidden threat to people with hepatitis B – a virulent liver coinfection that requires the presence of the hepatitis B surface antigen (HBsAg) to survive.
Hepatitis D (Delta), which causes the most severe liver infection known to humans, infects between 15 to 20 million people worldwide and an estimated 20,000 people living with chronic hepatitis B in the U.S.
For years, health officials assumed hepatitis D did not threaten Americans and occurred primarily in Central Asia and Sub-Saharan Africa. However, recent U.S. Centers for Disease Control and Prevention (CDC) studies found 4 to 5 percent of Americans with chronic hepatitis B are also infected with hepatitis D.
As a result of these findings, researchers including Hepatitis B Foundation‘s Medical Director Dr. Robert Gish, are now pushing medical organizations to establish hepatitis D testing and monitoring guidelines so doctors will start testing patients for this dangerous liver disease.
Recently, the foundation sponsored a webinar, attended by dozens of healthcare providers, patients and officials from around the world, in which Dr. Gish outlined whom should be tested for hepatitis D, and how it should be treated. A new webinar that examines hepatitis D prevalence in the U.S. is scheduled for 3 p.m. (EST), Wednesday, June 28. To register for the webinar click here.
How do people get infected with hepatitis D? Infection occurs when people are exposed to blood and body fluids from someone with an active hepatitis D infection. Basically, they get both hepatitis B and D in one exposure. This is called an acute coinfection. Some healthy adults are able to clear both infections, but they often experience serious liver damage during the clearance or recovery phase.

Another way to become infected is if someone infected with chronic hepatitis B is exposed to someone with hepatitis D. This is called a superinfection, and in 90 percent of cases, people with chronic hepatitis B will also develop chronic hepatitis D.

Who is at risk of hepatitis D? Anyone with chronic hepatitis B who themselves or their family comes from Sub-Saharan Africa, China, Russia, Middle East, Mongolia, Romania, Georgia, Turkey, Pakistan and the Amazonian River Basin should be tested. Hepatitis D rates in some of these countries can reach up to 30 percent in people infected with chronic hepatitis B.

Banner CurveWhat medical conditions suggest hepatitis D? Anyone with chronic hepatitis B who is not responding to antiviral treatment, or who has signs of liver damage even though they have a low viral load (HBV DNA below 2,000 IU/mL) should be tested. Fatty liver disease (caused by obesity) and liver damage from alcohol or environmental toxins should be ruled out before testing for hepatitis D.
Often, people with hepatitis D have low viral loads (even if they are hepatitis B “e” antigen HBeAg-positive), but they have signs of liver damage, including elevated liver enzyme (ALT/SGPT) levels.

Do hepatitis B antivirals work against hepatitis D? No. The hepatitis D virus (HDV) is structurally different from the hepatitis B virus (HBV) and does not respond to tenofovir and entecavir used to treat hepatitis B. Hepatitis B antivirals will lower HBV DNA, but they don’t reduce HBsAg, which HDV need to thrive and reproduce.

How is hepatitis D treated? The only proven hepatitis D treatment is pegylated interferon. Interferon cures hepatitis D 15 to 25 percent of the time after one year of treatment. Once interferon clears hepatitis D, doctors treat patients who continue to be infected with HBV with antivirals. There are dozens of research companies now looking into hepatitis D treatment, and if researchers can find a cure for hepatitis B that eradicates HBsAg, it will also be effective against hepatitis D.

How should people with hepatitis D be monitored? According to Dr. Gish, doctors should:

  • Monitor patients’ ALT/SGPT and liver function at least every six months
  • Perform an ultrasound of the liver and conduct a liver cancer biomarker panel (including AFP, AFPL3% and DCP) every six months;
  • And, perform viral load (HBV DNA) and HDV RNA testing every six months.

How is hepatitis D prevented? The hepatitis B vaccine prevents hepatitis D infection, as does use of safe sex and safe injection practices. According to Dr. Gish, all hepatitis B-positive pregnant women should be tested for hepatitis D if they or their families are from a country with high rates of hepatitis D, or if they have signs of liver damage — even if they do not come from a region with high hepatitis D rates.

If a pregnant woman is infected with either hepatitis B and/or hepatitis D, immunizing her newborn with the first dose of the hepatitis B vaccine within 12 hours of birth and giving the baby a dose of HBIG (hepatitis B antibodies) will prevent both infections.

Bottom line, if you are infected with chronic hepatitis B, you should be tested for hepatitis D if:

  • You or your family comes from a region with high rates of hepatitis D; and/or
  • You have a low viral load, but you continue to have signs of liver damage, indicated by elevated ALT/SGPT or an ultrasound exam of your liver, if your doctor has ruled out fatty liver, NASH or alcohol-related liver damage.

Talk to your doctor about getting tested. Click here for a hepatitis D fact sheet to give to your doctor and click here for a patient-oriented fact sheet. An affordable hepatitis D test has recently become available in the U.S. For more information, click here.

  • Find answers to frequently-asked-questions about hepatitis D here.
  • To watch the webinar featuring Dr. Gish discussing the hidden, hepatitis D epidemic, click here.

Hepatitis B Diagnosis & Monitoring, Liver Cancer

Your Doctor Not Screening You for Liver Cancer? Time for a Talk

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Image courtesy of FreeDigitalPhotos.net
Image courtesy of FreeDigitalPhotos.net

The longer we have hepatitis B, the higher our risk of developing liver cancer. With every decade of life, our liver cancer risk increases 2.7-times, according to a report on Viral Hepatitis in the Elderly published in the American Journal of Gastroenterology.

But current medical guidelines don’t spell out exactly when liver cancer testing should begin in many hepatitis B patients who don’t have liver damage (cirrhosis) or a family history of liver cancer, and are not of Asian or African descent.

Age is clearly an important factor when it comes to liver cancer, “… but current guidelines only provide age-specific recommendations for (liver cancer) surveillance in hepatitis B carriers of Asian ethnicity (men over age 40 and women over age 50),” a team of University of Miami and Veterans Affairs researchers wrote in the journal article. Continue reading "Your Doctor Not Screening You for Liver Cancer? Time for a Talk" →

Hepatitis B Diagnosis & Monitoring, Hepatitis B Prevention, Hepatitis Delta (HDV)

Hepatitis D Coinfection with Hepatitis B

Hepatitis D virus (HDV) – the “D” is for delta – is a viral enigma that doesn’t act like a normal virus. It is helpless – that is, it can’t infect a cell – without its viral accomplice, the hepatitis B virus (HBV), and makes infection with HBV worse.

Delta virus can only cause illness in those already infected with HBV, said Timothy Block, Ph.D., President and Co-Founder of the Hepatitis B Foundation, Professor and Director, Drexel University Institute for Biotechnology and Virology Research.

“It can take quiescent HBV and turn it into an acute, lethal viral infection,” Block said. “Liver disease – cirrhosis, liver failure – that might take decades to develop or could only take a year or two. Delta virus converts HBV infection into an emergency situation.”

“It’s one of the most severe forms of human viral hepatitis,” said Jeffrey Glenn, MD, Ph.D., Associate Professor of Medicine at Stanford Cancer Institute.

“Delta virus is a parasite of HBV because it encodes its own genome and coat-like protein but it doesn’t make its own envelope protein,” Glenn explained. “It steals that from HBV. It needs the B envelope protein to make its own, and this provides a means to infect new cells and subsequently make a fully formed viral particle to get out of those cells to infect others.”

Individuals can acquire delta virus two ways: Either after infection with HBV, which is called a “superinfection” and more likely to stay chronic, or a “co-infection”, which entails becoming infected with both viruses at the same time. In the latter, acute infections are more severe and increase the likelihood of developing liver disease much more quickly.

Worldwide, more than 15 million are infected, though fewer than 100,000 in the U.S. have the virus. It is concentrated in particular regions worldwide. Mediterranean areas such as southern Italy and southern Greece, for example, have larger than usual numbers of affected individuals, and in Turkey it is endemic. There are eight reported genotypes of HDV, which vary by geographical distribution and pathogenicity. Some believe that HDV’s incidence is declining. This is likely due to the hepatitis B vaccined and the resulting decrease in HBV carriers.

Because HDV is not a huge problem in the U.S., it flies under the radar screen of public awareness. Screening for HDV is not routinely ordered; however, infection with delta virus should always be considered when a patient with chronic liver disease suddenly gets worse.

Researchers have been frustrated in their attempts to develop effective treatments against HDV. Newer antiviral drugs that keep down levels of HBV DNA don’t do much against delta virus because they don’t affect the HBV envelope protein. The response rate to pegylated interferon alpha is typically poor.

With research there is always hope. Currently, there is a clinical trial of lonafarnib for the treatment of those coinfected with hepatitis B and D in the United States. It was originally developed for the treatment of different types of cancers. Perhaps additional information will come out of this year’s International Meeting on Molecular Biology of Hepatitis B Viruses. We shall soon hear.

Hepatitis D Fast facts:

—   Delta hepatitis is one of the most severe forms of viral hepatitis.

—   It is an incomplete viral particle that was discovered in 1977.

—   Approximately 15 million people are infected with HDV worldwide.

—   In the U.S., an estimated 6,000-13,000 people suffer acute HDV infection 
each year; 30,000 suffer from chronic HDV; and 1,000 Americans die 
from HDV-related diseases annually.

—   It is transmitted by blood from people already infected with hepatitis B.

—   Preventing hepatitis B, especially vaccination, will prevent HDV.

—   There is currently no effective treatment for HDV

Living with Hepatitis B

Which is Worse Chronic Hepatitis B or C? What Do You Think?

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From HBF’s expert Guest Blogger, Dr. Thomas London…

If you ask doctors in the United States, or patients with liver disease, or the average person on the street, the answer that you usually get is that Hepatitis C is worse.  Hepatitis C has a bad reputation in the media and with the public. We, at the Hepatitis B Foundation, tend to think that hepatitis B is the worse disease, but until now we have not had any basis for that answer. Now we do.

Recently a group of investigators from Johns Hopkins University published a paper with the title “Comparative Risk of Liver-Related Mortality from Chronic Hepatitis B Versus Chronic Hepatitis C Virus Infection”.  The answer from this publication is that hepatitis B is more likely to cause liver related death than hepatitis C.  It is worth dwelling on how the authors came to this conclusion: unexpectedly, the AIDS epidemic triggered the studies, which made the conclusion possible.

Acquired immune deficiency disease (AIDS) was first reported in the United States in 1981. The disease appeared to be deadly, and it was thought-to-be confined to homosexual men. In fact, it was initially called Gay Related Immune Deficiency or GRID.  Although it was soon proven that this new immune deficiency disease was not limited to gay men, it is true that men who had sex with men (MSM) accounted for most of the early cases.  In the 1970’s there were several reports that MSM had a high incidence of hepatitis B.  For the initial clinical trial of the then new hepatitis B vaccine, MSM in New York City were selected as the study population because of their high risk for hepatitis B infection. In the trial about 27% of the unvaccinated population became infected with hepatitis B virus (HBV) within 18 months, whereas less than 3% of the men who received the vaccine became infected over the same time interval.  This result proved the efficacy of the vaccine.

Fast forward to 1984 before the virus causing AIDS was clearly identified, several researchers suggested that a variant of hepatitis B was the cause. A group of investigators proposed a prospective study of MSM who had been tested for hepatitis B and a newly reported anti-HIV antibody, but who did not have immune deficiency disease.  By following the men over time, the thought was that it would be possible to observe which infection – HIV or hepatitis B or a combination of both – led to AIDS.

MSM were recruited from 4 cities in the USA (Baltimore, Chicago, Pittsburgh, Los Angeles); thereafter called the Multicenter Cohort Study (MACS).  Over four time intervals from 1984 to 2002, 6972 MSM were enrolled.  The men were followed until 2010, on average for more than 8 years. Serum samples were collected every 6 months, frozen and stored.  Although the hepatitis C virus had not yet been identified in 1984, all the samples were later tested for HIV, HBV and hepatitis C virus (HCV).  All deaths were recorded as were all liver related deaths.

The results were surprising. Comparable numbers of men were infected with HBV and HCV, but MSM with chronic hepatitis B were twice as likely to die a liver related death as the men with chronic hepatitis C.  The statistical analyses were carefully done to account for the treatments of HCV, HBV, and HIV that were used during the course of the study.  Immunodeficiency further increased the risk of liver death in the men with hepatitis B over that in the men with chronic hepatitis C.

The study showed that in the two and a half decades after 1984, hepatitis B infection was more serious than hepatitis C. Now, in 2012, this difference is even greater. Chronic hepatitis C has become a curable disease.  Chronic hepatitis B is manageable, but not yet curable.  This means that hepatitis B, which was already a worse disease than hepatitis C before the new therapies for HCV, is now a much more important unsolved health problem.

– Dr. Tom London

Baruch S. Blumberg Institute