Carly Szabo

Terrence Witter never imagined that a simple blood test would change his life forever and strip away the very thing that gave him meaning. He never imagined he would get hepatitis C virus (HCV).

Witter was a stage manager for the Broadway musical, 

, for 18 years. While most stage managers frequently go from one show to the next, Witter remained a staple of the production team for Chicago for nearly two decades.

Witter was first diagnosed with the disease in 2000 at age 40. Witter said he had very little knowledge about HCV when he received the dire news.

“Initially I wasn’t very alarmed or concerned or anything. I was just kind of surprised and baffled by it,” Witter said.

His surprise mimicked that of his doctor, as Witter was not a part of any groups that place him at higher risk for contracting the virus, including intravenous drug users or people who had blood transfusions.

“I didn’t fit into any of the high risk categories. [The doctor] was kind of surprised and couldn’t figure out how I caught it,” Witter recalled.

At the time of his diagnosis, it was a little known fact that those born between the years 1945 and 1965 were at high risk for having HCV. Approximately 75 percent of those with HCV are a part of this Baby Boomer category.

As Witter learned more about both the origins of his disease and the consequences that accompany HCV, he became more frightened.

“The more I learned about it, the more I was scared and depressed. I felt a little bit like a pariah; like there was something I did. I felt very uneasy talking to anyone about it. I was very worried what my future was going to be,” Witter said.

He started treatment soon after diagnosis, and the effects were unforgettable.

“The interferon and ribavirin made me feel sick every week that I did the procedure. I just felt awful. I felt nauseous and I felt like I had the flu,” Witter recalled. “I just was rundown and feeling miserable. It was really difficult for me to function or just to get out of bed in the morning.”

“I was in the hospital with pneumonia at one point. I had lost 40 pounds and I got demoted from my job at Chicago from production stage manager to assistant stage manager,” Witter said.

The disease had truly taken a toll on his quality of life.

After nearly a year of intense treatment and horrible side effects, Witter still was not rid of the disease. With only a 45 percent success rate at the time, the interferon proved unable to effectively treat Witter’s HCV.

“I went through that awful treatment with no positive outcome and that was the point that I got really scared. It was the only treatment available and I just felt hopeless and depressed. Really for the last 15 years, I’ve just been scared and miserable about this whole thing,” Witter said.

The combination of hopelessness, depression and life-altering side effects turned Witter’s life completely upside-down. Following his unsuccessful treatment, Witter lost his job completely and was no longer a part of the Chicago production.

“It was sort of like a downward spiral through all of this. It was truly frightening. After I lost the job at Chicago, given my health situation, I was so depressed I was almost suicidal,” Witter said.

Depression is a common side effect for those dealing with the disease and receiving treatment. The effects of depression can be just as debilitating as other side effects including anemia, insomnia and migraines.

Depression was not the only one of Witter’s symptoms that kept him under HCV’s control. The fatigue that accompanies the virus rendered him utterly incapacitated, unable to even get out of bed in the morning.

“It really limited my ability to function both at work and socially,” Witter said.

But perhaps the most detrimental of Witter’s reactions to having HCV was not the chronic fatigue, nor the depression. Instead, it was his inability to talk about the impact of the disease with others due to the stigmatization of patients with HCV.

“I think that’s part of the difficulty of being diagnosed with this virus, that there is a real stigma attached to it that made it difficult to talk about. And because of that it’s difficult to get information about it because you’re scared about other people knowing and you don’t really want to talk about it,” Witter said.

Even his closest family members reacted in a way that made him unwilling to talk about it with them at first. Conversations were strained and awkward as his family made private judgments about his disease and where he had gotten it.

“The only conversations I would have about it would be with my doctor and my family. Of course, when I started the interferon treatment, I had to tell my employer, but even then I was afraid to tell anybody else at work because I was afraid of what people might think,” Witter said.

Alone in dealing with the disease save for a few family members and his doctor, Witter became hermit-like, focusing only on the management of his depression and of his HCV. The negative thoughts abounded inside Witter’s mind, and he thought there would be no way out of this downward spiral.

“I really 100 percent believed that I would have a liver transplant in the future or die young from this disease,” he said.

Witter discussed the possibility of doing another interferon regimen with his doctor due to the increased percentage of success; however, the failed treatment the first time around gave Witter little hope that the treatment would actually work. As a result, he opted not to do it a second time.

For years, Witter patiently waited for an alternative treatment for his HCV. The effects of the disease took hold, leaving him depressed and almost suicidal. He did not see a way that he could regain his old life back, and he especially did not see a life for himself without the disease.

But in September of 2014, his doctor spoke with him about Harvoni, a new curative treatment that had a 99 percent success rate in clinical trials.

“When my doctor first mentioned it to me, I didn’t believe it because it was so completely different from the whole interferon ribavirin treatment that didn’t work for me,” Witter said. “The things he told me about it sounded too good to be true. The word cure is unbelievable to me that you can actually be cured of this thing that I’ve been dealing with for 15 years.”

Unlike the ribavirin/interferon combination therapy, the Harvoni regimen lasts a mere 90 days, taking one pill per day during that time period. Not only is the treatment simple and quick, but the side effects are nothing compared to what patients must suffer under treatment with interferon.

“I was able to really function while I was doing the 90 day treatment,” Witter said.

His waiting paid off tenfold when after only 30 days of treatment, his bloodwork came back completely clean. He continued the treatment for the full 90 days as recommended by his doctor, and was deemed cured as of February 1, 2015.

“My doctor told me that I was completely cured of HCV and my liver function was completely normal as if I had never contracted the disease at all. I contacted many people about it,” Witter said.

Shortly thereafter, Witter was able to regain aspects of his old life by working part time on the Broadway productions Aladdin and The Curious Incident of the Dog in the Nighttime. He is now more social and active than ever before, a pleasant change from the whirlwind of side effects that tore apart his life.

But how was Witter able to obtain the curative treatment so easily? Why was he not denied access to Harvoni like so many other patients with HCV?

Witter was lucky to have been informed about the treatment prior to its official release to the public by the FDA.

“The FDA approved Harvoni on a Friday, and Monday morning I called my insurance company and asked them about it. It was so new that they didn’t even have any data about it and I discovered that they denied coverage for the Harvoni because they didn’t have enough information,” Witter explained.

It was a setback, but Witter made the firm decision to not take no for an answer and pursued other avenues of receiving treatment.

“I contacted Gilead, the manufacturer, and they had a wonderful program called Support Path. The people there were just amazing,” he noted. “Not only in terms of guiding you through the process of trying to get the medication, but also once I got the medication, having a nurse on call that I could contact anytime to ask questions about it and get help throughout the whole thing.”

Within two weeks of contacting Support Path, Witter received a phone call from his pharmacy that the medication would be paid for in full.

“I was completely shocked. I could not believe this was happening to me,” Witter said. “Nothing like this had ever happened to me before. They basically said that I fit the criteria for someone who is either underinsured or uninsured to get the medication. My understanding through doing research online about Support Path is that they will try to bridge the gap if you’re underinsured, they will try to get the medication to the people that need it.”

Witter’s journey to a healthy life was a difficult one to say the least, but has taught him much about the availability of help to those in need. Additionally, it has taught him about the importance of conversation about this disease, and about the significance of the stigma attached to patients with HCV.

“I really feel like people do need to talk about it. So much of the stigma was lifted for me when I understood about the whole Baby Boomer thing,” Witter added. “There’s a lot of hope out there. The whole playing field has been leveled. It’s not a death sentence. There are treatment options.”

Witter now enjoys the comfort of knowing there is a cure, and he says others should rejoice in that fact, too. He advises patients to take responsibility for their care and fight hard when faced with insurance companies denying coverage to those in need.

“You just have to arm yourself with knowledge and figure out the best way to get the medication and to do the treatment. It’s definitely something that you can overcome,” he said.

For Witter, he has certainly overcome a great deal. But as they say on Broadway, the show must go on.

Articles

From the bright lights of Broadway to the darkness of hepatitis C infection, effective new drugs help patient start life anew.

Emerging from the Shadows of Hepatitis C

A hepatitis C testing protocol established by urban emergency departments saw high rates of infection among intravenous drug users and people born between the years 1945 and 1965. Of the 10.3 percent testing positive for hepatitis C, 75% were unaware that they were infected and 70% were chronically infected.

Hepatitis C virus is the most common chronic blood-borne infection in the United States, affecting an estimated 3 million people. The virus is a leading cause of end-stage liver disease, liver cancer and liver transplants.

Of those infected, people born between the years 1945 and 1965 (Baby Boomers) account for at least 4%. Baby boomers account for 75% of people living with HCV infection, with up to 1.75 million of them unaware they are infected.

Typically, those acutely infected with HCV are asymptomatic, with some people developing symptoms such as nausea, fatigue, general aches and pains, and abdominal pain.

Those tested in the study included high-risk patients such as intravenous drug users, Baby Boomers and patients with unspecified liver disease. Factors associated with testing positive for hepatitis C virus included injection drug use (38.4%), homelessness (25.5%), diagnostic testing (14.8%), birth cohort (13.7%) and male sex (12.4%).

“In addition to the myriad public health functions they already perform, urban emergency departments may play an important role as safety net providers for HCV screening,” said Douglas White, MD, of Highland Hospital, Alameda Health System in Oakland, California. “We have a better than even chance of reaching many of the three million people who are infected since they tend to be heavy emergency department users already. It gives us a chance to connect these people to ongoing care at HCV clinics or elsewhere in the health care system.” 

Urban caregivers on the front lines of fighting HCV.

Urban Emergency Departments Confront Emerging Hepatitis C Trends

Depending on the patient’s race, the genes of colon cancer may differ, according to a study published in the 

Researchers from the Mayo Clinic analyzed the genes of more than 3,300 stage III colon cancer patients in order to determine if racial disparities in colon cancer outcomes persist even after controlling for clinical and pathological variables.

The patients were stratified into categories based on race: Asian, black, or white. The investigators examined the mutations of two key cancer related genes known as BRAF and KRAS — both of which have been linked to worse overall outcomes.

BRAF mutation frequency more often occurred in tumors of white patients (13.9%), more than twice the rate of tumors of Asians or blacks, the researchers discovered. KRAS mutations were the highest in black patients at 44%. For Asian patients, KRAS/ BRAF wild type mutations were the most common, at about 66%, the researchers found.

“These findings put the issue of race more prominently on the radar of investigators that cancer biology may contribute to race based disparities,” the study’s co lead author and Mayo Clinic oncologist Harry Yoon, MD, explained in a press release. “While it is too early to change the way we treat these patients, our results indicate that future studies are needed to examine potential biological drivers of these differences more closely.”

Colon cancers were most likely to recur in black patients, but only in patients younger than 50 years old. For Asian or white patients, the rate of recurrence within five years ranged between 22 and 35%, the researchers said.

Some of the reasons for the differences among races may be attributed to socioeconomic factors, like diagnoses at a later stage, or decreased access to healthcare and suboptimal treatment, the authors continued in the statement. However, all the patients in this particular study were treated and had their disease monitored through a clinical trial, so the researchers believe these are not adequate explanations.

“In addition to published data indicating that a limited number of genes are preferentially mutated in colon cancers from black versus white patients, our study revealed differences in the mutation frequencies of BRAF and KRAS oncogenes that provide prognostic information in colon cancer patients,” concluded the study’s other co lead author and Mayo Clinic oncologist Frank Sinicrope, MD. “Our data provide further evidence that colon cancers from blacks are intrinsically different and are associated with more aggressive clinical behavior in young black patients.”

Research may offer hope for hepatitis C patients with liver disease.


Groundbreaking Study Yields Large Amounts of Functional Liver Cells from Stem Cells

The AASLD and IDSA HCV Guidance Panel recently released updated guidelines for the treatment of hepatitis C virus (HCV) infection.

 editorial board members Arthur Y. Kim, MD, Michael R. Charlton, MD, and HDV Next Co-Chief Editor Michael S. Saag, MD, reviewed information for the HCV guidance. Sources of information included peer-reviewed research; FDA research and safety information on products; manufacturer information; drug interaction data; prescribing information from FDA-approved products.

The study outlined recommendations for various topics ranging from HCV testing and linkage to care, when and in whom to begin therapy, initial treatment, treating unique patient populations, coinfection with HIV, and acute HCV.

Of those most at-risk for HCV, the panel identified those born between 1945 and 1965 as individuals who should be tested at least once for HCV. Those born between these years are in the baby boomer birth cohort and account for 75 percent of those infected with HCV.

The panel also identifies the following risk factors as those that put patients at higher risk for contracting HCV: injection drug use; intranasal illicit drug use; long-term hemodialysis; getting a tattoo in an unregulated setting; health care, emergency medical, and public safety workers after needle-sticks, sharps or mucosal exposures to HCV-infected blood; children born to HCV-infected women; prior recipients of transfusions or organ transplants; HIV infection; unexplained chronic liver disease and chronic hepatitis including elevated ALT levels; and solid organ donors (deceased and living).

The panel recommends antiviral treatment for anyone diagnosed with chronic HCV infection except for those with limited life expectancy due to “non-hepatic causes.”

The guidelines set forth by the panel also indicate that practitioners should treat those at greatest risk for disease complications before treating those with less advanced disease. To determine who is at greater risk, the panel suggests a biopsy of the liver for assessing hepatic fibrosis stage.

Depending on the stage and type of infection, there are different suggested regimens assigned by the panel for those affected by HCV. For instance, for treatment-naïve patients with HCV genotype 1a, the panel recommends a daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for 12 weeks, a daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir/dasabuvir (Viekira Pak), and weight-based ribavirin for 12 weeks in patients without cirrhosis or 24 weeks in patients with cirrhosis, among other treatments.

“Infection with HCV is considered to be acute during the first 6 months,” the researchers wrote.

The panel recommends the following procedures for treating and diagnosing acute HCV infection: undergoing HCV antibody and HCV RNA testing when acute HCV infection is suspected; regular laboratory monitoring until alanine aminotransferase levels are normal and HCV RNA is undetectable; and counseling to prevent transmission and other “hepatotoxic insults.” 

Panel suggests different regimens for different hepatitis C patient groups.

Risk Factors and Treatment Options for Those Infected with HCV

The liver offers the body a unique function in being able to regenerate itself in times of need. However, the process of self-reparation remained a mystery to scientists until recently.

Researchers at the University of California at San Diego School of Medicine (UCSD) recently discovered what they call hybrid hepatocytes in mice and humans. The hybrids are cells that generate new tissue more efficiently than normal liver cells, and they divide and grow without causing cancer, a risk associated with rapid cell division.

“This is the first time anyone has shown how liver cells safely regenerate,” said William Suk, PhD, director of the Superfund Research Program at the National Institute of Environmental Health Sciences (NIEHS), part of NIH.

The researchers studied liver function in mice by exposing them to carbon tetrachloride, a chemical commonly associated with Superfund sites. After observing how the tissue regenerated, scientists were able to isolate the hybrid hepatocytes.

Following this, the scientists exposed the mice to three different cancer-causing pathways and observed the hybrids closely. Liver cancer never originated from the cells.

“The entire program at UCSD is focused on the effects of toxicants on liver metabolism and functionality,” Dr. Suk said.

Another goal of the Superfund Research Program is to better understand how toxic chemicals affect human health. The liver plays an essential role in removing toxins from the body.

“Hybrid hepatocytes represent not only the most effective way to repair a diseased liver, but also the safest way to prevent fatal liver failure by cell transplantation,” noted lead researcher, Michael Karin, PhD, distinguished professor of pharmacology and pathology at UCSD and a member of the prestigious National Academy of Medicine.

With the arrival of this latest understanding of liver functionality, many patients will breathe a sigh of relief as new treatments develop and become available to the public. Hybrid hepatocytes may eventually bring newer and better treatment options for patients suffering from severe liver disease. 

Hope on the horizon for patients with liver damage.

Research Paves the Way for New Liver Disease Treatments

A recent Canadian study verified for researchers that hepatitis C virus (HCV) infection is a clear indicator of hepatic fibrosis when adjusting for alcohol dependence and age. Moreover, the study found that for socially disadvantaged people, the risk for illness and death is greater due to their socioeconomic status.

The study was based in a socially disadvantaged neighborhood in Vancouver, Canada where 371 participants were observed. In order for the participants to be a part of the study, they must have been living in single room occupancy hotels or recruited from the Downtown Community Court.

The participants were followed for a median 3.8 years and observed for 1269 person-years. They were assessed for physical and mental illnesses for which treatment is currently available. Patients’ health status were assessed using past medical records of their health-related hospitalizations, which were collected and analyzed by a team of psychiatrists.

Additionally, standardized interviews were conducted to establish a baseline of wellness for each individual involved in the study. During the study, 31 of the 371 participants died.

A Coroner report was collected and analyzed by the team of researchers for each individual who died during the study. Among participants aged 55 years and younger, psychosis and hepatic fibrosis were associated with earlier mortality.

Additionally, the study found that treatment rates for these conditions were low, with 32% of participants being treated for psychosis and zero being treated for HCV. Comparatively, other common disorders found within this group, such as HIV and opioid dependence, were treated more frequently than HCV and psychosis.

“Adults living in marginalized conditions have significantly greater all-cause mortality rates than other Canadians,” the researchers wrote. “We found a greater than eightfold increase in mortality rate.”

The study concludes that hepatic fibrosis and psychosis are associated with increased mortality in people living in marginal conditions. Due to their mental states and socioeconomic status, patients are less likely to seek treatment for their treatable conditions despite the fact that Canada offers free health care to its inhabitants.

The study states that timely diagnosis and intervention could reduce the high mortality in marginalized inner city populations.

Risk for illness and death greater due to socioeconomic status of patients with hepatitis C. 