DiscoverCounselor Toolbox PodcastAddressing Viral Hepatitis
Addressing Viral Hepatitis

Addressing Viral Hepatitis

Update: 2020-07-31


Addressing Viral Hepatitis

Based in part on SAMHSA TIP 53

Dr. Dawn-Elise Snipes Executive Director,

CEUs are available for this presentation at

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– Overview of viral hepatitis

– Screening and evaluation

– Counseling Approaches for People Who Have Viral Hepatitis

– Ensuring Safety

– Providing Reliable Information

– Building the Therapeutic Relationship

– Helping Clients Understand Their Diagnoses

– Incorporating Client Needs in Substance Abuse Treatment Planning

– Developing a Prevention Plan

– Using Motivational Approaches

– Confronting the Social Factors of Hepatitis

– Addressing Relapse

– Building Support Systems

– Providing Effective Case Management

Overview of Viral Hepatitis

– 3.5–5.3 million people in the United States live with chronic viral hepatitis

– Symptoms can take decades to manifest, so many people who are infected do not seek timely treatment

– SUD does not cause, but can exacerbate Viral Hepatitis

– As many as 90 percent of people who have HIV infection have been infected with HBV

– 33 percent of people who are infected with HIV are co-infected with HCV

– Chronic hepatitis infection affects approximately 5% of psychiatric inpatients

Overview of Viral Hepatitis

– More than 90% of infants that are infected will develop a chronic hepatitis B infection

– Up to 50% of young children between 1 and 5 years who are infected will develop a chronic hepatitis B infection

– 90% of healthy adults over the age of 19 will recover from a Hep B exposure

– HCV will spontaneously clear in 25% of the population

Love Your Liver

– Breaks down toxins found in the blood and excretes them as harmless byproducts either in the stool or the kidneys

– Metabolizes drugs, alcohol, and prescription and over-the-counter medications

– Makes cholesterol and clotting factors

– Stores sugar (as glycogen –> glucose), fats, and vitamins



• Fever

• Fatigue

• Loss of appetite

• Nausea

• Vomiting

• Abdominal pain

• Dark urine

• Clay-colored bowel movements

• Joint pain

• Jaundice (yellow color in the skin or the eyes)

Hepatitis A Transmission

– An estimated one-third of U.S. residents have had HAV which is down 92% since the discovery of a vaccine.

– HAV is spread by the oral transmission of fecal matter (stool) of a person who is infected with HAV and it is extremely contagious.

– HAV can survive outside the body for several days and in water for several months.

– People are most infectious during the 2 weeks before the onset of symptoms.

Hepatitis B Transmission

– Hepatitis B is spread when blood or body fluid infected with the hepatitis B virus enters the body of someone who is not infected.

• Birth (spread from an infected mother to her baby during birth)

• Sex with an infected partner

• Sharing needles, syringes, or drug preparation equipment

• Sharing items such as toothbrushes, razors, or medical equipment (like a glucose monitor) with an infected person

• Direct contact with the blood or open sores of an infected person

– Hepatitis B is not spread through food, sharing utensils, breastfeeding, kissing, hand holding, coughing, or sneezing.

– Many people with hepatitis B don’t feel or look sick. However, they can still spread the virus to others.

– The hepatitis B virus can survive outside the body (even in dried blood) and cause infection for at least 7 days.

Hepatitis C Transmission

– Hep C is commonly spread by:

• Sharing drug needles or accidental needlestick injuries

• Being born to a mother who has hep C

– Less commonly, Hep C is spread by:

• Contact with someone's blood via razors or toothbrushes

• Sex

• Getting a tattoo or body piercing in an unregulated setting

– Hep C CANNOT be spread by:

• Food, water, or sharing eating utensils

• Hugging, kissing, holding hands, coughing, or sneezing

Who Should Be Regularly Tested

– People at risk for infection by sexual exposure

– People who inject drugs

– People with HIV

– Household and sexual contacts of people with hepatitis B

– People requiring immunosuppressive therapy

– Hemodialysis patients

– People with hemophilia who receive blood clotting factors

– People with another form of viral hepatitis

– Pregnant women

– Infants born to infected mothers

Who Should Get Vaccinated (A & B)

• All infants

• People at risk for infection by sexual exposure

• People whose sex partners have hepatitis B

• Sexually active people who are not in a long-term, mutually monogamous relationship

• People at risk for infection by exposure to blood

• People who inject drugs

• People who live with someone who has hepatitis B

• Health-care and public-safety workers at risk for exposure to blood or blood-contaminated body fluids

• People who receive hemodialysis or, prior to 1992, blood or organ transplants

• People with diabetes who are 19–59 years of age

Who Should Get Vaccinated (A & B)

• International travelers to countries where hepatitis B is common

• People with hepatitis C virus infection

• People with chronic liver disease

• People with HIV infection

• People who are in jail or prison

• All pregnant women during each pregnancy

Screening and Evaluation

– Verbal screening at intake for all people

– Those who are at risk should be counseled to seek medical screening.

– Screening is an opportunity to educate about hepatitis.

– Note: Some people confuse hepatitis (HBV/HCV with HIV) CLARIFY!

– Antibody vs. antigen

– Antigens (virus) –contagious

– Antibody (indicates prior exposure)

– A “positive” HCV antibody test could mean the person is a chronic carrier of HCV (75 percent to 85 percent), has been infected but has resolved infection (15 percent to 25 percent), or is one of the few recently (acutely) infected

– Follow-up to a positive: A qualitative HCV RNA test determines whether the virus is present in the blood.

Counseling Approaches

– Providing Reliable Information

– Liver Foundation


– Know More Hepatitis

– Locations

– Posters in the lobby

– Reading material in your office

– Posters in bathroom stalls

Counseling Approaches

– Ensuring Safety

– Confidentiality

– Establish rapport

– Discuss overlapping symptoms to prevent defensiveness

Counseling Approaches

– Helping Clients Understand Their Diagnoses

– Acute vs Chronic (> 6 months)

– A, B, C

– Among those who develop chronic HCV or HBV infection, an estimated 20 to 30% will develop cirrhosis

– Progresses faster in those infected after 40

– Increased risk of developing Type 2 Diabetes

– Abdominal swelling (Ascites) indicates treatments are no longer working.

– Hepatic encephalopathy will occur in approximately 30 to 40% of individuals with cirrhosis is the illness becomes more severe.

– Neurologic and psychiatric manifestations including apathy, irritability, decreased energy level, impaired sleep-wake cycle, impaired cognition, diminished consciousness, or loss of motor control

Counseling Approaches

– Helping Clients Understand Their Diagnoses

– Interventions (Consult with physician)

– Medication to slow progression of cure the disease

– Get screened for liver cancer annually

– Avoid or limit alcohol and smoking since both cause a lot of stress to your liver

– Eat a healthy diet with lots of vegetables since fried, greasy foods are hard on your liver

– Control blood sugar and prevent diabetes

– Limit sodium intake to less than 2000 mg per day

– Maintain a healthy weight to prevent fatty liver

– Drink coffee-

– Individuals with chronic HCV who do not have cirrhosis can often take acetaminophen, aspirin or NSAIDs at low or standard recommended dosages.

– Persons with chronic HCV infection and cirrhosis should, in general, avoid taking acetaminophen, NSAIDs or aspirin

– Those with chronic HCV are often told to avoid taking iron supplements or a daily multivitamin that contains iron

– Vitamin D deficiency is common with chronic HCV infection (and depression)

Counseling Approaches: Motivation

– Readiness

– Precontemplation

– Contemplation

– Preparation

– Action (testing)

– Maintenance (treatment/prevention)

Counseling Approaches: Motivation

– For Testing or Treatment

– Physical (relieve symptoms)

– Affective (anxiety/depression)

– Cognitive (provide direction and clarity)

– Environmental/Relational (know they are not putting anyone else at risk or how to mitigate risk)

– OARS: Open-ended questions, Affirmation, Reflection, Summarizing

– FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Support

Counseling Approaches

– Developing a Prevention Plan

– Prevent self and loved ones from infection

– Prevent additional infections or development of confounding issues

– Prevent infecting others if infected

Counseling Approaches

– Building Support Systems

– Educate about prevention and to reduce stigma

– Family counseling

– Community education

– Support groups

– For the patient

– For the family

– For each stage: New Dx, Chronic Illness, Terminal Conditions

– Encourage development of synchronous support groups in your community (hospitals, churches, libraries)

– Online support groups

Case Management (Disease and Tx)

– Physical

– Pain management

– Disability income- /Lost wages

– Nutrition

– Medication maintenance (patient assistance programs)

– Clinical trials

– Affective/Cognitive

– Anger

– Anxiety

– Depression

– Grief

– Brain fog / concentration

– Environmental/Relational

– Housing

– Stigma and discrimination (Advocacy/Education)

– Enhance support for both the individual and SOs


– Hepatitis impacts millions of people physically, affectively, cognitively, financially and relationally

– Several symptoms of hepatitis overlap with that of depression or cognitive impairment including

– Fatigue

– Difficulty concentrating

– Loss of appetite

– Dark colored urine* (if dehydrated)

– Achiness (joint pain)

– Hepatitis, like other blood borne pathogens carries a stigma and is highly contagious

– Clinicians have an obligation to educate the public about hepatitis to destigmatize and advocate for health prevention activities


– Counseling should focus on where the person is (testing/treatment) and their level of readiness for change.

– Counseling goals should be to

– Reduce risk of infection/complications or infecting others

– Improve health literacy regarding hepatitis

– Encourage social support

– Assist the person in connecting with needed biopsychosocial resources









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Addressing Viral Hepatitis

Addressing Viral Hepatitis

Charles Snipes