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Hepatitis and the Homeless: The Coming Storm. An Update of a Hepatitis C Strategic Plan for Action Hepatitis Prevention, Education, Treatment & Support Network Honolulu, HI (808) 221-6204 Fax (808) 738-5797 [email protected]

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slide1

Hepatitis and the Homeless:The Coming Storm

An Update of a Hepatitis C Strategic Plan for Action

Hepatitis Prevention, Education, Treatment & Support Network

Honolulu, HI

(808) 221-6204 Fax (808) 738-5797

[email protected]

clouds gathering
Clouds gathering…
  • “Despite over 20 years of knowledge, millions of dollars thrown into prevention and the distribution of countless condoms, many people in the U.S. are contracting HIV and Hepatitis at an alarming rate.”
  • WHY?

Slide modified from Countny East, APRN, 12/2004

slide4

Estimated US HCV Prevalence including Select Populations: 5 MillionUnited States (Gish et al, J Clin Gastro Hep, 2005)

Incarcerated, ~310,000 (15%)1;Ever incarcerated, ~1,400,000

Injection drug users~300,000 (80-90%)2,3

HIV-infected ~300,000 (30%)4

Alcoholics~240,000 (11-36%)5

Living below poverty level ~940,000 (2.4%)6

Homeless ~175,000 (22%)7

Veterans ~280,000 (8%)8

Children (6-19 years) ~100,000 (0.1%)9

1MMWR Recomm Rep. 2003;52(RR-1):1-36. 2Edlin. Hepatology. 2002;36(5 Suppl 1):210-9. 3NHSDA Report. 2003. 4Khalili and Behm. Clin Inf Dis. 2000;31:154-61. 5Labreque and Sandt. In Hepatitic C: Choices. 2002. 6Alter et al. N Engl J Med. 1999;341(8):556-562. 7Nyamathi et al. J Gen Intern Med. 2002;17(2):134-43. 8Bräu et al. Am J Gastroenterol. 2002;97(8):2071-8. 9Jonas. Hepatology. 2002;36(5 Suppl 1):S173-8.

sirens to wail
Sirens to Wail

60 Second Hepatitis C PSA from New Orleans

adults who are at the most risk for infection with hepatitis c
Adults who are at the most risk for infection with Hepatitis C
  • Homeless substance abusers
  • Injection Drug Users
  • Prisoners sharing injection drug using equipment or tattooing needles or ink
  • People who snort drugs may be at risk
  • Those with multiple sex partners and a history of sexually transmitted diseases
  • Hemophiliacs
  • Healthcare workers including EMT and others
  • Military and others in other parts of the world who may exposed to blood

Slide by Ken Akinaka, MRA 10/2005

risk factors for transmission of hepatitis viruses and hiv in the usa

Risk Factor

HBV

HCV

HIV

Injection drug use

14%

60%

31%

MSM

15%

1%

47%

Heterosexual partners

40%

20%

10%

Transfusion

rare

Past

7- 20%

Past

2%

Occupational

5-7%

(past)

<<1%

<<1%

No Identified Risk

30%

10%

9%

Risk Factors for Transmission of Hepatitis Viruses and HIV in the USA

Proportion of Infections

Slide by Countny East, APRN, 12/2004

groups of high rates transmission of hepatitis c virus in the usa

Research indicates

HCV

25%

30%

30%

Residential SA Tx (Day Top, NY)

>2 xs Nat. Avg.

Homeless with Mental Illness & Substance Abuse (St. Louis, MI)

Co-infected with HIV (CDC, USA)

Veterans (UW-SPH, USA)

Higher with Vietnam era Veterans

LOCAL RESEARCH IS NEEDED WITH THESE HIGH RISK GROUPS TO TARGET PREVENTION, TESTING, & TREATMENT EFFORTS!

Groups of High Rates Transmission of Hepatitis C Virus in the USA

Proportion of Infections

Slide by Ken Akinaka, MRA, Jan. 2005

other groups with high rates transmission of hepatitis c virus in the usa

In USA

HCV

Inmates

25 - 30%

On Methadone Maintenance Treatment

85 to 95%

Other Groups with High Rates Transmission of Hepatitis C Virus in the USA

Proportion of Infections

Slide by Ken Akinaka, MRA, Jan. 2005

slide10

The number of homeless is growing because of the exploding real estate market, the high costs of rent, and in Hawai`i because of the consistent pleasant weather and environment.

  • In fiscal year 2004, emergency shelters in Chicago served 13,108 unduplicated clients, up from 11,050 in fiscal year 20031.

1. http://www.chicagohomeless.org/factsfigures/causesandfacts.htm#shelter

slide11

Each day at least 800,000 persons are homeless in the USA. That includes 200,000 children. On any given night, almost 300,000 veterans experience homelessness nationwide, a number far greater than the roughly 58,000 U.S. soldiers who died during the Vietnam War. 

  • As many as 18,000 veterans are estimated to experience homelessness every night in the six counties of the Chicago metropolitan area.
  • Over the course of a year, between 2.3 and 3.5 million people experience homelessness nationwide and approximately 166,000 people experience homelessness in the Chicago Metropolitan area.
slide12

Hepatitis B, Hepatitis C, Human Immunodeficiency Viral Infections and Tuberculosis In A Homeless Veteran Population

RAMSEY CHI-MAN CHEUNG, M.D.

Chief of Hepatology

Veterans Affairs, Palo Alto, CA

Cheung et al, J Clin Gastroenterol, 2002

domiciliary for the homeless
Domiciliary for the Homeless
  • Rehabilitation program
  • Homelessness of any duration
  • Ability for self-care
  • Monthly income < $1,200
  • Willingness and ability to return to work

Cheung et al, J Clin Gastroenterol, 2002

slide19

What most people still do not know: The delay in signs and symptoms of HIV or chronic Hep infections can result in people who don’t feel sick and who disregard that possibility of spreading HIV or Hep infection.

Slide by Countny East, APRN, & Ken Akinaka, MRA 12/2004

the face of the hepatitis c hcv epidemic is also changing
The face of the Hepatitis C (HCV) epidemic is also changing!
  • The new infections are estimated at 25,000 (CDC) to 40,000 (HRSA) per year.
  • Injection drug use and experimental injection drug use appear to be the greatest source of the spread of new infections.
  • 44% of the Homeless with mental illness and substance abuse may have already been infected with hepatitis B and/or C.

Slide by Ken Akinaka, MRA 10/2005

slide21

Other High risk groups that may continue to be a “Reservoir” of HCV infection unless they are tested, become aware of their infection, and are treated:

  • 5.4% to 8% of Veterans appear to have been infected.
  • Prisoners and people who have been incarcerated in the past appears to be about 15%. In many prisons it is 25% to 30%.
  • It has been estimated that over 300,000 people may have HCV that had a blood transfusion before our blood supply was required to be tested for HCV in July 1992.
  • Many of them still do not know it yet!

Slide by Ken Akinaka, MRA 10/2005

the face of the hiv pandemic is changing and it is younger
The face of the HIV pandemic is changing, and it is younger.
  • 25% of persons living with HIV in the world are 15 -24 years old.
  • ½ of all new infections of HIV occur in 15 to 24 year olds.
  • 51% of the new infections occur in women and girls.

Slide by Countny East, APRN, 12/2004

what youth are the most at the most risk for hiv infection
What youth are the most at the most risk for HIV infection?
  • Street youth (40% of homeless youth identify themselves as being gay or lesbian.)
  • Runaways
  • Teens having “survival sex”
  • Those with a history of sexual abuse
  • Teens with psychiatric diagnoses, such as mood disorder, substance abuse, and depression.
  • Teens lacking resources – housing, safety
  • Teens with older partners

Slide by Countny East, APRN, 12/2004

contributing factors to risk
Contributing factors to risk:

What is it about teens and young

adults that makes them so vulnerable

to contract HIV or Hep B or C?

Slide by Countny East, APRN, 12/2004

developmental stages in adolescence
Early teens (10 – 13)

Sex drive begins

Peer pressure, separation from parents

Poor future orientation.

Sexual interest usually exceeds activity

Mid Teens (14 – 16)

Sex drive surges

Peak conflict with parents

Peer group sets standards.

Increasing sexual behavior and experimentation.

Developmental stages in adolescence

Slide by Countny East, APRN, 12/2004

some quick numbers
Some quick numbers…
  • 17% of 7th and 8th grade students report that they have had sexual intercourse.
  • By the time teens turn 18, 56% of girls and 73% of boys report having had intercourse.

Slide by Countny East, APRN, 12/2004

late adolescence developmental stage 17 21
Late adolescence developmental stage (17 – 21+)
  • Maturation complete
  • Close friendships formed.
  • Intimacy.
  • Focus on role in society.
  • Future oriented.
  • Refinement of values.
  • Sexual orientation consolidates.

Slide by Countny East, APRN, 12/2004

teen behavior and their risks to acquire hiv or hepatitis b or c
Teen behavior and their risks to acquire HIV or Hepatitis B or C:
  • Have multiple sex partners.
  • Relationships are short-lived.
  • Teens fall “in-and-out of love” and it can be dangerous.
  • Teens tend to be “serially monogamous”…for a very short period of time!
  • Some experiment with using Injectable drugs
  • Some have Tattoos (or in Hawai`i Tatau or Polynesian Tattoos) or body piecing that is not done with new Needles or that uses shared ink.

Slide by Countny East, APRN, 12/2004

challenges that predispose teens adults to disregard hiv or hepatitis risk
Challenges that predispose teens & adults to disregard HIV or Hepatitis risk
  • The fear of HIV or Hepatitis has been lost.
  • HIV & Hepatitis command less urgency that it once did, feeding the perception that HIV is no longer a threat.
  • Infallibility, “HIV or Hep can’t happen to me.”
  • A belief by teens and others that HIV can be cured.
  • HIV medications are portrayed as being easy to take.
  • Sexual risky behavior is back in vogue.

Slide by Countny East, APRN, 12/2004

almost 50 of students have had sex before leaving high school 1
Almost 50% of Students Have HadSex Before Leaving High School1
  • 54% of HBV infections in U.S. attributed to sexual contact2
  • Like HIV, HBV is spread by infected blood and body fluids, but can be 100 times more infectious than HIV3

1. CDC. MMWR 2002;51(SS04):1–64., 2. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th ed. 2004., 3. CDC. MMWR 2003;52(RR-01).

slide31

Why is it so important to get

teens’ attention?

Every hour 2 adolescents

in the United States are infected with HIV,

and most never know they are at risk.

ExposureSero-conversionAsymptomaticSymptomatic AIDS Death

0 - 3 mos 3 - 6 mos 8 - 10 years 2-3 years 8 mos – 2 years

The Natural History of HIV infection

Slide by Countny East, APRN, 12/2004

stds and teens
STDs and Teens
  • It is believed that at least 25% of sexually active American teens have contracted an STD. That’s 3 million teens a year.
  • Bottom line, if teens are getting STDs, they either aren’t consistently using condoms or they aren’t using them right!

Slide by Countny East, APRN, 12/2004

a word on gay teens
A word on gay teens
  • There are nearly 1 million gay teens in the U.S.
  • There is a lack of information about safe-sex practices for gay teens.
  • Sex education ignores gay youth…it renders them “invisible”.
  • Experience emotional isolation.
  • Experience widespread harassment.
  • High suicide and dropout rates.

Slide by Countny East, APRN, 12/2004

traces of blood a hepatitis c video
Traces of Blood – A Hepatitis C Video

Training Video for Staff and Injection Drug Users

e ho omalu kakoa i ka po e nele a hune lets shelter protect those who are in need
E Ho\'omalu Kakoa I Ka Po\'e Nele A Hune"Lets Shelter & Protect Those Who Are In Need"

Save-A-Life Free Safety

Kits Campaign

  • Razors & Shaving Cream
  • Tooth Brushes & Tooth Paste
  • Nail Clippers
  • Toe Nail Clippers
  • Nail Files
  • Band-Aids
  • Antiseptic or Alcohol Wipes
  • Soap &/or Anti-Bacterial Hand Gel
  • Condoms
free save a life safety kit campaign
Free Save-A-Life Safety Kit Campaign
  • In May 2006, we informed a person with Hep B & a person with Hep C at the new 300 people Kakoa`ako Homeless Shelter that they were positive.
  • They both stated that they had been sharing razors.
  • In June 2006, we started our new free Save-A-Life Safety Kit Campaign!
can razor blades transmit hepatitis b
Can Razor Blades Transmit Hepatitis B?
  • “Determination of Hepatitis B Virus at Used Razor Blade by PCR”
  • 78 used razor blades were purchased from different barber’s shops in Turkey.
  • HBV DNA was detected in 6 (7.7%) razor blade samples.

CONCULSION: Reuse of razor blade that carry HBV will infect other people. Hence any HBV control & prevention program should educate barbers (and others) about the importance of contagious diseases, proper sterilization tech., and avoiding reuse and sharing of contaminated equipment and supplies like razor blade.

  • ICAAC, Reported by Jules Levin, Sept. 27-30, 2006, San Francisco, CA.
hepatitis c contamination of toothbrushes myth or reality
Hepatitis C – contamination of toothbrushes: myth or reality?
  • 30 patients with chronic hepatitis C had their saliva and rinsing water tested.
  • 40% of the toothbrush rinsing water specimens tested HCV-RNA-positive.
  • CONCULSION: Study demonstrates a contamination with HCV-RNA of considerable portion toothbrushes used by hepatitis C patients
  • Journal of Viral Hepatitis, Volume 13, No. 9, Sept. 2006, pp. 571-573(3)
hcv may survive on environmental surfaces at room temp at least 16 hrs up to 4 days
HCV may survive on environmental surfaces at room temp. at least 16 hrs. up to 4 days!

This re-emphsizes the importance of:

  • Cleaning and disinfection procedures,
  • Safe therapeutic injection practices, and
  • Harm reduction counseling and services for injection drug users.
get the facts
Get The Facts

Video by Diana Slyvestre, MD, and Patients who have Hepatitis C at Oasis Clinic in Oakland, CA

hawai i has the highest rate of liver cancer in the usa because of our high rates hep b c

Hawai`i has the highest rate of Liver Cancer in the USA because of our high rates Hep B & C.

Immigration from Pacific Island and Asian countries, which have extremely high rates of chronic hepatitis B is why we have the second highest rate of Hep B in the USA.

slide42
Population HBsAg+ % Infected with

Hepatitis B

American Samoa 50,923 3,565 7%

China 1,299,180,000 155,901,600 12%

Fiji 883,000 97,130 11%

Kiribati 72,000 22,320 31%

S. Korea 46,403,000 5,568,360 12%

Marshall Islands 190,000 22,800 12%

Micronesia, FSM 190,000 22,800 12% to 15%

New Zealand 3,662,000 29,296 0.8% (10% of Maori)

Palau 16,386 1,966 12% to 15%

Papua New Guinea 4,845,000 969,000 20% to 25%

Philippines 77,473,000 7,747,300 10%

Samoa (Western) 190,000 15,200 8% to 10%

Tonga 92,000 18,400 20%

Vietnam 82,427,000 9,891,240 12%

Here are the rates of hepatitis B in these other Pacific Island countries as reported by the World Health Organization.
slide43

The homeless are one of the highest at-risk groups that will continue spreading chronic viral hepatitis B and/or C unless we can start to effectively test & treat them for these hidden epidemics and vaccinate them for Hepatitis B.

  • Most states do not have any special case management program to help the homeless populations that are infected with chronic hepatitis and that are at risk of spreading these infections to others.
many homeless want to receive treatment for their hepatitis c
Many Homeless want to receive treatment for their Hepatitis C!

Hepatitis C treatment study in 2005 by Alan D. Tice, MD, 32 of 150 methadone patients that thought they had active hepatitis C volunteered to be treated with pegylated interferon and ribavirin.

An important new finding was that of those who were interested in treatment for their hepatitis C, 40% were homeless!

these efforts will save lives limit the spread of disease and in the long run be cost effective
These efforts will save lives, limit the spread of disease, and in the long run be cost-effective!
  • Earlier testing and more housing, medical benefits, support, and case management are needed for effective treatment.
  • Medical Costs of Cirrhosis or End Stage Liver Disease related complications (even before a Liver Transplants is needed) is very costly to our Healthcare Systems.
  • Liver Transplants cost $250,000 to $350,000 apiece with about $10,000 of anti-rejection medications per year.
chronic liver disease due to hepatitis c causes between 10 000 and 12 000 deaths per year
Chronic liver disease due to hepatitis C causes between 10,000 and 12,000 deaths per year!
  • It is the leading indication for liver transplantation each year in the United States.
  • By the year 2010, the number of deaths from hepatitis C is expected to rise to 38,000 each year.
  • It is also now the primary reason for death from HIV.
slide47

A number of Homeless drink Alcohol.Should they be treated for their HCV?“Alcohol use and treatment of hepatitis C virus: results of a national multicenter study”

  • A total of 4061 subjects were enrolled.
  • The aim of study was to determine the impact of alcohol use on HCV tx outcomes.
  • Recent alcohol use was associated with increased higher HCV tx discontinuation and lower SVR.
  • However, patients who use alcohol and completed HCV tx had a response comparable to that of nondrinkers.

CONCULSIONS: Patients with a history of alcohol use should not be excluded from HCV tx. Instead, additional support should be provided to ensure their ability to complete HCV tx.

  • Gastroenterology. 2006 May;130(6):1912-4. Dept. of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas. PMID: 16697724 [PubMed – in process]
free hepatitis b or c tests for the homeless other at risk groups
Free Hepatitis B or C Tests for the Homeless & other at risk Groups

We now give a Free T-Shirt to those who test at:

  • Health Fairs
  • Community & Organizational Talks
  • Free for Homeless or people with risk factors who cannot afford special low cost tests
  • $15 for HBV
  • $25 for HCV
  • $35 for Both Tests
where can they be tested for hcv if you do not have health insurance
Where can they be tested for HCV if you do not have Health Insurance?
  • Very limited resources in the USA
  • Home Access Hepatitis C test Kits for $59.95 at http://www.homeaccess.com/02/
  • Through the State Department of Health in Hawai`i if you have been an injection drug user
  • Check with your local Health Dept. if you do not have Health Insurance or cannot be tested by your physician or a local Community Health Clinic

Slide by Ken Akinaka, MRA 10/2005

another important health concern the homeless as well as many otherwise healthy people

Another Important Health Concern!The Homeless as well as many otherwise Healthy People

Need to Be Protected from Hepatitis A & B and need to be vaccinated!

reminder persons with hiv or hepatitis c need to be protected against hbv
Reminder - Persons With HIV &/or Hepatitis C need to be Protected Against HBV
  • HBV can survive at room temperature on environmental surfaces for at least one month
  • 50% of infected adults are asymptomatic and can spread HBV without knowing it
  • HBV is the leading cause of liver cancer in the U.S.1
    • 2nd only to tobacco among known human carcinogens1

Nearly one-third of persons infected with acute hepatitis B have no identifiable risk factors.

CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th ed. 2004.

Slide from Twinrix, June. 2005

persons without identifiable risk factors may also wish to be protected against hav
Persons Without IdentifiableRisk Factors May Also Wish to BeProtected Against HAV
  • Possible settings for hepatitis A transmission include:
    • Restaurants—infected food handlers or contaminated food/water2
    • Daycare—poor hygiene among young children and diaper-changing activities among staff2
    • Healthcare institutions2
    • Schools2
    • Outdoor concerts/camping events3 (and Homeless settings)

Nearly half (45%) of persons infected with

hepatitis A have no identifiable risk factors.1

1. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th ed. 2004., 2. CDC. MMWR.1999;48(RR12)., 3. CDC. MMWR.2003;52(35).

twinrix over 98 effective after a 3 dose series
TWINRIX—Over 98% EffectiveAfter a 3-dose Series

Complete TWINRIX safety summary to follow.

Slide from Twinrix, June. 2005

are you at risk for vaccine preventable hepatitis vph page 2
Are You at Risk for Vaccine-Preventable Hepatitis (VPH)? Page 2
  • I come from Asia or the Pacific Islands
  • I take street drugs
  • I am a man who has sex with men
  • I have a blood-clotting disease with clotting factor infusions
  • I had more than one sex partner during the last 6 months
  • I have sex with or live with a person with hepatitis B
  • I provide direct services to people with developmental disabilities

Adapted from CDC Adult Vaccination Screening Form. Accessed at www.cdc.gov/nip/recs/adult_vac_scrn_hcp.pdf on 2/11/04. (Data on file, TWR404, GlaxoSmithKline.)

60 000 adults die each year from vaccine preventable diseases
60,000 Adults Die Each Year FromVaccine-Preventable Diseases
  • Medical visits are often missed opportunities to provide needed immunizations
  • Add adult vaccination to your practice
    • Identify adults at risk through pre-existing conditions and/or diagnosis codes
      • Age
      • Disease State

CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th ed. 2004.

vaccinate adults at risk for vaccine preventable hepatitis vph it s needed
Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH)It’s Needed!
  • Vaccine-preventable hepatitis (VPH) is a significant public health problem in the U.S.
    • VPH causes 5,100 deaths per year
    • HBV is the leading cause of liver cancer in the U.S.
      • 2nd only to tobacco among known human carcinogens

CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th ed. 2004.

vaccinate adults at risk for vaccine preventable hepatitis vph it s recommended
Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH) It’s Recommended

1. CDC. MMWR 1998;47(RR19)., 2. CDC. MMWR 1991;40(RR13)., 3. CDC. MMWR 1999;48(RR12).,

4. CDC. MMWR 2002;51(RR08).

vaccinate adults at risk for vaccine preventable hepatitis vph it s reimbursed
Vaccinate Adults at Risk for Vaccine-Preventable Hepatitis (VPH)It’s Reimbursed
  • Vaccination routinely reimbursed for patients at risk
    • Persons with chronic liver disease/hepatitis C
    • Persons with sexually transmitted diseases
      • Chlamydia, Gonorrhea, Herpes, HPV, Syphilis, etc.
    • Men who have sex with men
    • HIV-positive persons

Data on file, TWR1602, GlaxoSmithKline.

merck will provide free vaccines to adults who are uninsured unable to afford vaccines
Merck will provide free vaccines to adults who are uninsured & unable to afford vaccines!

Starting the third quarter of 2006, Merck vaccines will become available through their new Patient Assistance Program.

All of Merck Vaccines are available in this program including Hep A, Hep B and Pneumococcal vaccines that are recommend for people with chronic viral Hepatitis.

Uninsured people with incomes less than $19,600 are eligible (twice the Federal poverty level).

Forms can be faxed to the patient’s physician’s office with a processing goal of less than ten minutes – so that qualifying patients can receive Merck vaccine during that visit!

May 26, 2006, News Release Media Contacts: Maggie Kohn

(908) 423-5655 & Mary Elizabeth Blake (215) 652-5558

slide61
Please Remind people:“It’s not who you are but what you do that puts you at risk for HIV or Hepatitis B or C.”

Slide by Countny East, APRN, 12/2004

we need to help save lives before it is too late
We need to help save lives before it is too late!
  • HCV is often “CURABLE” if people do not wait until they feel ill to be tested and treated. Most people will not feel ill until it may be too late to be treated.
  • Many homeless and substance abusers, who have been treated for Hepatitis C, are now helping to educate others in ways that outreach workers, who are not infected with Hepatitis C, cannot do!
  • We can help stop the spread of Hepatitis C, save lives, and reduce the “Reservoir” of these viruses by educating the homeless and other at risk groups, vaccinating them for HAV and HBV, and treating them before it is too late!
many of the homeless will eventually find stable housing and become productive citizens again
Many of the homeless will eventually find stable housing and become productive citizens again!
  • However, chronic viral hepatitis B & C will continue to be “silent epidemics” that will infect and eventually kill many of them unless they are tested and treated.
resources
Resources

Viral Hepatitis

  • www.cdc.gov/hepatitis
  • www.hcvadvocate.org
  • www.hepcproject.org
  • www.immunize.org
  • www.hepb.org
hepatitis and the homeless the coming storm
Hepatitis and the Homeless:“The Coming Storm”

Ken Akinaka, MRA

In association with Alan D. Tice, M.D.

Hepatitis Prevention, Education, Treatment & Support Network and www.IDLinks.com

Honolulu, HI

(808) 221-6204 Fax (808) 738-5797

[email protected]

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