How to cure hepatitis C with modern drugs and not go broke

One day I turned as yellow as a lemon.

It was a cold January 2000. I woke up with chills, looked in the mirror and was stunned: the whites of my eyes turned into “yolks”, and my skin acquired a cheerful shade of citrus fruit. A terrible hydrogen sulfide belch also appeared, and I realized that I urgently needed to see a doctor.

Go to the doctor

Our articles are written with love for evidence-based medicine. We cite reputable sources and seek comments from reputable doctors. But remember: responsibility for your health lies with you and your doctor. We do not write prescriptions, we give recommendations. Whether you rely on our point of view or not is up to you.

How I was diagnosed

The local therapist immediately called an ambulance, which took me to the city infectious diseases hospital, to the ward with the same “fruits”. Then a blood test and diagnosis: viral hepatitis C.

I won’t say that the news about hepatitis shocked me. It just so happened: reckless youth in the dashing nineties. I couldn’t let the heroin wave pass me by - I got completely screwed. At that time, I had already had more than two years of “experience.” And although there was still money for a new syringe, the use of common utensils to prepare the potion for use occurred sporadically. Back then I couldn’t believe it was so dangerous. I still have no idea at what point I caught the virus. But if it’s through drugs, there’s no option.

What is viral hepatitis C

Hepatitis C is a liver disease caused by the hepatitis C virus. The disease can occur in both acute and chronic forms.

Hepatitis C is one of the main causes of liver cancer. Chronic inflammation provokes damage to this organ, which often leads to malignant degeneration of cells.

The hepatitis C virus is transmitted through blood. Transmission is possible through injecting drug use, during medical procedures, including transfusion of contaminated blood, and in rare cases through sexual contact.

In 2022, hepatitis C was detected in 45 thousand Russians. In total, this disease in our country affects, according to various estimates, from 2.2 to 4.9 million people. 70% of them learned about their diagnosis by accident.

The attending physician’s lecture about the “gentle killer,” cirrhosis and other delights of this incurable, according to the lecturer, disease did not impress me at all. At the age of 25, it wasn’t that I didn’t believe, but rather, I didn’t see anything terrible in the fact that I would die someday later. And this “later” will not happen tomorrow or even the day after tomorrow. And if it’s “incurable,” then what’s the point of reflecting?

With these thoughts, I was discharged two weeks later, having removed all the symptoms of acute hepatitis with the help of droppers, injections and tablets. With the discharge, I went to the infectious disease specialist at my place of residence, and she registered me. She ordered me to get tested every six months. On this we parted ways.

For the next ten years I hardly remembered my problem. My head fell into place: I settled down, changed my lifestyle, got married. My wife found out about my virus in the first days of our acquaintance. Being an educated and sensible person, she took this news adequately. In the future, we did not focus on this point. The impact of the disease on our life together was manifested only in the need to use condoms, since the risk of transmitting the virus to a woman during unprotected sexual intercourse is quite high, 5–7%. As for the rest, hepatitis did not remind me of itself.

At some point, I noticed that I still knew exactly where my liver was located. Any increased physical activity led to a feeling of bloating and heaviness in the right hypochondrium. Since bad habits in the form of alcohol were still present in my life, I began to notice that hangovers were becoming more severe and were accompanied by a bitter taste in my mouth. After some time, similar symptoms began to be caused by banal overeating. I again realized that I urgently needed to see a doctor.

Depriving forms

The disease can be typical or atypical.

In the atypical form, symptoms may be mild:

• In the abortive form, the rash is absent or there is a single focus;
• Bullous form - multiple blisters with clear liquid;
• Hemorrhagic form - blisters with bloody fluid, in place of which scars remain.
• The gangrenous form leaves difficult-to-heal ulcers and rough scars.

How I thought about treatment

The infectious disease specialist from the local clinic, a woman about 60 years old, was neither happy nor upset when she saw me. The duty officer asked why I had never come in all this time, and wrote me a referral for tests with a week to come for the results.

A week later I was like a bayonet. I found out that everything is bad with me, as it should be given my attitude to health: the viral load - the number of viral particles in the body - is growing, liver enzymes are also elevated, and on ultrasound the liver itself is not well enlarged.

I repented of my sloppiness and promised to improve. The doctor prescribed me medications to maintain liver health - so-called hepatoprotectors, gave me a printout with a special diet and was already ready to say goodbye to me. And then I asked if there was any news in terms of a complete cure for my hepatitis. Her answer surprised me a little:

- There is treatment, but do you need it?

It turns out that since the nineties there has been a treatment regimen for hepatitis C with interferons - special proteins similar to those secreted by the human body in response to the invasion of any viruses. It is believed that this protein is capable of modifying the membrane of uninfected liver cells and thereby protecting them from the penetration of the virus. In general, the scheme works, but there are some nuances:

• The effectiveness, depending on the genotype of the virus, ranges from 45 to 90%.
• The course of treatment lasts from six months to one and a half years.
• Treatment is by daily injections.
• The drugs have a huge list of side effects, some quite serious.

Simply put, it is possible to undergo treatment, but it is long and difficult, with no guarantee of cure and with a high probability of significantly worsening the quality of life as a result. But there is a program, and they will put me on the waiting list if I insist. In the meantime, as a farewell, the doctor gave me a business card with contacts of a local group of patients undergoing interferon treatment.

And here I dived deeply into the topic for the first time. I met and communicated with a girl named Yulia, who at that time had been on the pegylated interferon + ribavirin regimen for almost six months. Pegylated interferon works in the body much longer than usual. Thanks to this, Yulia needed to get an injection once a week, and not daily. But this is every week throughout the year! And you can’t get injections in your hands or give them to yourself. You need to come to the clinic every week. And that's not the worst part.

The most unpleasant thing is the side effects. From the first injections, the temperature rises and a prolonged flu-like state sets in with aching bones. Yulia told me that you get used to it after about a month. Much worse is constant itching of the skin and various digestive disorders. Almost all patients also experience severe depression, which in itself is a serious pathological condition.

And the most painful topic for the female half is hair. During treatment they begin to fall out. I’ll say right away that Yulia endured all these “charms” like a steadfast tin soldier. Working, raising a child. She also constantly encouraged me to start therapy. And thank God, her treatment worked, the virus went away and did not return.

But then I didn’t make up my mind. I read how they give up injections halfway through, when there is no more strength to continue. Or due to lack of response to treatment. I thought about it and didn’t sign up for the program. In addition, with hepatoprotectors, my discomfort gradually subsided, and for several more years I limited myself to symptomatic treatment.

Kinds

There are several types of hepatitis in cats, as well as the causes of its occurrence. The main types of inflammatory processes in the liver are toxic, allergic and infectious.

According to the nature of the course, hepatitis in a cat can be acute or chronic. Thus, toxic type hepatitis is caused by poisoning with poisons of mineral origin, most often used to bait rodents. So, cats that catch mice or rats can be poisoned by phosphides, zoocoumarins or arsenic.

Toxic hepatitis is also possible in those animals that live in unfavorable environmental conditions, as well as when consuming poisonous plant species. Often the cause of liver inflammation against the background of intoxication of the body is the use in the animal’s diet of low-quality feed contaminated with pathogenic fungal microorganisms.

The development of toxic hepatitis is also caused by long-term use of medications, especially sulfonamide drugs and antibiotics. Substances filtered by liver cells remain in the organ, gradually accumulating, leading to poisoning.

Another type is infectious hepatitis. This pathology develops against the background of various viral diseases. In most cases, it is a primary lesion, but a secondary type of infection is also possible, developing as a complication of bacterial or parasitic infection.

Viral hepatitis often accompanies infections such as leptospirosis, feline panleukopenia, toxoplasmosis, and chlamydia. This is due to the fact that waste products of parasitic organisms, fungi or pathogenic bacteria accumulate in the liver structures and gradually their concentration leads to poisoning.

An allergic inflammatory process in the liver develops as a result of complications caused by infection or toxic substances. Certain factors are of no small importance in the development of inflammatory processes in liver cells - stagnation due to poor outflow of venous blood, disruption of the body's defenses, reduced body weight and chronic diseases of internal organs.

The causes of hepatitis in cats are also associated with other factors:

1. Pathological processes in the body of an autoimmune nature. Violation of the functional characteristics of various systems in the body due to autoimmune processes also negatively affects the functioning of the liver. Hepatitis can be caused by diseases such as autoimmune thyroiditis, dermatitis herpetomorus, erythema nodosum, hemolytic anemia, fibrosing alveolitis, primary sclerosing cholangitis, systemic lupus erythematosus. All this can cause chronic hepatitis.
2. Toxic and chemical substances penetrating through mucous membranes or along with feed. Hepatitis can be caused by long-term use of medications.
3. Ailments that provoke increased accumulation of an element such as copper in the body.

How I learned about modern methods of treating hepatitis C

I would like to note that I went through all the tests and studies, as promised to the doctor, strictly. But everything that they did at the clinic - they took blood for biochemistry and performed an ultrasound - did not help in any way to assess how quickly my hepatitis was moving towards cirrhosis. Another safe and painless diagnostic method was fibroscan - ultrasound using a special device that determines the degree of fibrosis, that is, damage to liver tissue. If there is no access to a fibroscan, the only option left is a biopsy - a puncture in the liver with a special needle, which removes a piece of tissue for examination.

Fibroscan was found in a specialized gastroenterology center, and I went there. I paid about 2500 R and went through the research. I was diagnosed with the first, very initial stage of fibrosis. By luck, the result had to be taken from a local hepatologist. The young woman explained to me the essence of the research results and asked why I was not receiving treatment.

I immediately figured that they probably had their own paid program at the center. Well, I immediately briefly said everything I thought about interferon therapy. She wasn't embarrassed at all. I just asked why I don’t take normal pills.

- Normal pills?

Then I learned that three years ago the American company Gilead registered the first tablet form of a drug that directly affects the RNA of the hepatitis C virus and prevents it from being copied. This drug is called sofosbuvir. Combinations of this drug with later new products from the DAA line - direct-acting antiviral drugs - are by far the most effective means of treating hepatitis C. The cure rate is 95-97%, with virtually no side effects, and in tablet form!

This was great news. The bad thing is that a course of treatment with the original drug cost somewhere at the price level of a five-room apartment with European-quality renovation. But we were lucky. Gilead has licensed 11 Indian companies to produce generic drugs for the needs of poorer countries. Therefore, it was possible to purchase an analogue of the original drugs for quite reasonable money. The problem was that generics were not officially supplied to Russia, since our country was not considered the poorest. It was necessary to contact authorized trading companies in India directly and place the order privately.

Period of rash

The type of rash depends on the severity of the disease. At the initial stage, the rashes look like small pink spots located on healthy skin.

If the process develops typically, then the next day they are replaced by bubbles with a clear liquid - grouped vesicles. After 3 days, their contents become cloudy. The rash occurs in spurts, with breaks of several days.

If a severe gangrenous form develops, the filling of the vesicles may be mixed with blood. It seems that the bubbles move to another place, located around the body.

If the form of inflammation is mild, the manifestation of the disease can only be neurological in nature, when the patient feels pain, but there is no rash. This is herpetic neuralgia.

How effective is modern therapy for hepatitis C?

Nikolay Golovenko gastroenterologist at GMS Clinic

With the advent of drugs from the group of RNA polymerase inhibitors, treatment of hepatitis C with interferons has lost its relevance. For example, the effectiveness of treatment with PEG - pegylated interferon - did not exceed 60%. Treatment took from six months to two years and was accompanied by multiple side effects.

Moreover, the effectiveness of RNA polymerase inhibitors, according to various sources, ranges from 80 to 95%. In case of insufficient effectiveness in the first three months, this drug is prescribed for another 12 weeks, which, as a rule, leads to complete elimination of the virus and recovery of the patient. The exceptions are patients with transformation of hepatitis into cirrhosis and patients with hepatocellular carcinoma.

Unfortunately, according to the requirements of the Ministry of Health, infectious diseases hospitals and hepatology departments can only purchase the original drug, the cost of a course of treatment ranges from 500,000 to 1,000,000 RUR. Therefore, due to a shortage of drugs, some patients are still prescribed interferon therapy. Or they informally offer treatment at their own expense.

Thanks to the appearance of generics on the market, the cost of a course of treatment with polymerase inhibitors has decreased and currently ranges from 35,000 to 100,000 RUR. The effectiveness of generics is approximately the same compared to the effectiveness of the original drug.

The hepatologist estimated the average cost of a course of generics at $1,000 (74,166 RUR). For the exact amount, it was necessary to decide on a specific drug and its quantity, and then check with the sellers. The sellers in this case were intermediary companies that had established communication with the Indian side. These were pure intermediaries. They simply processed requests from Russian patients on their websites and forwarded the information to a trading partner in India. Buyers paid for the medicines and delivery directly to the Indians.

Many individuals offered drug delivery services. The doctor gave me a business card from one of these “helpers,” who, according to her, had already been checked. But first I had to make a fundamental decision to take such a sharp turn. The new information looked too fabulous to be true.

Symptoms of feline hepatitis

Parenchymal jaundice, which is hepatitis, gives a bright yellow, even lemon-colored color to the mucous membranes and conjunctiva.

Signs of hepatitis in cats:

• high body temperature;
• lack of appetite;
• the animal drinks a lot and often, laps up the water very loudly and greedily;
• presence of vomiting;
• diarrhea and constipation replace each other, and the stool is yellow or gray-yellow;
• the urine will be dark. This is due to the large amount of protein including bilirubin and bile pigments;
• the cat looks exhausted.

During the examination, the veterinarian palpates and taps the liver area, and the animal is clearly restless, showing this by behavior and plaintive meowing. If the pain is severe, the cat will use its teeth to stop palpating.

If an allergy is added to hepatitis, the skin will itch and peel, and hives will appear. Parts of the skin may even bleed, but this is not common.

If the liver is severely damaged, then any type in the acute form begins to turn into chronic, which is fraught with inflammation of the peritoneum with the appearance of effusion fluid into the cavity (ascites) and hemorrhagic diathesis (increased bleeding).

Diagnosis of the disease

The veterinarian will make an accurate diagnosis called “hepatitis” only after collecting a complete medical history. The owner will be asked about food and housing conditions, where and with whom the cat came into contact, what it was sick with, and how it was treated.

Clinical examination includes examination with palpation and percussion of the liver area.

Also, venous blood will be taken from the sick pet for biochemistry, and all types of feces for laboratory research. The indicators will be eloquent: they will reveal excessive urobilin and bilirubin in the blood, but there will be a low amount of stercobilin in the feces.

How I decided to take generic treatment

And I took a break. I was observed for about another year at the gastrocenter. During this time, my maintenance treatment changed somewhat: the doctor replaced an expensive hepatoprotector drug with a cheaper drug and additionally prescribed several courses of anticholecystitis therapy to maintain gallbladder function. It turns out that in most cases any pain in the liver area is caused by the gall bladder. I only bought pills - doctor’s consultations and all examinations were free under the compulsory medical insurance policy.

At the same time, at this time I was actively surfing the Internet in search of information about a new treatment. I found out that these revolutionary tablets act as RNA polymerase inhibitors. They inhibit the enzyme necessary for the virus to multiply. I studied a lot of specialized forums with reviews about providers' websites, treatments and results. Everything looked like the treatment was really working.

I understood that something needed to be done about the pain. The viral load continued to grow, the symptoms also caused more and more inconvenience, and it was clear how it would all end.

And in September 2022, I finally made up my mind, saved up money for treatment and went to the doctor again, took a genotype and viral load test. Based on the test results, the hepatologist selected the drug Ledihep for me, an Indian generic of the original drug Harvoni. The active ingredients are two polymerase inhibitors: sofosbuvir and ledipasvir. The course of treatment was 12 weeks, one tablet per day. It was necessary to buy 3 jars of the drug, 28 tablets each.

I read specialized forums and, based on reviews, chose the site where I planned to place an order, but just in case, I also contacted the person on the doctor’s business card. My costs if ordering through him would be $300 higher compared to ordering through the website. I figured I could handle it myself and refused the services of a private contractor.

This is what the main page of the site where I bought medicine looks like. Source: HCV24

Prevention of hepatitis

You should definitely pay more attention to the prevention of liver disease. Care must be the most attentive: you must also ensure that the cat does not bite the poisonous plant again or pick up parasites. Deworming is carried out according to schedule, it is easy to study all the issues related to this process.

Vaccination should be carried out strictly on time and according to the recommendations of specialists.

We watch the video and take care of the health of our beloved kitty:
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How I bought Indian tablets

Now I catch myself thinking that I was lucky several times in this story. I was lucky to meet a competent hepatologist and lucky with the choice of the supplier’s website. After contacting me through the feedback form, my personal manager contacted me. She accompanied me promptly and competently until the very end of the transaction. In general, the organization of sales on our Russian side was a pleasant surprise.

First of all, in response to my application, I was introduced to the entire available range of medications with the active ingredient I needed. Since I had already initially decided with the doctor about the drug, I did not change anything and confirmed my order for three jars of Ladyhep. In response, they sent me payment details and an invoice - that’s what an invoice for payment is called in international commerce.

The intermediary offered five different generics of Harvoni, which varied slightly in price

This is what the payment details sent to me looked like:

Invoice for my order, the total cost of which was $740

With the invoice, I went to my bank and made a currency transfer. Then I sent a scan of the payment notification to the manager

My new generation drug. Source: LadyHep

I had to wait 12 days for confirmation of funds being credited. But the next day after confirmation, the parcel was sent immediately. I received a tracking code and waited another 12 days. In total, 27 days passed from the moment of application on the website to the moment of receipt of the shipment at the EMC point of issue.

I exhaled, decided to wait six days until the beginning of November, so that it would be easier to count the weeks, and start taking pills from the first.

How to legally import unregistered medicine into Russia

Polina Naydenkova lawyer in the field of pharmacology and medicine

There are two legal ways to buy the drug abroad: simple and complex.

Downtime is when the patient himself brings it in his luggage for his treatment. This option cannot be implemented by power of attorney; only legal representatives - parents and guardians - can transport medications. Obviously, not every patient and does not always have such an opportunity - this is a disadvantage of this method. In addition, this method is only suitable for drugs registered in the Russian Federation - you can check the availability of registration through the State Register of Medicines. However, if the drug is a prescription drug, you will need a prescription from your doctor to transport it.

The difficult way is to import it under a special permit issued by the Russian Ministry of Health. Under this permit, medications can be transported not only in person, but also by post.

To obtain such permission, you need to submit a package of documents to the Russian Ministry of Health:

• Protocol of the consultation of a federal specialized medical organization or institution of the Russian Academy of Medical Sciences or an institution of a constituent entity of the Russian Federation in which medical care is provided to a specific patient. This protocol must indicate the need to prescribe the drug for health reasons, and such a need for which the prescription of a drug registered in the Russian Federation is impossible. The protocol is signed by the chief physician of the institution.
• An appeal from the regional health authority about the need to import an unregistered drug, accompanied by a copy of the council’s conclusion.
• An electronic copy of the passport or birth certificate of the patient who is prescribed the drug, certified not by a notary, but certainly by the medical institution providing medical care.
• Application for obtaining permission to import into the territory of the Russian Federation an unregistered medicinal product necessary to provide medical care for the vital indications of a particular patient. The application form was approved by the Russian Ministry of Health.

All this - both on paper and at the same time in the form of an electronic document - is submitted to the address [email protected] and to the Russian Ministry of Health. The Russian Ministry of Health will review the documents and make a decision within one week. Such an application is not subject to state duty.

Violation of the rules for the import of drugs unregistered in the Russian Federation is subject to administrative and criminal liability. If a medicine is not registered in Russia, and there are no documents confirming the right of a specific individual to receive it, government agencies recognize it as falsified or of poor quality.

According to Art. 6.33 of the Code of Administrative Offenses of the Russian Federation, illegal import of unregistered medicines into the territory of the Russian Federation entails the imposition of an administrative fine on a citizen in the amount of 70,000 to 100,000 RUR.

If the state sees in the actions of an individual a sales goal - this depends on the size of the batch of imported drugs - liability is threatened in the form of imprisonment for a term of 3 to 5 years.

How I received treatment

And so it began. One tablet per day, preferably at the same time, with plenty of water. According to the instructions, side effects could appear in the first week of treatment: headache, rash and itching, fatigue and a few other non-serious symptoms. But according to my doctor, none of her patients have encountered them.

And I didn’t feel anything at all. I swallowed the pill like a piece of chalk, following a signal on my phone, and forgot about the treatment for a day. There were so many new sensations that, closer to the two-week mark, the thought began to itch: “Have they really been bred into a dummy?”

Two weeks later I went for the first control test. There are several of them: after 2, 4, 12 weeks, and then, after the end of treatment, after six months and a year. I took a qualitative PCR test, a test that determines the presence of a virus in a blood sample. It is the fact of presence itself, and not its quantity. I would like to note right away that I took all the control tests at my own expense in commercial laboratories, since I did not officially undergo treatment and there were no grounds for prescribing tests under the compulsory medical insurance contract. Depending on the laboratory and current promotions, I paid from 500 to 700 RUR for each sample.

The doctor explained that the first test, two weeks after the start of treatment, can be either positive or negative. The analysis after four weeks should already be negative, like all subsequent ones. If not, you need to supplement the treatment regimen or interrupt it.

And now my first two weeks are over. I really hoped that I would receive confirmation that everything was not in vain. But the analysis turned out to be positive. And although I knew that the virus could still be detected at the first cutoff, after this result I began to openly worry about success. The next two weeks were the hardest. I still spent hours taking pills, dieting, giving up alcohol completely, and dreading the next test. And finally he waited.

For the first time in 17 years, the test did not detect HCV in my body. My “everything is lost” mood instantly changed to “hurray, we are breaking, the Swedes are bending.” And although I knew that sometimes the virus returns several months after treatment, it was at that moment that I believed that everything would work out for me. I already automatically took the therapy and did not feel any side effects. At the end of the course, the test again did not detect the virus in my blood.

The course ended, and I began to get used to living without hepatitis. I still couldn’t believe that the once incurable disease was gone. And I felt that I had left for good, even though there were still two control tests ahead.

By the first half of the year without hepatitis, I began to feel the effect of the treatment. The bitter taste in my mouth stopped bothering me. The feeling of bloating in the right hypochondrium disappeared, sleep improved, and performance increased. I had one last control test left to say with a clear conscience: I had cured hepatitis C.

This is how my epic with the treatment of hepatitis C ended. The legacy of the disease left antibodies in my blood, which are now always with me. Therefore, now it makes no sense for me to carry out ELISA - an antibody test to diagnose hepatitis - and doctors need to be warned about this. At the same time, despite the presence of antibodies, after treatment, immunity to the virus is not developed, so I can catch this infection in the second round. There are also problems with the gallbladder - cholecystitis has not disappeared. But you can live with it, it can be treated, and you can’t infect anyone with it.

My first positive test after two weeks from the start of treatment

The first “minus” four weeks after the start of treatment

12 weeks from the start of treatment - no virus detected

Six months after treatment: still no virus

A year after treatment - no virus, hurray!

Liver functions in cats

To understand how important it is to maintain normal liver function in cats, you need to familiarize yourself with the main functions of the organ:

1. Synthesis of blood coagulation factors.
2. Production of factors that break down blood clots in blood vessels.
3. Synthesis of transport proteins that transport iron, immunoglobulins, some types of hormones and drugs.
4. The production of bile and its conduction through the hepatic tract.
5. Maintaining oncotic pressure of blood plasma due to protein synthesis.
6. It is in the liver cells that carbohydrate metabolism is carried out, due to which the pet’s body receives the necessary amount of energy.

The liver performs one of the most important functions, converting toxins, poisons, and chemical compounds into insoluble substances. The insoluble form of the substance is unable to be absorbed into the intestines or blood, causing poisoning of the body.

The liver works in conjunction with other organs, which is why with hepatitis, symptoms of damage to the kidneys, brain, digestive and respiratory systems are observed.

How much did hepatitis C treatment cost me?

Now, three years later, the situation with the treatment of hepatitis C in Russia has not changed. The state can only offer interferon therapy as free treatment programs. Generics of modern inhibitors cannot be purchased in pharmacies. The situation with the procurement of patented drugs is extremely confusing. Purchases of small quantities of expensive original drugs are periodically announced, but they are not available either in pharmacies or in programs.

This whole story with the treatment of hepatitis once again convinced me that something is wrong with the world order in general. A huge number of people do not have access to modern medicines only because large corporations decide who and how much to make money from. I also learned that we have many competent doctors, caring specialists who, in the face of this global injustice, help people literally survive. Now I'm used to searching for health-related information on the Internet. This helps, when communicating with a doctor personally, to understand who is in front of me: an expert or simply a “person with a profession” who is ossified in the dogmas of the times of obtaining a medical diploma.

Well, the main lesson, or rather a confirmation of well-known truths: you have to pay for everything and some things are better to prevent than to correct later.

I paid about 51,000 RUR for the treatment of hepatitis C

Remember