The past decade has presented new challenges and opportunities for the elimination of hepatitis C virus (HCV), the leading infectious disease killer in the United States. The increase in injection drug use (IDU) has catalyzed its spread, resulting in 50,000 cases in 2018—a three-fold increase compared to 2011. Meanwhile, new medicines have made HCV curable in just a few months with limited side effects. However, many people who inject drugs are unable to access harm reduction services to protect themselves from HCV, and many people living with HCV are unaware of their status or unable to access treatment.

Fortunately, local health departments (LHDs) across the country are taking a coordinated approach to address the syndemic of substance use and viral hepatitis by connecting harm reduction clients to HCV treatment. As most new cases of HCV are associated with IDU, harm reduction settings are an ideal location to reach people living with HCV, and the trust they build with their clients is critical to overcoming the stigma and misinformation that often prevent people from seeking care.

A recent NACCHO survey revealed that three-fourths of LHDs offer HCV screening in harm reduction settings, nearly two-thirds conduct linkage to care, and one in six provide HCV treatment. To learn more about this work, NACCHO reached out to LHDs in Kentucky and Iowa that have designed innovative models to identify harm reduction clients living with HCV and help them overcome barriers to care.

On-Site, Rapid Initiation of Treatment & Targeted Education (Frankfort, KY)

The Franklin County Health Department (FCHD) operates a syringe exchange which is embedded into their medical clinic, enabling them to offer comprehensive health and harm reduction services to clients. In 2019, two FCHD nurse practitioners and two FCHD nurses participated in the Kentucky Hepatitis Academic Mentorship Program, providing them with intensive training on HCV, including genotypes, stages of liver fibrosis, laboratory tests, and treatment regimens. This has allowed them to treat HCV on-site in the integrated medical clinic and syringe exchange.

Many people living with HCV are unaware of their status, and stigma, misinformation, and other barriers deter people who use drugs from seeking care. Consequently, FCHD invested in Neo360, which is an electronic harm reduction monitoring and reporting system. This system makes it easy to identify patients living with HCV or who may benefit from testing. When syringe exchange clients test positive or indicate that they are living with HCV, they are encouraged to seek treatment on-site within the medical clinic and are offered same-week appointments.

People who use drugs often face stigma and discrimination when seeking healthcare services. Many providers are unwilling to treat people for HCV if they are actively using drugs and insurers have historically limited treatment to patients who are sober and/or have severe liver damage. Consequently, FCHD staff provide comprehensive and targeted education to address stigma and misinformation. Patients are informed that insurance will cover treatment regardless of when they were first diagnosed, whether they use drugs, and whether they have liver damage. FCHD staff also explain the improvements in treatment, including that new medicines can cure HCV, have fewer side effects, and that treatment regimens are shorter.

By integrating harm reduction and HCV services, offering same-week appointments, and addressing stigma and misinformation, FCHD has been able to overcome many of the barriers to care. Fortunately, FCHD has been able to maintain this program throughout the COVID-19 pandemic and to date has evaluated 13 people, 8 of whom have completed treatment.

Leveraging Community Leaders to Identify People Living with HCV (Cedar Rapids, IA)

While syringe services are illegal in Iowa, Linn County Public Health (LCPH) provides health and harm reduction education and services through community outreach. In addition to offering HCV testing at their clinic, LCPH provides testing at a variety of locations throughout the county, including parks, libraries, homeless shelters, food pantries, substance use treatment centers and halfway houses, and correctional settings. To better engage and build trust with people who use drugs and LGBTQ+ people, LCPH sub-contracted a community member with strong ties to these populations who supports outreach efforts.

During these outreach efforts, LCPH conducts HCV testing using rapid test kits, which provide results within 20 minutes. Participants who test positive undergo a blood draw that will be used for confirmatory testing and are asked where they’d like to seek treatment and whether they need help finding a provider. Once the confirmatory tests are complete, LCPH refers clients to their primary care provider, a gastroenterologist clinic, or a federally qualified health center that accepts uninsured patients. LCPH also uses these visits to provide harm reduction education and supplies, including the overdose reversal medication Narcan, wound care kits, and personal hygiene equipment. Clients are also asked to complete a survey assessing social determinants of health and are often offered a $5 gift card as an incentive to participate in testing.

By engaging the community and meeting people where they are, LCPH has been able to build trust and offer HCV testing and harm reduction education and supplies to people who are often disconnected from care. Since the initiation of the street outreach efforts in 2017, LCPH has been able to provide over 3,900 HIV test and 1,700 Hepatitis C test to community members.