Chapter 8: Hepatitis C Testing and Linkage
In years past, rates of HCV screening suffered due to the challenges associated with HCV treatment. Varying efficacy rates, high cost, and detrimental side effects prevented those eligible for treatment from seeking it. In 2014, Direct Acting Antivirals (DAAs) changed the course of HCV treatment. Rates of HCV cures increased to 95%, duration of treatment reduced to 8-12 weeks, and reinfection rates of only 5% were promising. One would think that HCV treatment would be offered to all who needed it, but that was/is not the case.
Instead, many people with HCV, particularly PWID, are not offered a cure due to the high cost of the medication and the belief that PWID will not be medically adherent. Conversely, since the majority of new infections occur in PWID, it is imperative that this community receive treatment to reduce overall viral load within this community. Additionally, offering curative treatment to PWID opens doors to encourage substance use treatment and other services.
Studies show that adherence among PWID is comparable to those who do not inject drugs. The high cost of curative treatment is less than ongoing healthcare cost of those with high fibrosis scores, and ultimately, it is unethical and discriminatory to withhold curative treatment based on implicit biases, sobriety restrictions, and/or perceived financial limitations.
The CDC released HCV screening recommendations for persons based on age, risk of exposure, medical condition, and history of drug use. Screening can take place in a laboratory or point-of-care setting and is oftentimes offered alongside HIV and/or STD screening as many of the behavioral risk factors and priority populations overlap.
A foundational strategy for screening a population for anything is meeting them where they are. PWID and individuals who are justice-involved experience higher rates of HCV. The following webinars feature specific strategies for testing individuals at risk for HCV and linking them to care through SSPs (32 min, 35 sec), jails (56 min, 48 sec), and prisons (58 min, 32 sec).
Health Department Examples
Illinois’ Summits of Hope program connects justice-involved individuals to health services within their community. Participants are offered voluntary services, such as HIV and HCV testing and health insurance enrollment. Drug screenings are also offered, but are not punitive. Instead, if a participant tests positive they are linked to an appropriate community-based treatment center. Since its founding in 2010, the Summits of Hope program has engaged more than 30,000 individuals, and has helped to destigmatize participants and reintegrate them into their community by connecting them to local services.
The HCV Testing and Linkage to Care Program is a Maryland Department of Health initiative, piloted in February 2017, to increase the number of Marylanders that are made aware of their hepatitis C (HCV) status and successfully linked to care in the community. This program was developed to expand HCV testing services, infrastructure, and coordination in local jurisdictions lacking this much-needed support. The long-term goal of the program is to ensure that targeted testing services are available in all counties in Maryland, paying special attention to high burden jurisdictions and reaching people most at risk for HCV.
New Mexico’s U-30 Enhanced Hepatitis C (HCV) Surveillance Project aims to collect accurate information on individuals under 30 years old who are living with HCV and to provide them with health education, prevention messages, and referrals. The U-30 Project was developed in 2013 in response to the sharp increase in the HCV rate among young adults in New Mexico. It is designed to conduct basic surveillance activities such as identifying new cases, monitoring disease trends, and obtaining accurate risk factors.
The Oklahoma Department of Health developed a culturally appropriate and effective HCV awareness campaign for baby boomers (i.e., persons born between 1945 and 1965) who seek medical care within the Cherokee Nation. This awareness campaign focused on reducing new infections, was one component of a multi-party collaborative effort to eliminate HCV and improve the health of Native Americans in the Cherokee Nation Health Service (CHNS) by developing a community-based program to test, treat, and cure HCV.
Implementing Routine Hepatitis C Screenings for At-Risk Clients in Buncombe County. Buncombe County, North Carolina is home to 16 substance abuse treatment centers, ranking it near the top in the state for the number of treatment centers. Most of these centers traditionally have not offered testing for or education on HIV and hepatitis C to their clients. Additionally, the county’s jail historically has not provided its inmates with the opportunity to get tested for hepatitis C. In 2010, the North Carolina Department of Health and Human Services (NCDHHS) implemented CDC’s Program Collaboration and Service Integration (PCSI) initiative. One of the primary goals of PCSI is to maximize opportunities for individuals to receive the best preventive service and treatment possible. During the initial planning phase, the state PCSI team conducted an epidemiologic review of each participating county. This review, coupled with their hypothesis that Buncombe County contained a significant proportion of the state’s current and former injection drug users, led Buncombe County Department of Health (BCDH) to explore ways to implement hepatitis C testing in the area.
Check Your Understanding
Who should be offered HCV testing?
The CDC released HCV screening recommendations based on age, risk of exposure, medical condition, and history of drug use.
What are non-clinical settings that your health department can access to implement HCV testing that have not yet been tapped?
Options may include community-based organizations, correctional facilities, mobile testing units, SSPs, housing shelters, etc.
What are your health department’s greatest barriers to HCV testing and linkage to care?
Barriers may include, but are not limited to, sobriety restrictions, financial burdens, and lack of community and provider education.