United States

A hepatitis testing and linkage-to-care initiative reaches those at greatest risk of HCV and HBV infection

The U.S. Centers for Disease Control and Prevention (CDC) developed the Hepatitis Testing and Linkage to Care initiative (HepTLC), which awarded grants to 34 organizations committed to increasing hepatitis B and C testing and linkage-to-care efforts. The initiative targeted people at risk for hepatitis B and hepatitis C infection and tested over 87,000 people. Of the 4,766 people found to have hepatitis B or C, 44% were linked to care. The HepTLC Initiative identified lessons learned on how to effectively test and link high-risk populations to care.

What is the HepTLC initiative?

The HepTLC initiative had two main goals:

  1. Early identification and linkage to care of foreign-born people with hepatitis B.
  2. Early identification and linkage to care of people with hepatitis C.

The HepTLC initiative provided grants to 34 organizations across the United States that demonstrated capacity, skill and experience working with the initiative’s target populations. The organizations designed and implemented their testing and linkage-to-care programs independently. The CDC provided access to educational materials, fact sheets, training tools and support for data collection and data entry.

Each organization was expected to conduct 1,000 to 4,000 hepatitis B or C tests per year over a two-year period from September 2012 to September 2014. Organizations included HIV prevention and education centres, state and local health departments, community health centres or coalitions, drug treatment centres and universities. Testing sites for hepatitis B included community outreach events, health centres and community-based organizations that serve foreign-born people. Testing sites for hepatitis C included homeless shelters, harm reduction programs, methadone clinics, alcohol and drug treatment centres and correctional facilities.    


A total of 87,860 people were tested for hepatitis B or C (71% of the CDC’s 123,139 testing goal).

Hepatitis B testing and linkage to care

A total of 23,144 hepatitis B tests were conducted. Most of the people tested (86%) originated from countries where hepatitis B is endemic. Among all the people tested, 6% (1,317 people) were hepatitis B positive. Of the people who tested positive, 90% received their test result, 83% were referred to care and 46% were successfully linked with follow-up care (had a verified visit to a healthcare provider).

Hepatitis C testing and linkage to care

A total of 64,716 people were tested for hepatitis C (with an antibody test and/or hepatitis C RNA test).  Of those tested, 13% were positive for hepatitis C antibodies and 63% received a follow-up hepatitis C RNA test. Of the 4,765 people who received a hepatitis C RNA test, 72% tested positive, meaning they had a chronic hepatitis C infection. Of the 3,449 people with a chronic hepatitis C infection, 81% received their results, 76% were referred to care and 44% were successfully linked with care.

What does this mean for Canadian service providers?

The HepTLC initiative demonstrates that it is possible to reach, test and find people who are positive, and provide linkage to care for high-risk populations using targeted testing and linkage-to-care interventions across a range of organizations and venues. Venues which already served high-risk populations were well suited to design and implement hepatitis testing and linkage-to-care interventions in their communities. 

The initiative shows that offering hepatitis testing and linkage-to-care services can be effective in a range of clinical and non-clinical sites (including homeless shelters, methadone clinics, drug and alcohol treatment centres, and correctional facilities).

While rapid hepatitis C antibody testing enables testing in a range of settings, non-clinical settings can have greater challenges in ensuring follow-up hepatitis C RNA testing is completed and people successfully linked to care. This is because people need to return for testing or accept a referral for RNA testing at another location. In addition, sites that don’t have clinical care services integrated within them also have to refer people to other locations for clinical services. This presents barriers to RNA testing and linkage to care.

One of the successful ways that some projects in the HepTLC initiative overcame these barriers was to use patient navigators to support people to attend follow-up testing and linkage-to-care services, especially when initial testing was done in a non-clinical setting. Hepatitis B testing was more successful when done by staff members who were culturally and linguistically similar to the clients being tested.

Organizations that offered a one-stop shop model of care with a range of services in one location were more effective at getting people into care. Each additional offsite referral or medical appointment provided another barrier to follow-up testing and linkage to care. Integrated services were particularly beneficial at linking to care clients who used injection drugs, were homeless or did not have a permanent address.


Ramirez G. Cabral R, Patterson M, et al. Early Identification and Linkage to Care for People with Chronic HBV and HCV Infection:  The HepTLC Initiative. Public Health Reports. 2016;131 (Supplt 2):5–11.