Integrated care model for hepatitis C, HIV and substance use during the COVID-19 pandemic
This program was developed early in the COVID-19 pandemic to address the need to continue the initiation of hepatitis C and opioid use disorder treatment for people who use drugs. The program bundled testing for hepatitis C, HIV and opioid use disorder within a needle and syringe program. Outreach workers and clinicians used phone calls and texts to connect with people to streamline treatment workup instead of holding in-person appointments. There were 29 people cured of hepatitis C through the program. It also helped individuals who were co-infected with HIV achieve or maintain viral load suppression and people initiate or maintain substance use treatment.
This program took place at the New Haven Syringe Services Program (NHSSP), a community-based service for people who use drugs in New Haven Connecticut. It was launched in mid-2020 in the early part of the COVID-19 pandemic. Before the COVID-19 pandemic, the NHSSP provided:
- drug equipment distribution through a storefront (including through outreach and home delivery)
- overdose prevention and education, including naloxone and fentanyl test strips
- a mobile medical clinic aboard a bus, which offered services including HIV and hepatitis C testing and treatment
- provision of buprenorphine therapy or referrals for methadone programs
Starting in March 2020, the pandemic disrupted NHSSP services because of public health measures, including the need for physical distancing. This led to dramatic reductions in hepatitis C and HIV testing and reduced access to harm reduction supplies and treatment for hepatitis C, HIV and substance use.
In response, the NHSSP shifted from in-person rapid point-of-care hepatitis C and HIV testing to bundled testing for hepatitis C, HIV and opioid use disorder at an off-site community laboratory because the laboratory could maintain physical distancing protocols. The storefront hours were reduced, request for supplies were made by telephone, and home delivery of harm reduction supplies was expanded. The program used a care model that minimized clinical demands and focused on identifying people with opioid use disorder in need of hepatitis C treatment. The clinicians in the mobile medical clinic shifted to providing medical services via telehealth. Outreach workers provided support to clients undergoing hepatitis C treatment by phone and liaised between clients and clinicians to organize testing and treatment services. The following approach was used in the model developed during the COVID-19 pandemic.
Screening and referral to the program: Clients who accessed NHSSP services (e.g., home delivery of harm reduction supplies) underwent an initial verbal screening for opioid use disorder. Those interested in receiving screening for hepatitis C and HIV were referred for further testing.
Testing and diagnosis for hepatitis C and HIV: Clients went to a community laboratory to undergo urine drug testing for opioid use disorder as well as testing for HIV and hepatitis C. Hepatitis C and HIV results were automatically sent for reflex testing, including confirmatory and liver assessment testing for hepatitis C and viral load and CD4 testing for HIV.
Clinical follow-up and treatment workup: A clinician at the program reviewed the test results and if the individual was eligible for hepatitis C treatment, a care plan was developed. This care plan could be integrated with treatment for HIV if the client had a co-infection, as well as opioid agonist therapy. All consults were done by phone, with additional treatment support from outreach workers via phone, or in person during harm reduction home deliveries.
Hepatitis C treatment: Treatment was based on client preference and needs, and medications were delivered to a client’s home, to a local pharmacy or to the NHSSP site for pickup. The treatment approach was simplified to an assessment and a test 12 weeks after treatment completion to confirm cure. Phone appointments with the clinician were available upon request, and outreach workers conducted regular phone or in-person check-ins.
HIV treatment: Treatment was initiated for clients testing positive for HIV if they were not already on treatment, and clients were counselled about medication adherence by their prescribing clinician if they had not achieved virological suppression. Clients who were not adherent were given the option of having their medications delivered to their home, a local pharmacy or the NHSSP. Follow-ups were completed by telephone as needed. In-person appointments were made if an individual experienced adverse effect of their treatment.
Opioid use disorder treatment: Clients not already on opioid agonist therapy could receive same-day initiation of buprenorphine through the NHSSP, guided by an instructional phone app. Clients starting buprenorphine received an initial 7-day prescription, followed by monthly prescriptions by telephone with no requirement for urine drug testing. Prescriptions were sent to a clients’s pharmacy. Those that preferred methadone could receive a referral to a nearby clinic for same-day methadone initiation. The treatment plan varied by client and depended on treatment program regulations.
Between March and June 2020, 66 individuals who were actively injecting drugs underwent bundled testing for hepatitis C, HIV and opioid use disorder, 35 of whom tested positive for chronic hepatitis C. Of these:
- 28 people (77%) were men and 12 people (39%) were unstably housed
- 31 people (89%) initiated hepatitis C treatment and 29 people (94%) were cured of hepatitis C; 83% of those unstably housed were cured of hepatitis C
- 100% of those on hepatitis C treatment had active substance use (either injecting, snorting or smoking drugs)
There were seven people identified with HIV, all of whom were on antiretroviral therapy. Six people with HIV started treatment for hepatitis C, two of which were not virally suppressed. At 12-weeks following hepatitis C treatment, all six people with HIV achieved viral load suppression.
Eighty-four percent of people were taking medication for opioid use disorder by the time they completed hepatitis C treatment. This includes 20 people who initiated opioid substitution therapy during hepatitis C treatment (14 began buprenorphine and six began methadone) and six people who were taking opioid substitution therapy at the start of the study.
What does this mean for service providers?
This study shows the feasibility of bundling screening and treatment of hepatitis C, HIV and opioid use disorder in a way that lessened the clinical resources needed to treat hepatitis C in the context of the COVID-19 pandemic. This included reduced in-person clinical visits, bundling of screening for hepatitis C, HIV and opioid use disorder and use of telehealth for support. Outreach workers were utilized as trusted and familiar contacts who could connect with people when delivering harm reduction supplies to their homes, over the phone or via text message.
The integration of hepatitis C along with HIV and opioid use disorder treatment is an important element of this model. This program had positive outcomes across all three domains, potentially creating added value by combining treatments. By integrating these services, a program can offer more wholistic services that meet multiple health needs of people who use drugs.
The COVID-19 pandemic has exacerbated challenges in healthcare access, particularly for those who are most marginalized. This model would continue to be valuable after the pandemic as long waits for treatment and the need for multiple appointments can be significant barriers for many people. Consideration must be given, however, to the possibility that the target populations may have limited access to a telephone or the Internet.
- Integration of hepatitis C care into community drug and alcohol clinics
- Integrating hepatitis C testing and treatment into community settings or primary care to reach priority populations
- Expanding hepatitis C testing and treatment through task-shifting
Sivakumar A, Madden L, DiDomizio E et al. Treatment of hepatitis C virus among people who inject drugs at a syringe service program during the COVID-19 response: The potential role of telehealth, medications for opioid use disorder and minimal demands on patients. International Journal of Drug Policy. 2022 Mar;101:103570.