Hepatitis C Treatment Best Practices

Information on hepatitis C (HCV) treatment best practices from three Syringe Service Programs (SSP) in MA.

Berkshire Harm Reduction, Fenway Health’s Access: Drug User Health Program, and Health Imperatives integrate Hepatitis C (HCV) treatment into harm reduction and sexual/reproductive health services, reducing barriers to care for people who use drugs (PWUD) and other underserved groups. All models emphasize low-barrier access, integration with existing harm reduction/sexual health services, insurance navigation, regular follow-up, and reinfection prevention counseling. The use of telehealth, on-site SSP clinics, and multi-site reproductive health services demonstrates flexible approaches to meet client needs. We thank Berkshire Harm Reduction, Fenway Health, and Health Imperatives for their participation and feedback throughout the creation of this toolkit.

HCV Treatment Using Telehealth (Berkshire Harm Reduction)

Berkshire Harm Reduction (BHR) aims to mitigate health complications from substance use by providing comprehensive services to people with substance use disorder. In addition to sterile supplies, fentanyl test strips, and naloxone, BHR offers testing for HIV/HCV/STIs as well as basic wound care and abscess prevention.

BHR has fully integrated HCV testing and treatment into harm reduction programming, enabling provision of comprehensive health and support services, and facilitating continuity of treatment for HCV infection. Clients do not need a primary care provider to be treated for HCV infection at BHR.

Testing for HCV at SSP:

Once a person makes the decision to treat their HCV infection, they can be linked to the HCV Navigator as soon as the same day. The HCV Navigator will enroll the client in health insurance if needed, draw additional labs as needed, and schedule a telehealth appointment with a provider.

Provider telehealth visit:

All telehealth visits are via video unless the client is incarcerated, in which case the appointment is conducted via phone call. The visits take place at the SSP, with the HCV Navigator and the client participating together. A Nurse Practitioner (NP) and the HCV Navigator co-facilitate the visits. NP reviews medical history, labs, any drug interactions, and assesses interest in PrEP (if HIV negative). The provider will decide on treatment (in conjunction with the individual) and send the prescription to a specialty pharmacy that BHR works with. The pharmacy will deliver the medications to the SSP (where they can also be securely stored, if needed).

Client starts treatment:

At the one-week mark, the HCV Navigator will check in with the client via phone call. They will provide ongoing harm reduction services, adherence support, and linkage to other services, as needed, at the SSP.

Follow-up:

At four weeks, monitoring labs will be done, and the client will meet with the provider via telehealth. Additional telehealth visits can be made as needed. The HCV Navigator will continue to check in and schedule labs to be done at the SSP to confirm sustained virologic response at 12 weeks post treatment completion, known as SVR12.

HCV Treatment Onsite at an SSP (Fenway Health’s Access: Drug User Health Program)

Fenway Health’s Access: Drug User Health Program provides a safe and confidential space for injection drug users to access HIV/HCV/STI testing and treatment. If someone is interested in HCV treatment and has not been treated previously, they can see the provider and medication can be ordered the same day. As a PWUD-centered location for health services, the Access: Drug User Health Program provides a crucial and well-accepted source of HCV knowledge and services for PWUD.

Weeks 1-2: Once the decision to start treatment is made, the client can be seen in clinic at the SSP on Wednesday or Friday mornings (9am-12pm). During this time, the client will meet with the provider and decide on a course of treatment for them. The SSP team will work with the client’s insurance to approve the medication and a specialty pharmacy to deliver the medications either to the SSP or another address of the client’s choosing.

Weeks 2-8: The client can pick up their medication at the SSP and receive a gift card incentive for starting treatment. The SSP provides lockers for clients to store their medication and they can pick it up at a frequency that works for them. The SSP team will provide ongoing harm reduction services, adherence support, and linkage to other services, as needed, at the SSP.

Weeks 8-12: Depending on the course of treatment, the client may finish in 8 or 12 weeks. The client will receive a gift card incentive for treatment completion. Depending on client-specific factors, an end of treatment viral load may be completed.

Week 24: Twelve (12) weeks after treatment is completed, the client will return for SVR12 labs to confirm that their HCV is cleared. The client will receive a final gift card incentive during this testing encounter.

Low-Barrier HCV Treatment (Health Imperatives)

Health Imperatives (HI) provides a range of low-barrier health care and other health services aimed at improving the health and well-being of low-income or vulnerable families and individuals at seven locations throughout Southeastern Massachusetts. This includes treatment for HCV infection, which is integrated into HI’s sexual and reproductive health services and HIV/HCV/STI testing. Clients do not need a primary care provider to be treated at HI.

Staff initiate the HCV treatment conversation with clients at the time of results delivery. If the client declines treatment with HI, staff will help navigate them to a different provider. If a client is interested in pursuing treatment, the Harm Reduction Specialist (HRS) or Medical Assistant will schedule the initial visit – usually within one week, but sometimes as soon as the same or next day. Clients can be seen at any one of HI’s seven sexual and reproductive health clinics. The client will see the prescribing provider four times during the course of treatment – once at the beginning, twice during treatment, and the fourth time upon treatment completion. Staff stay connected with the client regularly to ensure adherence and offer harm reduction services during the course of treatment.

1^st appointment (in person): An intake is done and the medical provider and HRS meet with client together to review treatment options. Labs are drawn and the HRS works with the client to obtain health insurance (if needed) or work with existing insurance to ensure any prior authorizations (PAs) are in place. The HRS also begins navigation for any other services as needed (e.g., Primary care provider, housing, substance use disorder treatment, etc.)

2^nd appointment (telehealth visit on video through the electronic health record portal or in person): The prescribing provider and HRS meet with the client to review labs and initiate treatment. Hepatitis A & B vaccines are administered as indicated. Next appointment scheduled for 4 weeks (in person due to labs).

3^rd appointment: The prescribing provider and HRS meet with the client to see how treatment is going. Labs are drawn. The medication prescription is renewed/refilled (new PA if required).  End of treatment appointment scheduled.

4^th appointment: End of treatment! The medical provider and HRS meet with the client. Labs are drawn. SVR12 appointment scheduled (12 weeks from the end of treatment).

Weekly:

• HRS calls client to check in on medication adherence, side effects, barriers, etc.
• HRS continues navigation process for other needs
• Harm reduction/reinfection prevention counseling (at every appointment)