This document discusses integrating hepatitis C screening and prevention programs into existing HIV/AIDS and other health services. It provides an overview of hepatitis C and its prevalence among people living with HIV. Integrating hepatitis C services can meet more client needs, reduce barriers, and leverage existing infrastructure. Modules cover hepatitis basics, risk assessment, harm reduction, and strategies for different settings like HIV/AIDS programs, LGBT organizations, and corrections. Lessons learned indicate developing HIV/hepatitis co-infection curricula and integrating hepatitis services can better meet client needs. Next steps include creating more inclusive HIV programs and training non-medical providers.

1. AIDS Community Research Initiative of America
Integrating HIV Prevention with Hepatitis C Co‐
Infection Programs
HIV Health Literacy Program
230 West 38th Street 17th Floor
230 West 38 Street, 17
New York, NY 10018

2. Issues
Treatment and prevention programs focus on HIV
While HIV and HCV co‐morbidity continues to increase
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MSM sexual transmission is emerging as a common risk
factor, while sexual transmission in other populations,
factor while sexual transmission in other populations
remains low
Understanding unique circumstances for clients and
Understanding unique circumstances for clients and
providers in different settings

3. Project and Setting
National Program completed in 15 cities nationwide
All 5 boroughs in NYC
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3 year CDC‐funded, NYSDOH and ACRIA initiated
Targeting both clients and staff at ASOs, LGBT
T ti b th li t d t ff t ASO LGBT
organizations, agencies and programs within criminal
justice system, substance use centers

4. Background
A national advisory panel guided the development of this
training between 2003‐2006
CDC and experts from service delivery settings that
provide care to people living with or at risk for HCV
Input was gained from six focus groups that were held
throughout the United States
Combination of administrators, supervisor and direct client
staff representing different settings

5. Training Format
Training materials are comprehensive
Design is flexible and modular in format
Design is flexible and modular in format
Tailored content for special settings
Focus on integration
Skills‐based
Skills based

6. O i fM d l
Overview of Modules
epa s
Hepatitis C
Overview of the Liver and Disease Prevalence
Transmission/Non‐Transmission
Spectrum of Illness and Common Symptoms
Prevention
Diagnosis and Testing
Diagnosis and Testing
Treatment
Risk Assessment and Tailored Harm Reduction Messages
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Risk Assessment
Cultural Awareness and Values Clarification
Harm Reduction Messages
Safer Injection Practices

7. Hepatitis
= Inflammation of the liver
Hepato liver
itis inflammation

8. Causes of Hepatitis
Immunologic
Infections
Damage
‐ Vi
Viruses
‐ Bacteria
Inflammation
Toxic Damage
Toxic Damage
‐ Alcohol
‐ Drugs
‐ Poisons/Chemicals

9. Chronic HCV Monoinfection
~ 80% develop chronic infection
80% develop chronic infection
Of those with chronic infection:
~ 35% remain stable
~ 20% will develop cirrhosis and serious illness
20% will develop cirrhosis and serious illness
Of those with cirrhosis:
~ 25% will develop liver cancer, need a transplant,
25% will develop liver cancer, need a transplant,
and/or die as a result of liver disease

10. Chronic HCV Monoinfection
Another way to look at HCV disease
progression …

11. Progression of HCV Infection over 10‐25 Years
100% (100 people)
Acute Infection
20% (20) 80% (80)
Resolved Chronic
35% (28) 65% (52)
Slowly Progressive Disease
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Stable
S bl
(some symptoms)
70% (36) 30% (16)
Some liver damage,
Some liver damage
Cirrhosis
no cirrhosis
75% (12)
( ) 25% (4)
( )
Slowly progressive Liver failure, cancer,
cirrhosis transplant, death

12. Setting‐Specific Modules
Integrating Hepatitis C
Rationale and Opportunities for Integration
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Brainstorm: Barriers to Integration
Model Programs for Integration
Strategies for Integration
Implementing a Successful Plan for Integration

13. HIV/AIDS Programs:
HIV/AIDS Programs:
Rationale for Addressing HCV
Co‐existing epidemics
25‐30% of HIV‐positive people are co‐infected with
25 30% f HIV iti l i f t d ith
HCV
In some studies, up to 90% of IDUs with HIV are co
In some studies up to 90% of IDUs with HIV are co‐
infected with HCV

14. HIV/AIDS Programs:
HIV/AIDS Programs:
Overlapping Risk Factors
Behaviors associated with the transmission of HIV are
also associated with transmission of HCV:
50‐90% of IDUs are infected with HCV – most users become
infected with HCV during first five years of injecting
Sharing injection equipment is a highly efficient means of
spreading HCV

15. Integration of HIV and HCV services will be
beneficial to clients
Meets more needs of the clients
Convenient for clients
Convenient for clients
Reduces barriers to service
May help reduce costs
May help reduce costs
Uses existing, trusted infrastructure
Complements services that target the same population
Complements services that target the same population
Provides additional services that may bring in more
clients

16. Promoting Wellness for PWHIV/AIDS
Educating clients and providing access to viral hepatitis
screening and vaccination is a critical component of
wellness for PWHIV/AIDS
wellness for PWHIV/AIDS
HIV providers need to be well versed in viral hepatitis
in order to serve clients who are co infected with viral
in order to serve clients who are co‐infected with viral
hepatitis

17. LGBT Organizations:
LGBT Organizations:
Rationale for Addressing HCV
Sexual Stigma & Discrimination Create High Levels
of Lifelong Stress
GLB individuals suffer from more mental health problems
including substance use disorders, depression, and
suicide
Gay men use substances and alcohol at higher rates than
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heterosexual men
LBT women smoke almost 200% more than heterosexual
LBT women smoke almost 200% more than heterosexual
women

18. l
Correctional Settings:
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Rationale for Addressing Viral Hepatitis
High risk group
Higher rates of HCV, STIs, HIV and TB
12‐39% of all Americans with chronic HBV or HCV
were released from correctional facilities during the
previous year
Adult prison inmates: 16‐41% have evidence of HCV
infection; 12‐35% have chronic infection

19. l
Correctional Settings:
Rationale
83% of state and 73% of federal prisoners report past
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IDU
57% of state and 45% of federal prisoners report drug
use in the month before their offence
60‐90% of IDUs are infected with HCV
14‐42% of incarcerated people are infected with HCV

20. l
Correctional Settings:
Rationale
Benefits the general community
Reduces disease transmission and medical costs
Inmates who participate in health programs have lower
recidivism rates and are more likely to maintain health‐
conscious behaviors

21. Integration Benefits Inmates and Entire
Community
Opportunity to provide critical health services to those
at highest risk
Vaccination helps prevent future infection/illness for
inmates
Screening helps identify cases and prevent further
transmission to family members and the general
community
i
Translates into overall cost savings for the community

22. Integration
eg a o ac es ca be de e ed ou
Integration activities can be delivered without
significant cost or need for new resources
Integrating screening for HCV in non‐traditional
Integrating screening for HCV in non‐traditional
settings can be an important step in expanding access
to these services for those at highest risk
Include questions about viral hepatitis screening,
vaccination and history of disease during the initial
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client intake and/or health history

23. Integration
Providing an integrated prevention message about viral
Providing an integrated prevention message about viral
hepatitis, HIV, and STIs is a benefit to clients because it
treats them as a “whole person”
Integration is most effective when it has become a
routine part of services offered
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1) All relevant forms (intake, medical history, reassessment,
etc) address viral hepatitis,
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2) Agency standards, policies and procedures outline
specific tasks to be performed by staff, and
3) Agency quality assurance activities monitor progress
toward meeting these standards

24. Integration
There is no one size fits all approach to integration
How and when integration is accomplished in your
How and when integration is accomplished in your
agency depends on how your program is organized and
run
Innovative programs across the country have reviewed all
aspects of their program’s operation and found many new
and creative ways to integrate viral hepatitis services

25. Lessons Learned
Development of HIV/HCV co‐infection curriculum is
essential to meeting needs people living with both HIV
and HCV
and HCV
Programs specializing in HIV treatment and prevention
education can enhance their services and better meet the
needs of co‐infected clients through the adoption and
integration of a co‐infection curriculum
integration of a co infection curriculum

26. Next Steps
Creating HIV programs that are inclusive of hepatitis as
well as other STIs
Providing easy‐to‐understand information helping non‐
medical service providers to become part of the
prevention/treatment/care continuum