International Journal of Drug Policy 18 (2007) 417–425
Integrating multiple programme and policy approaches to
hepatitis C prevention and care for injection drug
users: A comprehensive approach
Guthrie S. Birkheada,b,c,1, Susan J. Kleina,∗,2, Alma R. Candelasa,3,
Daniel A. O’Connella,4, Jeffrey R. Rothmana,5, Ira S. Feldmana,6,
Dennis S. Tsuia,7, Richard A. Cotroneoa,8, Colleen A. Flanigana,9
aAIDS Institute, New York State Department of Health, Albany, NY 12237, United States
bCenter for Community Health, New York State Department of Health, Albany, NY 12237, United States
cSchool of Public Health, University at Albany, Albany, NY, United States
Received 4 October 2006; received in revised form 4 December 2006; accepted 8 January 2007
Background: New York State is home to an estimated 230,000 individuals chronically infected with hepatitis C virus (HCV) and roughly
171,500 active injection drug users (IDUs). HCV/HIV co-infection is common and models of service delivery that effectively meet IDUs’
needs are required. A HCV strategic plan has stressed integration.
Methods: HCV prevention and care are integrated within health and human service settings, including HIV/AIDS organisations and drug
treatment programmes. Other measures that support comprehensive HCV services for IDUs include reimbursement, clinical guidelines,
training and HCV prevention education. Community and provider collaborations inform programme and policy development.
Results: IDUs access 5 million syringes annually through harm reduction/syringe exchange programmes (SEPs) and a statewide syringe
access programme. Declines in HCV prevalence amongst IDUs in New York City coincided with improved syringe availability. New models
of care successfully link IDUs at SEPs and in drug treatment to health care. Over 7000 Medicaid recipients with HCV/HIV co-infection had
health care encounters related to their HCV in a 12-month period and 10,547 claims for HCV-related medications were paid. The success rate
of transitional case management referrals to drug treatment is over 90%. Training and clinical guidelines promote provider knowledge about
HCV and contribute to quality HCV care for IDUs. Chart reviews of 2570 patients with HIV in 2004 documented HCV status 97.4% of the
time, overall, in various settings. New HCV surveillance systems are operational. Despite this progress, significant challenges remain.
Discussion: A comprehensive, public health approach, using multiple strategies across systems and mobilizing multiple sectors, can enhance
IDUs access to HCV prevention and care. A holisitic approach with integrated services, including for HCV–HIV co-infected IDUs is needed.
Leadership, collaboration and resources are essential.
© 2007 Elsevier B.V. All rights reserved.
Keywords: HCV; Hepatitis C virus; Injection drug use; IDU; Prevention
∗Corresponding author. Tel.: +1 518 473 8778; fax: +1 518 486 1315.
E-mailaddresses:email@example.com (G.S. Birkhead), firstname.lastname@example.org (S.J. Klein).
1Director, AIDS Institute and Center for Community Health, NYSDOH, United States. Tel.: +1 518 402 5382; fax: +1 518 486 1455.
2Deputy Director for Program Planning, Development and Evaluation, AIDS Institute, NYSDOH, United States.
3Director, Bureau of Special Populations, Division of HIV Prevention, AIDS Institute, NYSDOH, United States.
4Director, Division of HIV Prevention, AIDS Institute, NYSDOH, United States.
5Assistant Director, Bureau of HIV Ambulatory Care, Division of HIV Health Care, AIDS Institute, NYSDOH, United States.
6Director, Division of HIV Health Care, AIDS Institute, NYSDOH, United States.
7Evaluation Specialist IV, Division of HIV Health Care, AIDS Institute, NYSDOH, United States.
8Director, HIV Education and Training Programs, Office of the Medical Director, AIDS Institute, NYSDOH, United States.
9Hepatitis C Coordinator, AIDS Institute, NYSDOH, United States.
0955-3959/$ – see front matter © 2007 Elsevier B.V. All rights reserved.
G.S. Birkhead et al. / International Journal of Drug Policy 18 (2007) 417–425
Hepatitis C is a major public health problem in the
United States (US), where an estimated 3.2 million peo-
ple in the general population have chronic hepatitis C virus
(HCV) infection. Injection drug use is the strongest risk fac-
tor (Armstrong et al., 2006). Injection drug users (IDUs)
are also at high risk for infection with human immunode-
ficiency virus (HIV) and studies have suggested that HIV
can accelerate progression of HCV-related disease (Bica et
al., 2001; Serfaty et al., 2001). Prevention of HCV infection
amongst IDUs relies upon many of the same interventions
used to prevent HIV infection (Alter & Moyer, 1998; Hagan,
Strauss, Astone, & Des Jarlais, 2005). IDUs can be treated
successfully with HCV antiviral treatment and strategies to
prevent relapse to drug use and minimize risk of reinfection
can be implemented (Backmund, Meyer, Von Zielonka, &
Eichenlaub, 2001; Davis & Rodrigue, 2001). Comprehen-
sive public health programmes for HCV, similar to those for
HIV, are recommended to conduct surveillance, prevent new
cases, ensure early detection, counsel HCV-infected persons
and offer appropriate medical care (Alter & Moyer, 1998;
NIH, 2002; USDHHS, 1998, 2001b).
While the epidemiology of HCV has largely mirrored the
emergence of HIV in the IDU community, HCV infection
lacks a well-developed advocacy community and resources
have yet to be mobilized for an effective public health
response (Edlin & Carden, 2006; USDHHS, 2001b). Inter-
ventions that prevent HIV infection may not prevent HCV
due to its greater infectivity; targeted HCV prevention strate-
gies are needed (Crofts, Caruana, Bowden, & Kerger, 2000;
Edlin & Carden, 2006; Hagan & Des Jarlais, 2000). Stan-
dards of care for HCV are evolving, as are methods to assess
and improve quality of care (Backmund et al., 2001; Davis
& Rodrigue, 2001; Edlin & Carden, 2006; Hagan et al.,
2006; Strader, Wright, Thomas, & Seeff, 2004; Sulkowski
& Thomas, 2005). The significant economic impact of
HCV infection morbidity and mortality underscores the
need for prevention, early detection and early entry into
care (Wong, McQuillan, McHutchison, & Poynard, 2000).
Addressing injection drug use as an underlying cause of
preventable morbidity and mortality is important for health
public health approaches to prevent HCV infection amongst
IDUs are needed.
HIV/AIDS epidemic for many years. Of 166,537 cumulative
a total of 64,145 (38.5%) indicated IDU risk. Of the 64,145
cumulative NYS AIDS cases having IDU as a risk, 51,147
(80%) were from New York City (NYC) with the remain-
der from other NYS regions (NYSDOH, 2006). There are an
estimated 171,500 IDUs statewide, including approximately
126,900 in NYC (Gallati, NYS OASAS, personal communi-
cation, November 1, 2005). HCV prevalence amongst IDUs
in NYC is estimated to be 63% overall and 38% amongst
Fig. 1. New York State’s HIV/AIDS Service Delivery Continuum.
new injectors. Despite declines in HCV seroprevalence, new
IDUs are becoming infected at a substantial rate, making
prevention an ongoing priority (Des Jarlais et al., 2005).
The NYS Department of Health (NYSDOH) is con-
fronting HCV with a comprehensive approach, using models
developed in response to HIV/AIDS together with HCV-
specific initiatives. New York’s approach to HCV prevention
builds upon a foundation of HIV/AIDS prevention, care and
supportive services, conceptualized as a continuum (Fig. 1).
Organizing principles for this comprehensive approach are:
(1) build on HIV successes, (2) maintain a focus on pri-
care system, and (4) expand capacity and access to ser-
the AIDS Institute coordinates HIV/AIDS programmes and
policies. To address HIV/AIDS in NYS, programmes and
services for IDUs were prioritized within a public health
framework embracing other health issues, including HCV.
HCV prevention and care benefit from the AIDS Institute’s
network of collaborators including government agencies,
health care providers and community-based organisations
and consumers. Federal funding for a Hepatitis C Coordina-
tor in 2002 and formation of an interdisciplinary Hepatitis C
Work Group provided a focus on HCV. An inclusive process
2004). This paper reviews areas where it has been possible
to integrate HCV prevention and care for IDUs into HIV
programmes and services, areas of HCV-specific focus and
issues yet to be addressed.
Programme development and impacts
Community-based primary prevention of HCV infection
Syringe access and safe disposal promote safer injection
and reduce availability of used syringes (USDHHS, 1997;
Edlin, 2002; Stancliff, Agins, Rich, & Burris, 2003). Syringe
exchange programmes (SEPs) are highly effective in reduc-
ing HIV (Wodak & Cooney, 2006). Sharing of syringes and
G.S. Birkhead et al. / International Journal of Drug Policy 18 (2007) 417–425
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