AIDS Community Research Initiative of AmericaAIDS Community Research Initiative of America
Integrating HIV Prevention with Hepatitis C Co‐Infection Programs
HIV Health Literacy Program230 West 38th Street 17th Floor230 West 38th Street, 17th Floor
New York, NY 10018
IssuesTreatment and prevention programs focus on HIV
While HIV and HCV co‐morbidity continues to increasey
MSM sexual transmission is emerging as a common risk factor while sexual transmission in other populationsfactor, while sexual transmission in other populations, remains low
Understanding unique circumstances for clients andUnderstanding unique circumstances for clients and providers in different settings
Project and SettingNational Program completed in 15 cities nationwide
All 5 boroughs in NYCg
3 year CDC‐funded, NYSDOH and ACRIA initiated
T ti b th li t d t ff t ASO LGBTTargeting both clients and staff at ASOs, LGBT organizations, agencies and programs within criminal justice system, substance use centers
BackgroundA 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
Training Format Training materials are comprehensive
Design is flexible and modular in formatDesign is flexible and modular in format
Tailored content for special settings
Focus on integration
Skills basedSkills‐based
O i f M d lOverview of ModulesHepatitis Cepa s
Overview of the Liver and Disease PrevalenceTransmission/Non‐TransmissionSpectrum of Illness and Common SymptomsPreventionDiagnosis and TestingDiagnosis and TestingTreatment
Risk Assessment and Tailored Harm Reduction Messagesg
Risk AssessmentCultural Awareness and Values ClarificationHarm Reduction MessagesSafer Injection Practices
Hepatitis
= Inflammation of the liver
Hepato liver
itis inflammation
Causes of HepatitisImmunologic Damage Infections
Vi‐ Viruses‐ Bacteria
Inflammation
Toxic Damage
Inflammation
Toxic Damage‐ Alcohol‐ Drugs‐ Drugs‐ Poisons/Chemicals
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
Chronic HCV Monoinfection
Another way to look at HCV disease progression …
Progression of HCV Infection over 10‐25 Years
Acute Infection
100% (100 people)
Resolved
20% (20)
Chronic
80% (80)
Resolved Chronic
S bl
35% (28)
Slowly Progressive Disease65% (52)
Stabley g(some symptoms)
30% (16)
Some liver damage70% (36)
Cirrhosis
25% (4)
Some liver damage,no cirrhosis
75% (12)
Liver failure, cancer,transplant, death
( )
Slowly progressivecirrhosis
( )
Setting‐Specific ModulesIntegrating Hepatitis C
Rationale and Opportunities for Integrationpp g
Brainstorm: Barriers to Integration
Model Programs for Integration
Strategies for Integration
Implementing a Successful Plan for Integration
HIV/AIDS Programs:HIV/AIDS Programs:Rationale for Addressing HCV
Co‐existing epidemics25 30% f HIV iti l i f t d ith25‐30% of HIV‐positive people are co‐infected with HCV
In some studies up to 90% of IDUs with HIV are co‐In some studies, up to 90% of IDUs with HIV are coinfected with HCV
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 injectingSharing injection equipment is a highly efficient means of spreading HCV
Integration of HIV and HCV services will be beneficial to clients
Meets more needs of the clients
Convenient for clientsConvenient for clients
Reduces barriers to service
May help reduce costsMay help reduce costs
Uses existing, trusted infrastructure
Complements services that target the same populationComplements services that target the same population
Provides additional services that may bring in more clients
Promoting Wellness for PWHIV/AIDS
Educating clients and providing access to viral hepatitis screening and vaccination is a critical component of wellness for PWHIV/AIDSwellness for PWHIV/AIDS
HIV providers need to be well versed in viral hepatitis in order to serve clients who are co‐infected with viralin order to serve clients who are co infected with viral hepatitis
LGBT Organizations:LGBT Organizations:Rationale for Addressing HCVSexual 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 y gheterosexual men
LBT women smoke almost 200% more than heterosexualLBT women smoke almost 200% more than heterosexual women
lCorrectional Settings:Rationale for Addressing Viral Hepatitisg p
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
lCorrectional Settings:Rationale
83% of state and 73% of federal prisoners report past p p pIDU
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
lCorrectional 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
Integration Benefits Inmates and Entire CommunityOpportunity 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
icommunity
Translates into overall cost savings for the community
IntegrationIntegrationIntegration activities can be delivered without eg a o ac es ca be de e ed ousignificant cost or need for new resources
Integrating screening for HCV in non‐traditionalIntegrating 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 y gclient intake and/or health history
IntegrationProviding an integrated prevention message about viralProviding 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 offeredp
1) All relevant forms (intake, medical history, reassessment, etc) address viral hepatitis, ) p ,
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
IntegrationThere is no one size fits all approach to integration
How and when integration is accomplished in yourHow 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
Lessons LearnedDevelopment of HIV/HCV co‐infection curriculum is essential to meeting needs people living with both HIV and HCVand 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 curriculumintegration of a co‐infection curriculum
Next StepsCreating 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