+Hepatitis C Prevention
Expand the number of SEPs in NYS and the existing SEPs’ geographic reach.
Fund expanded outreach to support people who use drugs through all methods of use.
Expand HCV Prevention Strategies in state and local correctional facilities.
Treatment should also be available to those with Opioid Use Disorder (OUD) who are not on treatment at the time of incarceration. MAT has been shown to reduce injection and is associated with reduction in transmission of HCV and HIV. These medications, along with access to sterile injection equipment, are vital to maintaining HCV cures achieved in NYS DOCCS and/or local jails.Furthermore, inmates with opioid use disorder are significantly more likely to engage in MAT upon release from incarceration if they have initiated or continued methadone or buprenorphine.
Create a NYS Medicaid waiver program to cover expenses of confidential OUD services, including MAT and HCV testing and treatment, for New Yorkers, including adolescents and young adults.
Improve access to substance use treatment for young people by increasing primary care and specialty system capacity to screen and treat adolescents and young adults.
Develop and implement a 2-year pilot study to assess feasibility and effectiveness of a medically supervised program where patients self-administer prescription pharmaceutical opioids (e.g., hydromorphone/dilaudid).
In addition, this program has been shown to decrease overdoses, decrease mortality, and facilitate ongoing treatment engagement. Recently, the Study to Assess Long-term Opioid Medication Effectiveness in Vancouver, British Columbia, Canada, demonstrated the noninferiority of hydromorphone as compared to diacetylmorphine (i.e., heroin) in terms of efficacy, and the superiority of hydromorphone over diacetylmorphine in terms of decreased adverse events. In 2017, the British Columbia Ministry of Health published the evidence-based Guidance of Injectable Opioid Agonist Treatment for Opioid Use Disorder.
Recognizing that the opioid epidemic is a public health emergency, allow for safer injection facilities across NYS.
Enhance efforts that raise awareness, provide information and education about preventing HCV for the public, patients, health care providers, social service providers, and elected officials.
Ensure messages reach schools and faith-based communities to meet all at-risk individuals. Well-designed health literacy materials both in print and using social media geared to populations at-risk, including PWID, formerly incarcerated persons, MSM, transgender people and affected communities, will serve to reduce the stigma associated with HCV and increase access to treatment. Materials should clearly explain the risk behaviors associated with HCV transmission including injection and non-injection drug use and sexual transmission, especially among men who identify as gay, bisexual or other men who have sex with men. For an effective awareness campaign, materials should be culturally responsive and in multiple languages to prevent stigmatize persons living with or at risk for HCV.
Engage adolescents, young adults and their support systems (i.e., families, teachers, faith leaders) in anti-stigma drug education efforts.
+Hepatitis C Care and Treatment Access
NYS should provide clear expectations and policy guidance for payers to ensure access to all clinically appropriate HCV treatment per NYSDOH AIDS Institute Clinical Guidelines Program and American Association for the Study of Liver Disease (AASLD)/Infectious Disease Society of America (IDSA) clinical guidelines and ensure the availability of necessary supportive services for all persons infected with HCV.
As per the guidelines of the NYSDOH AIDS Institute Clinical Guidelines Program and AASLD/IDSA, “Treatment is recommended for all patients with chronic HCV infection, except those with short life expectancy that cannot be remediated by HCV therapy, liver transplantation, or another directed therapy. Patients with a short life expectancy owing to liver disease should be managed in consultation with an expert.” Payers should approve appropriate drug regimens based on the evidence-based guidelines. Payers should not impose restrictions that are based on severity of liver damage (fibrosis), measures of sobriety, previous treatment experience, treatment readiness, or prescriber restrictions. Payers should also not be allowed to deny patients for retreatment, regardless of whether for virologic relapse or reinfection. NYS should monitor insurance providers’ compliance with these recommendations. Payers should be required to submit hepatitis C coverage information including prior authorization requirements to the State for publication on a publicly accessible NYSDOH website. Furthermore, NYS should provide financial support for full coverage of HCV treatment costs to NYS Medicaid plans and consider additional financial support through other means such as high-cost drug pools, risk corridors, and stop-loss provisions.
Increase resources to address patient barriers to treatment, such as substance use disorders, mental health disorders, cognitive impairment, and other social determinants of health.
Adherence is paramount for successful cure. Often, comorbid psychosocial issues are the biggest barrier for patients. Improved access to harm reduction services, mental health treatment, opiate agonist treatment and other evidence-based interventions improve patient outcomes. Patient navigators, case managers, directly observed therapy, and peer educators are instrumental for successful treatment.
Increase clinical education resources and support for providers regarding HCV diagnosis, management and treatment, particularly for providers in settings with high prevalence or limited HCV provider access. Encourage involvement of non-physician health care providers throughout the entire HCV treatment cascade.
To enhance the capacity of NYS’s health care workforce to deliver appropriate and evidence-based clinical services to patients with HCV and, therefore, to improve all patients’ ultimate health outcomes, more education resources and support for providers across the full spectrum of care for HCV are needed. This includes provider education in HCV screening, diagnosis, and management as well as how substance use, HIV co-infection, and mental health disorder intersects with HCV management. This is especially needed in urban and rural communities, which may have high prevalence or limited HCV provider access. Tele-mentoring, HCV telephone support (warmlines), trainings (live and distance learning), preceptorships, mentorships, and clinical toolkits are all potential strategies for increasing knowledge and skills of physicians and non-physician health care providers, such as nurse practitioners, physician assistants, pharmacists, and registered nurses.
Furthermore, increasing awareness of scope of practice for non-physician health care providers can encourage involvement of non-physician providers’ role throughout the HCV treatment cascade. For example, pharmacists can currently prescribe HCV medications and order labs under a collaborative drug therapy management plan. However, many physicians and pharmacists are not aware of such provisions or are utilizing the collaborative drug therapy management plan. Increasing awareness and encouragement for developing these types of collaborative arrangements should improve access and quality of care and treatment for HCV infection.
Commercial payers should limit out of pocket expenses that pose a barrier to access to HCV treatment.
Increase resources and attention for high risk and/or vulnerable populations: persons living with HIV, transgender persons, persons with substance use disorders, and other key populations that emerge with increased surveillance.
HCV infection disproportionately impacts people with substance use disorders, immigrants, transgender persons, and incarcerated persons. These same patient populations also face systems of stigma and health disparity. Improving health outcomes of these communities requires ongoing efforts to decrease health disparities. This entails increasing provider access, improved medication access, case management and/or care coordination, and strengthening ancillary services including mental health and substance use treatment, as well as harm reduction services and opiate agonist treatment. Providing treatment in diverse, patient-centered contexts, such as in methadone treatment facilities, harm reduction facilities, syringe exchange programs, long term residential drug treatment programs, and jail/prison health centers, will improve treatment access.
Increase uptake of telehealth services by health systems to reach underserved HCV populations with limited specialists.
Therefore, increasing awareness of telehealth availability and support for innovative reimbursable telehealth models to reach underserved HCV patient populations is needed. This can include a centralized technical assistance program and/or a tool kit for interested health systems to develop their own telehealth model, train providers on the use of telehealth, advocate for increased HCV telehealth reimbursement, and fund research for cost-effectiveness studies.
+Surveillance, Data and Metrics
Develop data use agreements, data sharing policies, and a regulatory agenda to facilitate necessary data sharing between public health entities, health care providers, other service providers [e.g., correctional facilities, Syringe Exchange Program (SEPs)], and regional health information organizations.
Data sharing is necessary to ensure the ability to track outcomes in a timely manner across service providers [e.g., newly diagnosed persons referred elsewhere for HCV care and treatment] and maximize collaboration across entities, and sectors conducting and overseeing implementation activities, taking into account state and local regulations.
Recognize and support viral hepatitis surveillance as a core public health function of state and local health departments. Systematically evaluate existing health care provider and laboratory-based surveillance systems and develop a robust infrastructure to strengthen surveillance so that key epidemiologic and programmatic questions about the HCV epidemic can be adequately addressed.
Viral hepatitis surveillance involves longitudinal population-based processes, including provider and laboratory-based reporting and timely local health department case investigation, to:
- Detect new or newly reported cases,
- Record demographic information, risk factors, and potential exposures, and
- Add new information (e.g., laboratory test results) to previously reported cases.
The monitoring of HCV trends in NYS, including measurement of disparities, disease outcomes, and the effectiveness of prevention measures and treatment, is dependent upon the timeliness, accuracy, and completeness of surveillance data along with expert interpretation of changes in surveillance practices and case definitions over time.
Thus, identifying and prioritizing ways to support and strengthen state and local HCV surveillance systems is of critical importance to the accurate monitoring of progress towards eliminating HCV and the success of the HCV elimination initiative.
Estimate baseline status for key outcomes to inform the development of realistic but ambitious targets for these outcomes as part of the NYS HCV elimination plan.
- Systematically consider available treatments, epidemiological data, surveillance data, resources, programmatic capacity, HCV-related policies, similar initiatives in other jurisdictions, and mathematical modeling scenarios to estimate baseline status for key outcomes related to HCV elimination in NYS.
- Set realistic but ambitious targets for these outcomes as part of NYS’ HCV elimination plan.
- Consider the creation of a working group within the initiative that includes people with HCV, for setting and periodically revisiting NYS’s targets for HCV elimination.
- Primary and secondary aggregate HCV elimination outcome metrics should be compiled semi-annually at the statewide, regional or county levels in relation to targets and disseminated to all stakeholders.
Systematically track and disseminate information on implementation strategies, efforts and policies that go into the NYS HCV Elimination Plan and that are expected to result in achieving the plan’s goals. There must be statewide and county-level data on activities directly supported or marshaled by the plan that are aiming to support the plan’s elimination goals.
The HCV elimination plan needs to have a systematic mechanism for tracking new programmatic implementation and policy development in support of the plan’s elimination goals. First, partner entities should be identified and their treatment capacity towards implementing the plan initiatives should be described, and aggregated metrics compiled, at the county level.
Second, a tracking system should be created to document in aggregate at the county level who is implementing HCV elimination activities and what is being implemented as well as where and when such activities are being implemented. An organization designated by the NYSDOH should be responsible for the management of this implementation tracking system. Aggregate HCV elimination implementation metrics should be compiled semi-annually at the county level in relation to targets and disseminated to all stakeholders.
Estimate the size of the population of PWID population and incidence of HCV infection among PWID in NYS.
This population is highly dynamic, with some members ceasing to inject drugs and new persons beginning to inject. Many of the persons ceasing to inject will require treatment for HCV infection, and all persons beginning to inject will need HCV prevention services. Thus, monitoring and assessing the effectiveness of Eliminating HCV in New York will require statewide knowledge of the size of and turnover in the PWID population and the extent of recent transmission of HCV infection in this population.
There are several research studies currently being conducted in NYS that have information that could be used to update old estimates of the size of and turnover in the PWID population in the state and estimate the incidence of new HCV infection in this group. A working group should be formed to integrate currently available information and perform new studies as needed to obtain these estimates. These estimates should also address demographic and geographic subgroups.
Systematically track and disseminate timely statewide, regional or county-level information on key HCV elimination outcomes to the initiative’s stakeholders, including people infected and affected by HCV, to convey progress towards achieving the goals and targets of the initiative.
Establish a dashboard to serve as a single comprehensive and definitive source of local data to track and report on the HCV elimination plan progress, as well as to help target resources and make appropriate course corrections at the county level when indicated by the data. This dashboard should include information on key outcomes and targets, as well as the status of the implementation efforts. Where time and resources allow, dissemination should take place in forums, including but not limited to peer-reviewed journals, conferences, online resources and community meetings.