Wound care as an engagement opportunity for improving the hepatitis c care continuum among syringe exchange participants in Hawaii

By Christina Wang and Thaddeus Pham

Hep Free Hawai`i (HFH) is a grassroots campaign started by hepatitis advocates in Hawai`i to bring attention to the epidemic of chronic hepatitis B and C and liver disease in the islands. Through increasing awareness, HFH hopes to encourage everyone in Hawai`i to learn their hepatitis status, and for those living with hepatitis or other liver disease to access the care they need to live healthy lives.

The Campaign

Over 60% of clients accessing syringe service programs (SSPs) in Hawaii have been exposed to or are infected with hepatitis C. This population is primarily made up of people who inject drugs (PWID) and the homeless.

The CHOW Project (Hawaii’s state-wide SSP) surveyed clients and identified that wound care was one of their top health concerns, especially since they experienced stigma when going to the hospital to seek care. This was a good opportunity to not only provide street based wound care, but to increase hepatitis C education, testing and linkage to care.

In collaboration with the Hawaii Department of Health, Hep Free Hawaii, the CHOW project and local hospitals and housing agencies, Christina Wang developed and implemented a street based wound care program that provided care at SSP sites. Clinicians would also ask clients about their hepatitis C status as part of their initial assessment.  For those who were unsure of their status, outreach workers would offer point-of-care hepatitis C antibody tests and onsite confirmatory HCV RNA testing (if antibody test was positive). An onsite Hepatitis Care Coordinator would immediately meet with the positive client to ensure linkage to care and other related referrals.









Achievements to date

These are our achievements to date:

  • Integration of HCV testing, linkage, and education into street-based wound care allows for more active engagement with PWID who are already receiving quality, trusted, low-threshold services. This has allowed for increased opportunities for education, skills-building for prevention of transmission with injection drug use, and relationship building for when clients are ready to address HCV infection
  • The programme reduced utilisation of under-resourced and over-burdened hospital emergency departments, allowing for more appropriate referrals and buy-in from medical providers in the community.
  • Co-locating HCV services with wound care at SSPs has increased uptake of both services for at-risk clients.
  • ‘According to the Hep Free Hawaii Hepatitis Care Coordinator, one SSP client was referred for HCV services through the wound care program. The patient had multiple issues including HCV infection, lack of housing, mental health diagnoses, and more. Through ongoing engagement with the Care Coordinator, the client was able to obtain housing, link to primary and dental care, start methadone, and initiate HCV treatment!’


We do, however, face some challenges, including:

  • Funding for staff. One clinical nurse and one care coordinator covered the bulk of the program, with the help of many student volunteers and social service partners. To try and overcome this, the programme continues to seek funding sources and to build community partnerships for referrals.


Top tips for success

We found that the following factors have made our activity a success:

  • Using the model of harm reduction to approach wound care allowed for trust-building within a marginalized community. In doing so, a whole other suite of services were able to be offered with less resistance and mistrust, including HCV education, testing, and linkage to care coordination.
  • Support from program staff and local partners in health and social services were essential for the successful implementation of this programme.

Key learnings

  1. Ask communities what their primary concerns are…then use that as an opportunity to engage!
  1. Create low-threshold, client-centred programs (using a harm reduction framework) to build trust and engagement with hard to-reach communities.
  1. Co-locate and integrate hepatitis services to make them part of a suite of desired and quality services.



Find out more

For more information please contact Hep Free Hawaii at hepfreehawaii@gmail.com