Wound care as an engagement opportunity for improving the hepatitis C care continuum among syringe exchange participants in Hawai'i

By Dr Christina Wang, DNP, MPH, APRN-Rx, AGPCNP-C, Hep Free Hawaii; Hawaii Health and Harm Reduction Center, and Thaddeus Pham – Hep Free Hawaii; Hawaii State Department of Health

Hep Free Hawai`i (HFH) is a community-driven coalition 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 its #HepFree2030 elimination strategy, HFH uses nimble, collaborative action to eliminate viral hepatitis in Hawaii by focusing on Awareness, Access, Advocacy, Equity, and Data.

The Project

Over 60% of clients accessing syringe service programmes (SSPs) in Hawaii have been exposed to or are infected with hepatitis C virus (HCV). Many of the people accessing this service are also houseless. At the Hawaii Health and Harm Reduction Center (HHHRC; formerly the CHOW Project), we surveyed SSP participants, who identified that wounds were one of their primary health concerns. Quality wound care was compromised by many who experienced stigma when going to hospital emergency departments to seek care. Due to the high incidence and prevalence of wounds amongst homeless people who inject drugs (PWID), we identified low-threshold wound care as an opportunity to also engage clients regarding HCV.

In collaboration with the Hawaii Department of Health, Hep Free Hawaii, HHHRC, and local hospitals and housing agencies, Dr. Christina Wang developed and implemented a street-based wound program that provided care at SSP sites. Clinicians ask wound care clients about their HCV status as part of the initial assessment.  For clients unsure of their status, outreach workers are then able to offer point-of-care HCV antibody testing and on-site confirmatory HCV RNA testing (if antibody positive).  An on-site Hepatitis Care Coordinator immediately meets with HCV-positive clients to ensure linkages to medical care and other related referrals. Through the programme, we have found that providing wound care is an effective way to engage clients likely to have HCV and that increased HCV education, testing, and care coordination can occur when offered in conjunction with street-based wound care.

Looking forward, future programme efforts include integrated consent forms and client registries to better identify clients who need HCV and/or wound care services. We are proposing that when electronic medical records systems are in place, electronic “flags” for HCV should occur for wound care clients. Our ongoing partnership with the Department of Health will also hopefully lead to increased data being available not only on incidence/prevalence of HCV and/or wound care, but also on cost savings which can then be used to advocate for changes in policies or increased funding.

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.

Challenges

  • Funding for staff. One clinical nurse and one care coordinator covered the bulk of the programme, 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 marginalised community. In doing so, a whole other suite of services was able to be offered with less resistance and mistrust, including HCV education, testing, and linkage to care coordination.
  • Support from programme staff and local partners in health and social services were essential for the successful implementation of this programme and enabled co-occurring issues that come with HCV infection in this population (e.g. housing, mental health, wounds, substance use) to be addressed and treated as opportunities for engagement.

‘The Hep Free Hawaii Hepatitis Care Coordinator shared that 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!’

Key learnings

  1. Ask communities what their primary concerns are…then use that as an opportunity to engage!
  1. Create low-threshold, client-centred programmes (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 which look at the broad needs of the individuals.

Find out more

Please find some further reading below;

https://www.hhs.gov/hepatitis/blog/2018/05/11/opening-doors-forhcv-services-at-syringe-services-programs.

http://healthhcv.org/wp-content/uploads/2019/05/Wound-Care-and-HCV-Care-for-PWID_T.Pham_S.Quigley.pdf

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