1. STD Control Branch Addressing HCV through a Drug User Health Framework NASTAD Viral Hepatitis Technical Assistance Meeting, October 21, 2014 Washington, D.C. Rachel McLean, MPH California Department of Public Health

2. STD Control Branch Overview 1.What is a drug user health framework? 2.What is the role of VHPCs in addressing HCV through a drug user health framework? o Perspective from California 3.Resources and questions for discussion

3. STD Control Branch What is a drug user health framework?

4. STD Control Branch CA Framework for Injection Drug User Health and Wellness Drug users have a right to protect their health and the health of those around them. All drug users should: – have the means by which to protect their health, including access to sterile injection equipment sufficient to meet their needs. – receive accurate, non-biased and non-judgmental information on illicit drugs and other substances. – receive the same level of care as any other individual accessing health care or social services. – have access to drug and alcohol treatment on demand. Providers should: – recognize the valid and valuable expertise that people who use drugs can give to designing, delivering and evaluating effective services. – ensure that the provision of services to drug users is not contingent upon the individual’s agreement to enter drug treatment, or abstain from drug use. Service providers must not withhold appropriate treatments or services from drug users. Services should be provided to encourage engagement and retention in care. Source: http://harmreduction.org/wp-content/uploads/2012/06/Framework-for-Injection-Drug-User-Health-and-Wellness.pdfhttp://harmreduction.org/wp-content/uploads/2012/06/Framework-for-Injection-Drug-User-Health-and-Wellness.pdf

5. STD Control Branch In other words… Source: HIPS, Washington, D.C.

6. STD Control Branch Is it ethical to have a health framework specific to drug users? Pros – Pushes the agenda forward to advocate for the rights of drug users – Has the potential to benefit drug users by changing hearts/minds/ behavior of providers – Has the potential to benefit invisible users and non-IDUs : “Grandma needs harm reduction, too” Cons – Potential to be further stigmatizing – Reinforces “separate and unequal” health care delivery for PWID – Continues compartmentalization that providers don’t have time to learn: “Please, not yet another toolkit!”

7. STD Control Branch What does a IDU health framework look like in practice? Policies Make services easy to access Involve consumers in program design Train/hire users as peers Train providers on IDU health and being nice to drug users Practice and advocate for “radical inclusion” of drug users in services (e.g., drug treatment, HCV care) Identify/address barriers Services Overdose prevention Safe injection equipment Tobacco cessation Methadone/buprenorphine HIV/HCV testing HAV/HBV vaccination Supportive housing Social/peer support Mobile/drop-in services Trauma/violence prevention Legal support

8. STD Control Branch What is the role of VHPCs in addressing HCV through a drug user health framework? Perspective from California

9. STD Control Branch Syringe Access Collaborating with pharmacists to promote new law allowing statewide sales of unlimited # of syringes w/o a prescription Assisted State Office of AIDS in developing regulations for state approval of syringe exchange programs not approved by county Received preliminary approval to use state STD general funds to purchase syringes

10. STD Control Branch HCV Testing HCV rapid testing guidelines – Prioritized people who have ever injected drugs for testing in non-healthcare settings (e.g., SEPs) – Analyzed positivity, referrals by IDU status, encourage testing sites to further prioritize IDUs Substance Abuse Prevention and Treatment Block Grant, HIV Set-Aside funds – Encouraged state to allow use for HCV testing – Provided training to alcohol and drug programs on how to use funds for this purpose

11. STD Control Branch HCV Treatment CA Department of Health Care Services HCV treatment policy for sofosbuvir (Sovaldi) – Estimated prevalence of HCV in Medicaid population – Provided extensive comments on draft treatment guidelines – Proposed using adherence rather than drug use as basis for HCV treatment eligibility 

12. STD Control Branch Overdose Prevention State-level overdose working group – Got ourselves invited by Connecting the Dots of Drug User Health: HIV/HCV/OverdoseConnecting the Dots of Drug User Health: HIV/HCV/Overdose – Promoted prescription of naloxone w/ opiates in draft state pain management guidelines – Shared sample overdose prevention materials for use by physicians when prescribing opiates Pharmacist distribution of naloxone – Participating in working group planning for promoting awareness of new law that allows distribution w/o a prescription (AB 1535)

13. STD Control Branch Health Care Reform Medicaid 1115 waiver – Submitted public comments encouraging expansion of office-based buprenorphine, use Medicaid funds for shelter (supportive housing) – Promoted role of CHWs (e.g., SEPs) in health homes for people with chronic conditions / substance use disorders – Convened group of SEPs to leverage their role in promoting drug user health; linkages to care; ensure long-term program sustainability

14. STD Control Branch Questions for Discussion 1.How have you addressed drug user health in your state? 2.What has worked well? What resources and ideas do you have to share? 3.What are you struggling with? Where could you use some advice/support? 4.How can other VHPCs and NASTAD support you in your work?

15. STD Control Branch Resources Harm Reduction Coalition www.harmreduction.org/ Adapting Your Practice: Recommendations for the Care of Homeless Patients with Opioid Use Disorders, Healthcare for the Homeless Clinicians Network http://www.nhchc.org/wp-content/uploads/2014/03/hch- opioid-use-disorders_adapting-your-practice-final-to-post.pdf SAMHSA Tip 53: Addressing Viral Hepatitis in People With Substance Use Disorders http://store.samhsa.gov/product/TIP-53-Addressing-Viral- Hepatitis-in-People-With-Substance-Use-Disorders/SMA11-4656

16. STD Control Branch Contact Information Rachel McLean, MPH Viral Hepatitis Prevention Coordinator/ STD Healthcare Policy Analyst STD Control Branch California Department of Public Health Phone: 510-620-3403 Email: Rachel.McLean@cdph.ca.govRachel.McLean@cdph.ca.gov Website: www.cdph.ca.gov/programs/pages/ovhp.aspx www.cdph.ca.gov/programs/pages/ovhp.aspx

17. Connecting the Dots of Drug User Health: HIV/HCV/Overdose Drug overdose is a common cause of non-AIDS death among people with HIV and the leading cause of death for people who inject drugs. 1 Emerging evidence shows that an increasing number of young persons in suburban and rural areas are transitioning from oral prescription pill use to injection of prescription pills or heroin after <2 years of prescription pill use, 2,3,4 putting them at elevated risk for HIV, HCV, and overdose. In 2011, the National Alliance of State and Territorial AIDS Directors (NASTAD) Executive Committee issued a Statement of Commitment: Promoting Injection Drug User Health, which called for coordinated efforts to prevent HIV, HCV, and overdose among persons who use injection drugs: 5 Statement of Commitment: Promoting Injection Drug User Health “In addition to becoming infected with HIV and viral hepatitis, people who inject drugs are fatally overdosing at elevated rates, despite available prevention tools. Access to substance use treatment is limited and overdose prevention efforts rarely have a “home” in state drug and alcohol, injury prevention or public health agencies. […] Recognizing the progress we have made in reducing new HIV infections among the IDU population, we acknowledge that our nation’s efforts are not sufficient to meet the comprehensive health needs of this population. To change the course it will require an honest and critical examination of our efforts among all stakeholders. NASTAD and its members commit to explicitly identify and implement effective public health programs for IDUs.” While overdose is not an infectious disease, CDPH, Center for Infectious Diseases has extensive expertise in serving injection drug users, who are risk for HIV, HCV, and overdose, including through the integration of preventive services into drug and alcohol treatment programs and primary care. References: 1. Green TC et al. HIV infection and risk of overdose: a systematic review and meta-analysis. AIDS. 2012 Feb 20;26(4):403-17.AIDS. 2. CDC. Viral Hepatitis Surveillance, 2011. 3. NIDA Research Report: “Prescription Drugs: Abuse and Addiction”NIDA Research Report: “Prescription Drugs: Abuse and Addiction” 4. HHS Technical Consultation: Hepatitis C Virus Infection in Young Persons who Inject Drugs, 2013HHS Technical Consultation: Hepatitis C Virus Infection in Young Persons who Inject Drugs, 2013 5. NASTAD. Statement of Commitment: Promoting Injection Drug User HealthStatement of Commitment: Promoting Injection Drug User Health