HCV therapy has been successful even when the patients have not abstained from continued drug or alcohol use or are on daily methadone. . . . [I]t is recommended that treatment of active injection drug use be considered on a case-by-case basis, and that active injection drug use in and of itself not be used to exclude such patients from antiviral therapy.30

—National Institutes of Health
Consensus Statement on Management of Hepatitis C (2002)

Expanding Access to Treatment

Clinical and systemic barriers to treating HCV coinfection are substantial. For example, patients often have psychiatric or medical comorbidities, struggle with addiction to drugs and alcohol and have chaotic lives. These issues must be overcome, because all PLWHA should receive HCV education and screening, HAV and HBV vaccination, and counseling on alcohol use and HCV transmission. All providers should offer these services, regardless of whether HCV treatment is offered onsite.

Some clinics will decide to offer onsite HCV treatment and care on the basis of the following factors:

Local priorities
Demographics and needs of patient population
Access to consultation or collaboration with a gastroenterologist or hepatologist
Lack of an acceptable referral option that offers culturally competent care and treatment.

Models have been developed for addressing HCV in PLWHA, including referral and co-management, co-locating services, and integrated care. Some clinics may not have the capacity to treat coinfected patients for HCV and thus refer patients to a gastroenterologist or hepatologist.

Although referral may be the most economically feasible and realistic option for some sites and providers, this approach has drawbacks and has been shown to be minimally effective in securing continuity of care over time. Disappointing follow-up rates among coinfected patients referred to liver specialists have been reported; for example, Clanon and colleagues reported that less than 10 percent of their coinfected patients kept their appointments.68 Low follow-up rates can be improved by identifying liver specialists who are experienced with or are willing to treat coinfected patients, by establishing and maintaining a relationship between HIV and liver specialists, and by developing a communication mechanism among providers. Support groups can help bolster referral follow-up rates, both by word of mouth and by group members’ accompanying each other to appointments.57,144

Co-location of liver specialty care in an HIV clinic may be a viable option, because many patients with HIV prefer “one-stop shopping” at a familiar and comfortable place. Co-location also enhances communication and collaboration among providers. Care can be co-located by providing a liver specialist at an HIV clinic one or two afternoons per month.When referral and co-location are not feasible, clinicians may need to provide their coinfected patients with educational resources (see Resources section).