Screening, Counseling and Linkage to Care for Hepatitis C Infected Patients

Local Service Bulletin 2020-01 supersedes Local Service Bulletin 2019-04.

Date Issued: September 18, 2020



· All OASAS certified programs

· Local Governmental Units (LGUs)



This document serves to support the NYS Office of Addiction Services and Supports (OASAS) recommendations for quality medical care and prevention services for hepatitis that can be carried out in the above noted programs.


Hepatitis is the inflammation of the liver. The hepatitis C virus (HCV) was first discovered in 1989. HCV is usually spread when blood (even microscopic/nonvisible blood) from a person infected with HCV enters the body of someone who is not infected. The primary risk factor for becoming infected with HCV is injection drug use, including the sharing of any drug paraphernalia. Other risks include tattooing and body piercing, by an unlicensed artist, blood transfusion prior to 1992 and organ transplant before 1990. Sexual transmission is rare, however, transmission increases in certain situations, such as with anal sexual intercourse, rough sexual intercourse or the co-occurrence of a sexually transmitted infection (STI) or the Human Immunodeficiency Virus (HIV).

Usually there are no marked signs of the acute infection, though one can experience fatigue, upper abdominal discomfort, loss of appetite, painful joints, and possible jaundice. HCV can be a progressive disease and can be asymptomatic. 80% of the patients who acquire the acute infection will develop chronic infection (while approximately 20% spontaneously will clear the infection). Of this number, approximately 15-20% may develop cirrhosis. However, treatment has improved significantly, and the vast majority of people (>95%) can be cured of the disease in as short as 8 (eight) weeks and with minimal or no side effects. Approximately 4 million people in the U.S. are infected with chronic HCV, with an estimated 40,000 new infections in 2017. New data released from the Centers for Disease Control and Prevention (CDC)

in May 2017 shows that, in over just five years, the number of new HCV infections reported to the CDC has nearly tripled, reaching a 15-year high. The greatest increases, and the highest overall number of cases, were among young people aged 20-29, with injection drug use as the primary route of transmission. More Americans now die from HCV than HIV/AIDS, and the cost burden of the disease will exceed over $80 billion nationwide during the next ten years. The CDC now recommends one-time hepatitis C testing of all adults (18 years and older) and all pregnant women during each pregnancy. The CDC continues to recommend people with risk factors, including people who inject drugs, be tested regularly. The New York State (NYS) HCV Testing Law, which went into effect in January 2014, requires health care providers to offer a one-time HCV screening test to all persons born between 1945 and 1965receiving services in primary care settings, to anyone receiving services as an inpatient of a hospital or from a physician, physician assistant, or nurse practitioner providing primary care, regardless of the setting.


  • All patients should be screened for HCV antibodies and receive their test results in a timely manner, with documentation that they received their test results in their patient record. Patients who screen negative, but have ongoing risk (e.g., positive toxicology results) should be screened at a minimum annually. Patients suspected to have acute HCV should be screened with an HCV RNA test in addition to an HCV antibody test, as they may be in the window period to manifest a positive HCV antibody response.
  • All patients who screen positive for HCV antibodies must have an HCV RNA test in order to determine whether they have chronic infection. This test should be conducted by the lab, at the same time as the antibody test (reflex testing).
  • All patients who screen positive should be made aware that they will always screen positive even if treated and cured of HCV.
  • Brief post-test HCV counseling should be made available to all patients. Those who screen positive for HCV antibodies should be counseled about the need for further testing and evaluation, basic health information and the availability of effective HCV treatment which cures HCV. Those who screen negative should be counseled on risk reduction and prevention strategies.

HCV Post-Test Counseling

For patients with a negative/non-reactive test result:

  • Discuss meaning of the test result.
  • Discuss the possibility of HCV exposure during the past 3 (three) months and need to consider retesting.
  • Discuss hepatitis A and B vaccination.
  • Reinforce personal risk reduction strategies:
    • Do not share any drug paraphernalia, including, but not limited to: needles, syringes, cookers, ties, water, stems, or straws.
    •  Provide referrals to syringe exchange programs (SEPs) for all patients who continue to inject as their route of administration.
    • Use latex condoms.

For the patient with a positive/reactive antibody test result:

  • Discuss the meaning of the test result, including that they were exposed at one time and are probably infected (80% chance of having chronic infection, 20% chance of spontaneous clearance).
  • Discuss the need for follow up testing with an HCV RNA test to determine if they are currently infected. A detectable HCV RNA test would indicate current HCV infection.
  • Discuss hepatitis A and B vaccination.
  • Discuss the recommendation to avoid or limit alcohol intake.
  • Do not share razors, toothbrushes, tweezers, or nail clippers.

For patients with a positive HCV antibody test and a negative HCV RNA test:

  • Discuss that this means the patient was infected at one time and either cleared the virus on their own or was successfully treated.
  • Discuss the fact that the HCV antibody will be present for a lifetime and it does not mean that they have immunity. In other words, if exposed to HCV again, they could become reinfected with HCV.


For the patient with a positive antibody test and a positive HCV RNA test:

  • Discuss the need for medical care and availability of HCV treatment.
  • Discuss the effects of alcohol use and HCV disease.
  • With pregnant patients, discuss clinical practice guidelines. Currently, no HCV treatment is approved for pregnant or breastfeeding persons due to a lack of data. Breastfeeding is not contraindicated with HCV unless the nipple and/or areola are cracked or bleeding. Discuss the risk of transmitting the virus to the child and the need to ensure the child is tested at 18 (eighteen) months of age. The risk of vertical transmission is approximately 6%.
  • Encourage sexual and needle-sharing partners to get tested for HCV.
  • Provide counseling or refer to counseling for coping with the emotional consequences of testing positive and behavior changes that will be needed to prevent the spread of HCV.
  • Provide or refer to needed medical support services.
  • Provide information on the prevention of the spread of infection to others:
    • Do not share any drug paraphernalia, including, but not limited to: needles, syringes, cookers, ties, water, stems, or straws.
    • Provide referrals to syringe exchange programs (SEPs) for all patients who continue to inject as their route of administration.
    • Provide referral to medication assisted treatment (MAT) for opioid use disorder (OUD) for all persons willing to take medication for active opioid use.
    • Do not share razors, toothbrushes, tweezers, or nail clippers.
    • Use latex condoms.
    • Cover cuts and sores on the skin.



All medical staff and counselors should receive updated HCV trainings that reflect the current standard of care. It is recommended that staff should be trained on HCV best practices a minimum of every 2 years (S. Strauss et el, "Enhancing Drug Treatment Program Staff's Self-Efficacy to Support Patients' HCV Needs" J Soc Work Pract Addict. 2011 January 1; 11(3): 254-269.)

· Provide onsite HCV care and treatment where possible. Programs that are unable to offer HCV RNA or genotype testing, liver fibrosis staging, or treatment onsite should establish a concrete referral system, including linkage agreements with medical providers experienced in

treating HCV. Referrals should be documented in the patient case record.

· Substance use counselors and medical providers should review the status of HCV care for patients with chronic infection as part of their treatment/recovery plan and help facilitate access to care when only available offsite.



If you require further clarification of the issues detailed in this Bulletin, please contact [email protected].