Screening and Prevention: Mandatory HCV antibody screening of all patients accessing opioid treatment programs and yearly screening of patients who currently use drugs. Onsite HCV RNA testing to confirm chronic HCV is best; reflex testing where possible If confirmation with an HCV viral load cannot be performed, HCV-antibody positive patients should be referred to a clinic where HCV RNA measurement can be done. Case managers, patient navigators, or peer escorts may facilitate adherence to follow-up visits. All HCV-antibody negative patients should be counseled to prevent future HCV infection. Patients should be advised not to share syringe, cooker, cotton, and rinse water. Patients should be referred to harm reduction/syringe exchange programs if necessary Clinical registries should be created to ensure that case management is provided for patients with HCV who are not currently engaging in care.

Education: Provide patient education on HCV transmission, risk factors for progression of fibrosis, HCV medication, adherence, reinfection, and harm reduction strategies to HCV-positive patients on OAT and/or who actively use drugs. All medical staff and substance use counselors should receive basic HCV-related education. HCV-related literature should be available to patients on-site Make regular HCV support groups available on-site Ideally, support groups should be co-facilitated by staff members (medical or non-medical) and patients. On-site HCV peer programs for patients who co-facilitate support groups should be considered. Provide education on substance use disorders and provide community based drug treatment resources to HCV specialists such as hepatology and Infectious Diseases physicians. Efforts must be undertaken to reduce the shame and stigma of substance use, opiate agonist treatment, and HCV, all of which are barriers to engaging HCV-infected patients in care.

Staging: Primary care and drug treatment providers not providing on-site HCV treatment must still have a basic understanding of HCV evaluation and management in order to help facilitate appropriate off-site care Liver biopsies are not necessary to stage liver disease. Patients should be made aware of this. Use non-invasive staging methods such as APRI or FIB-4 (readily available with basic labs including AST, ALT, and platelets) to determine advanced fibrosis and cirrhosis to increase the completion of disease assessment in patients on OAT and people who are currently using drugs. An attempt should be made to engage all patients with HCV in care, however if APRI score is >2 or FIB-4 >3.25 patients need to be educated about the possibility of cirrhosis and a more active process must be in place to get these patients into treatment.

Linkage to HCV Treatment: Provide care and treatment via multidisciplinary teams including HCV providers (practitioners with expertise in HCV treatment which may include hepatology, gastroenterology, infectious diseases, and/or trained primary care providers), addiction specialists and addiction counselors, psychiatric services and social support (including peer support groups if available). Use telemedicine to more readily facilitate these team efforts. Establish working relationship with HCV providers and communicate with HCV providers in real-time if issues arise (e.g. side effects or insurance problems that may lead to loss of access to medications) Linkage to HCV provider will be key for off-site treatment Establish working relationship with HCV provider that understands patient population Use case management and peers to support linkage Peer accompaniment to appointments can be beneficial Encourage patients who are currently using drugs to start substance use treatment as HCV treatment in conjunction with addiction treatment improves the rates of treatment completion. Do not withhold HCV treatment from patients who defer substance use treatment. Patients who are currently using drugs can be successfully treated for HCV and should be considered for treatment on a case-by-case basis. Motivation and engagement should help decide about treatment readiness, not patterns of drug use.

Onsite HCV Treatment: Consider establishing on-site treatment at OTP or primary care clinics with OAT. Evaluate HCV infection and treatment options by following an established protocol based on the latest established HCV guidelines. Use hcvguidlines.org as a resource. All DAAs can be used in patients on OAT without dose alterations and there are data to support the efficacy and safety of these regimens in this specific population. Consider all medications taken by each patient to assess drug-drug interactions with DAAs. For those with cirrhosis, HCC screening every 6 months with ultrasound and refer to gastroenterology for upper endoscopy to screen for varices. Establish a community of HCV providers to discuss issues as they arise e.g. side effect management, drug-drug interactions, etc. Refer to HCV specialists for treating complicated cases (e.g. autoimmune hepatitis; decompensated cirrhosis; any case that provider is not comfortable with). Train non-medical staff at OTPs to administer HCV therapy in DOT at methadone pick-up window and monitor patients for side effects. Substance abuse counselors should know the HCV status of each patient and be able to provide basic HCV-related case management, and know what services are available onsite. Substance abuse counselors should be able to identify lapse or relapse to drug and/or alcohol use and provide support; help with adherence to HCV visits and medications; and be aware of emerging psychiatric conditions while patients are on HCV therapy