Hepatitis C virus (HCV), a viral infection that causes liver inflammation and can lead to serious liver damage, disproportionately affects people who inject drugs (PWID) and people in prison: people currently injecting drugs account for an estimated 23–39% of new HCV infections. Globally, 5.5 million PWID are living with HCV.
This high HCV burden is particularly evident in India and Ukraine. In India, it was estimated in 2017 that 52.3% and 17.8% of PWID were living with HCV and HIV, respectively. HCV prevalence among PWID in Ukraine is high as well, estimated at 56%.
In parallel, access to HCV services is a challenge in both countries. In India, fewer than 5% of PWID have ever tested for HCV. The Government of India, through the National Viral Hepatitis Control Program, has acknowledged the need for increased HCV screening, especially among at-risk, key, and vulnerable populations, and in high-prevalence geographies. In Ukraine, the lack of convenient testing options is a major barrier to HCV diagnosis and treatment, and many people with chronic HCV are unaware of their condition. This leads to low treatment rates and higher morbidity and mortality: only about 6.2% of people with chronic HCV are under medical supervision.
To effectively reach PWID with HCV prevention services, integrated service delivery models are essential. Moreover, they must be person-centered, responding to client needs and prioritizing client choice.
The PATH-led, Unitaid-funded HCV Combination Prevention in PWID and Prisoners Project (HepC3P) is demonstrating new HCV diagnostic and treatment models. Below, we describe three health service models among PWID and people in prison in India and Ukraine that are connecting people to care.
India: Integrating HCV into existing HIV services
India had gathered early evidence on the feasibility of HCV integration into HIV and opioid agonist maintenance therapy (OAMT) services. However, there was a crucial need to further understand both operational challenges and pragmatic, scalable approaches for eliminating HCV among PWID through existing HIV prevention sites. To address these gaps, PATH’s HepC3P project implemented a 12-month pilot in Nagaland, in which HCV screening, treatment, and retesting were integrated with HIV service delivery in community-based settings.
HepC3P and government partners worked together to design a model that enhances the existing programmatic service model at community-based HIV prevention sites. We did this by adding education and awareness activities, demand generation, and trainings for HCV; enhanced HCV screening and active referral; strategic follow-up and counseling; treatment support and monitoring; and access to HCV retesting.
“The assurance of cure and consistent follow-ups with reminder calls helped me adhere to treatment and successfully complete my treatment and be cured.”— Client receiving HCV services
Through this pilot model, HIV prevention sites achieved strong results across the diagnostic and treatment cascade: 94% of PWID accessing services were screened for HCV, and 95% were linked for HCV confirmation.
Among those confirmed, 98% initiated treatment, and the treatment completion rate among initiators was 100%. For people who were eligible for re-testing after six months of sustained virologic response, 50% completed re-testing, and there was 0% re-infection among those tested.
Ukraine: Offering HCV self-testing (HCVST) at harm reduction sites
In Ukraine, interest in self-testing is high. The country had a positive experience introducing and scaling up HIV self-testing (HIVST). Both the government and PWID community have demonstrated significant interest in learning from the HIVST experience to introduce HCVST, which has the potential to improve testing access for HCV.
In response to this interest, HepC3P introduced HCVST as an additional HCV testing option within an existing OAMT service delivery model, tailored to the needs and preferences of the PWID community. This model aimed to assess the feasibility, acceptability, and potential integration of HCVST into routine HCV services, while maintaining existing pathways for confirmatory diagnosis and linkage to care.
Through this pilot, two types of HCV self-tests were offered: blood-based rapid tests and oral tests. Clients could choose to test at the OAMT site (with or without assistance from a provider) or take a test kit for use at home. Site staff referred people with reactive results for confirmatory ribonucleic acid testing, and for treatment (as necessary) in accordance with national clinical guidelines.
Between December 2025 and May 2026, 430 clients used HCVST, resulting in 172 reactive tests, 92 confirmatory diagnoses, and 70 people initiating treatment. Among those, 88.5% completed treatment, with no statistically significant difference across the HCV care cascade between oral and blood-based self-tests.
A sample of clients were surveyed through community-led monitoring; among them, more than half (54%) reported no challenges during testing. Reported barriers were primarily operational, including longer-than-expected testing time and the need for additional guidance on using self-tests.
Ukraine: needle and syringe programs in prisons
Despite Ukraine’s approval of prison-based needle and syringe programs (NSPs) in 2021, implementation has been limited to a few prisons, and there has been limited training and technical support to model how to practically integrate an NSP into prison settings.
HepC3P partnered with Ukraine Ministry of Justice’s Center of Health Care (MOJ’s CHC) to test a feasible model of NSP delivery within the Ukrainian prison system, assess how the intervention could be integrated with existing HIV and HCV services, and generate evidence to inform future scale-up across additional facilities.
International experience shows that prison NSPs can be implemented through different approaches, including peer-based distribution, dispensing machines, and distribution by health care staff. Each model has specific advantages and operational considerations related to security requirements, confidentiality, human resources, and sustainability.
This pilot assessed an alternative approach in which NSP services are integrated into the existing prison health system and delivered within established institutional procedures. The objective was not only to provide access to sterile injecting equipment, but also to determine whether such a model could operate in routine practice and be replicated in other prison settings with minimal additional resources.
A wooden box at a prison NSP site in Ukraine holds informational materials and injecting equipment for clients. Photo credit: PATH.
Across the two prison sites, more than 9,234 syringes and 23,852 needles were provided to NSP clients in the first seven months of the 12-month pilot. In addition, 249 clients were tested for HCV and 402 for HIV.
High service uptake was observed at both prison sites, although utilization patterns differed between facilities, highlighting the importance of local context and implementation conditions in shaping demand and engagement. Based on uptake, the demonstration suggested that NSPs can be integrated into routine prison health services and serve as an additional pathway to HIV and HCV prevention, testing, and treatment.
Community leadership to expand HCV service access
Across the HepC3P portfolio, the PWID community and other allied community-based organizations guide design, implementation, and evaluation of activities. For these models of care, community members led the efforts in various ways.
In India, the Community Advisory Board, comprising representatives from the Dimapur and Chumoukedima District Users’ Networks in Nagaland, provided important community perspectives and feedback from inception of the model concept through the implementation and analysis of the findings. Peer educators and outreach workers incorporated HCV awareness and screening messages into routine HIV-related outreach and counseling sessions and played a significant role in promoting HCV screening alongside HIV screening. The project utilized peer-led support groups and networks, along with screening, counseling, and referral for free treatment, to encourage participation.
Leveraging the existing and already trusted outreach at HIV prevention sites helped raise awareness, reduce stigma, and increase willingness to undergo HCV testing, with peer educators mobilizing willing PWID to the screening site with support from outreach workers.
In Ukraine, the HepC3P community partner VOLNA (The Ukrainian Network of People Who Use Drugs) spearheaded community-led monitoring of HCVST activities to collect feedback from service users, examine barriers, and evaluate experiences with different testing modalities.
Findings emphasized the role of community support itself.
"You don't even need in-person support [for self-testing], it can be done over the phone, with a social worker explaining and instructing the person step by step on what to do. That alone would be a great help,” one client said.
VOLNA provided information and navigation support to clients throughout the intervention, including information sessions, individual peer-to-peer counseling, dissemination of information and educational materials on HCV/HIV and available testing opportunities, and advice on various testing modalities. This ensured that implementation reflected the needs and preferences of PWID and strengthened trust in testing services.
Innovative models, broader impact
The impact of these new models for integrated HCV service delivery is already apparent. Based on the success of the India pilot, the state health department has formally requested that the model be replicated in other geographies. “An integrated approach not only improves health outcomes but also enables better use of public health resources. This model is replicable in a phased manner based on the geographies with the guidance and support from the Government of Nagaland,” reflects Kannan Mariyappan, a PATH Senior Program Officer in India.
In Ukraine, interim results from the prison pilot led the Government of Ukraine to include low-dead-space needles in the correctional sector’s proposal for Global Fund Grant Cycle 8, while learnings from the HCVST work will inform community and stakeholder advocacy efforts aimed at expanding HCV testing options within routine service delivery.
Through these efforts, HepC3P is demonstrating that HCV testing, treatment, and prevention can be integrated into existing HIV, harm reduction, and prison health platforms, expanding access for people who inject drugs without duplicating service systems. These models, and the barriers they address, are contributing to the goal of reducing incidence toward elimination of HCV, and providing accessible, person-centered services for all.
About HepC3P: The Unitaid-funded, PATH-led HepC3P project is addressing key access barriers that prevent the introduction and scale-up of HCV products and interventions in LMICs. HepC3P is contributing to closing HCV prevention and testing gaps through increased access to new and underused tools for prevention among PWID and people in prison in India, Nigeria, South Africa, Ukraine, and Vietnam. Together with country stakeholders, the project is generating evidence on low dead space syringes and needles and long-acting depot buprenorphine through two research studies, testing new models of care for HCV, conducting market shaping work for new HCV products, and identifying effective transition and scale-up pathways for HCV prevention and treatment services, all with extensive and meaningful engagement of stakeholders—including communities, PWID, and government—in the design, delivery, and monitoring of HCV services and as advocates for HCV prevention.
