California Fatal Opioid Overdose and HIV orHepatitis C Virus (HCV) Vulnerability AssessmentAction Planning ChecklistVulnerability to a rapid increase in HIV or hepatitis C virus (HCV) infections and/or fatal opioidoverdoses varies by county. Nonetheless, all counties in California have at least some risk. Forexample, several incidents of rapid increase in HIV and HCV transmission in low vulnerabilityjurisdictions, including a 2018 outbreak among people who inject drugs (PWID) in King County,Washington, have shown that a rapid increase can happen anywhere, including in geographicsettings with and without local resources.1Fortunately, there is strong evidence to support scaling up existing public health interventions toprevent HIV or HCV transmission and fatal opioid overdoses in California communities. Theseinclude 1) medication-assisted treatment (MAT) for opioid use disorder (such as buprenorphine);22) distribution of naloxone (an opiate antagonist that can reverse an opioid overdose);3,4 3) syringeaccess, including through syringe exchange programs and pharmacy nonprescription syringesales;5,6,7 4) HIV testing and treatment (and HIV pre-exposure prophylaxis, or PrEP);8 and 5) HCVtesting, linkage, and treatment.9The following checklist provides evidence-based strategies that local health jurisdictions,health care providers, community based organizations, local opioid safety coalitions, andother partners can use to reduce their county-level vulnerability. This list is not exhaustive;feel free to add your ideas. An accompanying Vulnerability Assessment Resource List hasinformation to support these action items.1) Expand Access to Medication Assisted Treatment for People withOpioid Use DisordersLeverage federal, state, and private funding resources to support MAT expansionSupport local safety net and jail health providers, including prescribers servingadolescents with opioid use disorders, in getting X waivered to prescribe buprenorphine10Enlist the support of available technical assistance providers to support X-waivered andemergency department providers in prescribing buprenorphine to their patients11Partner with local HIV prevention, primary care, homeless outreach, drug treatment,syringe exchange, and social service programs to develop MAT linkage pathways forPWIDHire navigators and leverage telehealth to offer MAT in key settings (such as emergencydepartments and syringe exchange programs) for people with a recent nonfatal overdoseTrain MAT providers in treating and retaining people with polysubstance use, includingthose who continue to use stimulants while engaging in MAT for their opioid use disorderPage 1 of 5

2) Distribute Naloxone to People Most Likely to Witness an OpioidOverdoseLeverage the California Department of Public Health Statewide Standing Order forNaloxone, existing naloxone access options in California, and/or issue a local standingorder to obtain and distribute naloxone to people at the highest personal risk of opioidoverdoseEnsure that new and existing naloxone distribution efforts prioritize those most likely towitness an overdose, emphasizing people who inject drugs and their friends, peers, andfamily members, as well as programs that serve themIntegrate routine overdose prevention education and naloxone distribution into settingsin which people may experience decreased opioid tolerance, such as jails, soberliving homes, and drug treatment programs: train staff and residents in naloxoneadministration, keep naloxone on-site for overdose response, and distribute naloxoneprior to release or exitCreate heat maps of opioid overdose deaths within the county to identify whethernaloxone is reaching people at highest risk for overdose, including by mapping overdosedeaths at the zip code level through the California Opioid Overdose SurveillanceDashboard3) Expand Access to Syringes and Safer Injection EquipmentCollaborate with local pharmacies to promote nonprescription syringe sales, such asAIDS Drug Assistance Program pharmacies and HIV/HCV specialty pharmaciesEncourage physicians and pharmacists to dispense syringes and other injectionequipment, which they may do without a prescription for anyone age 18 or olderEvaluate local syringe access policies to ensure programs can provide adequatesyringes for every PWID to have a new sterile syringe for every injection through needsbased distributionExpand the reach and scope of existing syringe access programs by increasingsecondary syringe exchange and funding core operating expenses and expanded hours,and locationsSupport the creation of new syringe services programs through local or stateauthorization in a variety of settings, such as MAT programs, homeless servicesprograms, and safety net clinicsPage 2 of 5

4) Expand HCV Testing, Linkages to Care, and Treatment, includingfor PWIDReview local public health surveillance data and/or clinic-level electronic health recorddata to assess the hepatitis C care cascade and implement quality improvementinitiativesWork with local public and private health plans to streamline HCV treatment priorauthorization requirements, gain buy-in for primary care providers treating hepatitis C(such as from HCV Project ECHO), and develop hepatitis C-related performanceimprovement projectsWork with local primary care providers, safety net clinics, tribal health clinics, and ruralhealth centers to identify an HCV clinician champion and train primary care physicians,mid-level providers, pharmacists, and medical team members to treat hepatitis C usingteam-based careIntegrate HIV and hepatitis C rapid testing and linkages to care into non-clinical settingsserving PWID, prioritizing syringe access program and drug treatment program settingsSupport health care professionals in treating PWID with a harm reduction approachSupport the hiring and cross-training of dedicated HCV patient navigators/carecoordinators to conduct outreach, rapid testing, phlebotomy, patient navigation, and/orcare coordination, prioritizing hiring people with lived experience with injection drug useand/or incarceration5) Expand HIV Prevention, Testing, Linkages to Care, and Treatment,including for PWIDIntegrate routine, opt-out HIV testing into settings serving PWID, including drug treatmentprograms, syringe exchange programs, jails, and emergency departmentsSupport dedicated patient navigators to assist PWID newly diagnosed with HIV or out ofcare to provide linkages and reengagement and to assure hepatitis C care for those withcoinfectionAssess and address local disparities in viral suppression, mortality among PWID livingwith HIVIntegrate substance use disorder services into HIV care, such as by training HIV careprovidersIntegrate HIV pre-exposure prophylaxis (PrEP) in services for PWID such as SSPs, HIV/HCV testing, overdose prevention, SUD treatment, and primary care and safety net clinicsettingsPage 3 of 5

Action Items and Next StepsAction Item/Next StepPerson ResponsibleDue DatePage 4 of 5

REFERENCESGolden M; et al. Outbreak of Human Immunodeficiency Virus Infection Among HeterosexualPersons Who Are Living Homeless and Inject Drugs — Seattle, Washington, 2018. MMWR. April 192019;68(15):344-349.2Platt L; et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis Ctransmission in people who inject drugs (Review). Cochrane Database of Systemic Reviews. 2017.3Wheeler E, Jones TS, Gilbert MK, Davidson P. Opioid Overdose Prevention Programs ProvidingNaloxone to Laypersons — United States, 2014. MMWR. June 19, 2015;64(23):631-635.4Keane C, Egan JE, Hawk M. Effects of naloxone distribution to likely bystanders: Results of anagent-based model. Int Journal of Drug Policy. 2018;55:61–69.5Des Jarlais DC, Nugent A, Solbert A, Feelemyer J, Mermin J, Holtzman D. Syringe ServicePrograms for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas — United States, 2013.MMWR. 2015 Dec 11;64(48):1337-41.6Stopka TJ, Donahue A, Hutcheson M, Green TC. Nonprescription naloxone and syringe sales in themidst of opioid overdose and hepatitis C virus epidemics: Massachusetts, 2015. J Am Pharm Assoc.2017 Mar-Apr;57(2S):S34-S44.7Meyerson BE; et al. Predicting pharmacy syringe sales to people who inject drugs: Policy, practiceand perceptions. Int J Drug Policy. 2018 Jun;56:46-53.8Note: CDC also recommends HIV pre-exposure prophylaxis (PrEP) for any adult person withoutacute or established HIV infection with any injection of drugs not prescribed by a clinician in past 6months and at least one of the following: Any sharing of injection or drug preparation equipment inpast 6 months or risk of sexual acquisition (see guidelines for sexual risk assessment tool). For moreinformation on HIV PrEP, visit Preexposure Prophylaxis for the Prevention of HIV Infection in theUnited States – 2017 Update: a Clinical Practice Guideline.9Grebely J, Hajarizadeh B, Dore GJ. Direct-acting antiviral agents for HCV infection affecting peoplewho inject drugs. Nat Rev Gastroenterol Hepatol. 2017 Nov;14(11):641-651.10The American Academy of Pediatrics (AAP) “recommends that pediatricians consider offeringmedication- assisted treatment to their adolescent and young adult patients with severe opioid usedisorders or discuss referrals to other providers for this service.” AAP Policy Statement: MedicationAssisted Treatment of Adolescents with Opioid Use Disorders. Pediatrics. 2016 Sep; 138(3):e20161893.11See, for example, the Providers Clinical Support System for technical assistance on implementingMAT.1Page 5 of 5

California Fatal Opioid Overdose and HIV or Hepatitis C Virus (HCV) Vulnerability Assessment Action Planning Checklist Vulnerability to a rapid increase in HIV or hepatitis C virus (HCV) infections and/or fatal opioid overdoses varies by county. Nonetheless, all counties in California have at least some risk.