HCV elimination in tribal communities: Embracing a syndemic approach

In the next installment of the Health Equity Series, Jorge Mera, MD, explores how tribal nations in the U.S. are uniquely positioned to lead efforts to eliminate hepatitis C virus but also face persistent structural and social barriers that need attention.

Hepatitis C virus elimination is increasingly understood as an achievable public health goal. (1) Yet in many communities, including tribal nations, HCV rarely exists in isolation. Instead, it intersects with substance use disorders, behavioral health needs, chronic diseases, HIV, housing instability and long-standing structural inequities. These overlapping conditions reinforce one another, creating a syndemic that requires integrated, community-centered approaches rather than siloed, disease-specific programs. (2, 3)

Through my work at Cherokee Nation Health Services and the Northwest Portland Indian Health Board, it became clear that tribal nations across the United States are uniquely equipped to lead this work, demonstrating what is possible when HCV elimination is approached through a syndemic lens. (4, 5, 6) However, many structural and social barriers, often outside the control of tribal governments or health systems, still require attention for true syndemic mitigation and prevention.

Why tribal nations are uniquely positioned

Many tribal nations operate tribally governed, publicly funded health systems that provide care at no cost to eligible American Indian/Alaska Native patients. (7) Functioning much like an integrated, socialized model, these systems can rapidly implement universal screening, simplified treatment pathways and coordinated public health responses without the payer fragmentation hurdles common outside tribal care. Tribal sovereignty further enables these nations to set their own health priorities, declare public health emergencies and align resources toward elimination goal.

Tribal health systems frequently integrate primary care, infectious diseases, behavioral health, SUD treatment and harm reduction within the same organizational structure, creating a naturally syndemic-informed model that addresses the interconnected drivers of HCV. Long-standing relationships with communities, health departments and academic partners also foster trust, innovation and population-level interventions. As a result, tribal nations possess both structural advantages and community credibility essential for effective, equitable HCV elimination.

Why a syndemic lens matters

A syndemic approach recognizes that HCV clusters with multiple health and social challenges, especially SUDs. In tribal communities, HCV often overlaps with high rates of opioid and methamphetamine use, co-occurring infections such as HIV, hepatitis B virus and syphilis, and chronic conditions like diabetes and hypertension. Community-based screening at food distribution sites, outreach events and mobile clinics has consistently revealed high burdens of chronic disease, gaps in preventive care and high lifetime exposure to homelessness, incarceration and intergenerational trauma. (8)

In this context, HCV transmission risk cannot be separated from lived realities. Addressing HCV alone is insufficient. A syndemic framework pushes health systems to embed harm reduction, behavioral health, social services and linkage-to-care into elimination strategies, approaches proven to accelerate diagnosis and cure while strengthening overall community well-being.

Barriers to HCV elimination in tribal communities

Despite innovation and leadership, tribal health systems face persistent barriers:

1. Limited access to specialty care
   Rural and remote settings make access to hepatology or infectious diseases specialists challenging, delaying evaluation and treatment. Many sites have addressed this through Project ECHO (9, 10, 11), a telementoring model that builds local provider capacity via virtual case-based learning.
2. Stigma and criminalization related to substance use
   Stigma surrounding injection drug use and the criminalization of substance use in some jurisdictions discourages individuals from seeking testing and care. This limits disclosure of risk factors and reduces retention in care.
3. Limited HCV testing and treatment access in jails
   Carceral settings offer a pivotal opportunity to address intersecting epidemics across the incarceration community continuum and advance equity-driven public health outcomes. (12) Short stays, unpredictable release dates and rapid turnover undermine screening and treatment initiation. Jails often lack standardized protocols, on-site specialty care and linkage systems. Insurance termination during incarceration shifts treatment costs to jails, leading many facilities to avoid testing altogether.
4. Fragmented funding streams
   HCV, behavioral health, harm reduction and SUD treatment are funded separately, hindering integrated, syndemic-informed models. Recently, the Substance Abuse and Mental Health Services Administration and Indian Health Service have attempted to bridge these gaps by requiring a syndemic approach to fund applicants. But funding has been limited to a small proportion of tribal sites nationally.
5. Insufficient harm reduction infrastructure
   Syringe services, medications for opioid use disorder, naloxone and fentanyl test strips remain underfunded, restricted or unavailable in many regions, sustaining preventable transmission even where treatment capacity exists.
6. Social determinants of health
   Housing instability, transportation challenges, unemployment, food insecurity and limited access to broadband impede every step of the cascade, from screening and follow-up to treatment completion.
7. Workforce shortages
   Chronic shortages of primary care clinicians, nurses, behavioral health providers and community health workers limit the ability to scale universal screening and treatment.
8. Data gaps
   Under-resourced systems often lack real-time data infrastructure, restricting their ability to track progress, identify cascade gaps and optimize interventions.

Models and evidence from tribal communities

Despite these challenges, many tribal health systems have demonstrated that syndemic-informed approaches can drive substantial progress. (13) Successful programs consistently include:

• Universal and opportunistic screening embedded across clinical settings
• Decentralized, primary care led treatment through Project ECHO
• Infectious diseases services integrated with harm reduction (including naloxone, MOUD linkage and syringe services)
• Dedicated navigation and community outreach
• Continuous quality improvement using local data

Collectively, these efforts show that treating HCV as part of a broader syndemic leads to faster, more sustainable elimination outcomes.

Equity and policy implications

HCV elimination in tribal communities is fundamentally an issue of health equity. Native communities face disproportionate HCV burdens due to historical trauma, chronic underfunding, and limited access to SUD treatment and harm reduction. Sovereignty and culturally grounded models are powerful assets, but supportive federal and state policy is necessary.

Key policy needs include sustained harm-reduction funding; flexible funding streams that support integrated care; investment in rural infrastructure, telehealth and workforce development; and affordable direct-acting antivirals with all access restrictions removed, including those that currently limit treatment for incarcerated individuals. A syndemic framework strengthens the case for these changes by demonstrating that HCV elimination improves community health, safety and long-term stability.

A call to action

As more tribal nations adopt HCV elimination goals, syndemic-informed strategies, rooted in community priorities and integrated with behavioral and social services, will be essential. When programs address the broader ecosystems shaping HCV risk and care, elimination becomes not only possible but sustainable. Tribal communities are already leading the nation in demonstrating what true, equitable HCV elimination can look like.

Learn more about the Health Equity Series on Science Speaks and read other posts in the series. 

References

1. Dore GJ, Bajis S. Hepatitis C virus elimination: laying the foundation for achieving 2030 targets. Nat Rev Gastroenterol Hepatol. 2021;18:91–92.
2. Singer M, Clair S. Syndemics and public health: Reconceptualizing disease in bio-social context. Med Anthropol Q. 2003;17(4):423-441.
3. Schwetz TA, Calder T, Rosenthal E, et al. Opioids and Infectious Diseases: A Converging Public Health Crisis.  J Infect Dis. 2019;220(3):346-349.
4. Essex W, Feder M, Mera J. Evaluation of the Cherokee Nation Hepatitis C Virus Elimination Program - Cherokee Nation, Oklahoma, 2015-2020. MMWR Morb Mortal Wkly Rep. 2023;72(22):597-600.
5. Mera J, Vellozzi C, Hariri S, et al. Identification and Clinical Management of Persons with Chronic Hepatitis C Virus Infection — Cherokee Nation, 2012–2015. MMWR Morb Mortal Wkly Rep. 2016;65:461-466.
6. Mera J, Williams MB, Essex W, et al. Evaluation of the Cherokee Nation Hepatitis C Virus Elimination Program in the First 22 Months of Implementation. JAMA Netw Open. 2020;3(12):e2030427.
7. Racehorse, VA. Tribal Health Self-Determination: The Role of Tribal Health Systems in Actualizing the Highest Attainable Standard of Health for American Indians and Alaska Natives. Columbia Human Rights Law Review. 2025;56(1):183-251.
8. Essex W, Mera J, Comiford A, et al. Assessing the Feasibility, Acceptability, and Effectiveness of a Pilot Hepatitis C Screening Program at Food Distribution Sites in Cherokee Nation, Oklahoma. J Community Health. 2023;48(6):982-993.
9. About the ECHO Model. University of New Mexico Health Sciences. https://projectecho.unm.edu/model/
10. It Started with Hepatitis C: 20 Years of the ECHO Ripple Effect. University of New Mexico Health Sciences. https://projectecho.unm.edu/story/echo-hepatits-c-treatment-impact/
11. Wirth AN, Cushman NA, Reilley BA, et al. Evaluation of treatment access and scope of a multistate hepatitis C virus Extension for Community Healthcare Outcomes telehealth service in the US Indian Health System, 2017-2021. J Rural Health. 2023;39(2):358-366.
12. Akiyama MJ, Bialek T, Simonson R. The Carceral-Community Cascade and HCV Elimination. JAMA. 2025;333(5):369–370.
13. Comiford A, Mera J, Lewis K, et al. Outcomes of a tribal community program on hepatitis C, HIV, and syphilis screening, confirmation testing, and treatment initiation for an underserved population. Front Public Health. 2025;13:1690448.