Form 0920-21EE 3c_Component 3

Annual Performance Report—Component 3

Integrated Viral Hepatitis Surveillance and Prevention Funding for Health Departments

Component 3: Special Projects—Prevention, Diagnosis, and Treatment Related to the Infectious Disease Consequences of Drug Use

Reporting Agency

Reporting jurisdiction
Contact name (person completing form)
Contact phone number (xxx-xxx-xxxx)
Contact email address
Additional contact name(s) (if applicable)
Additional contact phone number(s) (xxx-xxx-xxxx)
Additional contact email address(es)
Date of report submission (MM/DD/YYYY)
Reporting Period (Complete this form with information from Reporting Period selected)	Select one □ Year 1 □ Year 2 □ Year 3 □ Year 4 □ Year 5

Was Component 3 funded?

Select one

□ No NOTE: Stop here if not funded

□ Yes

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3.1—Improve access to services for people who inject drugs (PWID)

in settings disproportionately affected by drug use

Measures 3.1.1.a – 3.1.1.b

• Number of PWID served, by setting serving PWID (syringe services programs, substance use disorder treatment programs, correctional facilities, emergency departments, hospital-based programs, sexually transmitted disease clinics, homeless services, health centers, other)

• Syringes distributed, by setting serving PWID

	During this reporting period, number of:
Setting serving PWID	Clients served	PWID served	Syringes distributed
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >

Measures 3.1.2.a – 3.1.2.d

• Number of PWID who are linked to substance use disorder treatment, by setting serving PWID

• Number of PWID assessed for opioid use disorder, by setting serving PWID

• Number of PWID with opioid use disorder, by setting serving PWID

• Number of PWID with opioid use disorder who are linked to medication for opioid use disorder, by setting serving PWID

	During this reporting period, number of:
Setting serving PWID	PWID linked to substance use disorder treatment	PWID assessed for opioid use disorder	PWID with opioid use disorder	PWID with opioid use disorder who were linked to medication for opioid use disorder
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >	TOTAL: >

Measures 3.1.3.a, 3.1.4.a – 3.1.4.d

• Number of clients tested for anti-HCV, by setting serving PWID

• Number of clients testing positive for anti-HCV, by setting serving PWID

• Number of clients positive for anti-HCV tested for HCV RNA, by setting serving PWID

• Number of clients testing positive for HCV RNA, by setting serving PWID

• Number of HCV RNA (+) clients linked to hepatitis C treatment, by setting serving PWID

	During this reporting period, number of:
Setting serving PWID	Clients tested for anti-HCV	Clients testing positive for anti-HCV	Clients positive for anti-HCV tested for HCV RNA	Clients testing positive for HCV RNA	HCV RNA (+) clients linked to hepatitis C treatment
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >	TOTAL: >	TOTAL: >

Measures 3.1.3.b, 3.1.4.e – 3.1.4.f

• Number of clients screened (anti-HBc, HBsAg, anti-HBs) for HBV, by setting serving PWID

• Number of clients testing positive for HBsAg, by setting serving PWID

• Number of HBV (+) clients linked to hepatitis B care, by setting serving PWID

	During this reporting period, number of:
Setting serving PWID	Clients screened for HBV (anti-HBc, HBsAg, anti-HBs)	Clients testing positive for HBsAg	HBV (+) clients linked to hepatitis B care
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >

Measures 3.1.3.c, 3.1.4.g – 3.1.4.h

• Number of clients screened for HIV, by setting serving PWID

• Number of clients testing positive for HIV, by setting serving PWID

• Number of HIV (+) clients linked to HIV treatment, by setting serving PWID

	During this reporting period, number of:
Setting serving PWID	Clients screened for HIV	Clients testing positive for HIV	HIV (+) clients linked to HIV treatment
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >

Measure 3.1.4.i

• Number of clients referred for treatment for bacterial or fungal infections, by setting serving PWID

	During this reporting period, number of:
Setting serving PWID	Clients treated or referred for treatment of bacterial or fungal infections
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >

Measures 3.1.5.a – 3.1.5.d

• Number of hepatitis A vaccination doses administered to clients, by setting serving PWID

• Number of clients who completed hepatitis A vaccination series, by setting serving PWID

• Number of hepatitis B vaccination doses administered to clients, by setting serving PWID

• Number of clients who completed hepatitis B vaccination series, by setting serving PWID

	During this reporting period, number of:
Setting serving PWID	Hepatitis A vaccination doses administered	Clients who completed hepatitis A vaccination series	Hepatitis B vaccination doses administered	Clients who completed hepatitis B vaccination series
Setting 1 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 2 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 3 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 4 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 5 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 6 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 7 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Setting 8 Type: > If other, specify: > Name: >	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A	> □ Unknown □ N/A
Total number of settings: >	TOTAL: >	TOTAL: >	TOTAL: >	TOTAL: >

Measures 3.1.6.a – 3.1.6.c, 3.1.7.a

• Number of new confirmed acute hepatitis B cases reported among PWID in the jurisdiction

• Number of new confirmed acute hepatitis C cases reported among PWID in the jurisdiction

• Number of new confirmed HIV cases reported among PWID in the jurisdiction

• Jurisdiction reports data on hepatitis C continuum of care for PWID in the jurisdiction, consistent with CDC guidance

How many new confirmed acute hepatitis B cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?	> □ Unknown
How many new confirmed acute hepatitis C cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?	> □ Unknown
How many new confirmed HIV cases were reported among people reporting a history of injection drug use in your jurisdiction during this reporting period?	> □ Unknown
Do you report hepatitis C viral clearance cascade data for reported cases among people reporting a history of injection drug use in your jurisdiction?	Select one □ Yes □ No

Use this space if needed to provide additional information related to Component 3

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