This program provided low-barrier hepatitis C care integrated into supportive housing sites for people at risk of homelessness, including people who use drugs. Treatment nurses visited housing sites weekly to bring testing and treatment services to where people lived. Over an 11-month period, 180 people were tested, 51 had a current hepatitis C infection and 43 people started treatment. Overall, 91% of individuals who started treatment were cured. This program demonstrates that a targeted testing and treatment campaign within a high-prevalence setting for hepatitis C was effective. Bringing services directly to residents helped individuals to engage in and successfully complete testing and treatment.
Program description
This program provided low-barrier hepatitis C care in supportive housing sites for people at risk of homelessness. The program was run by the Victoria Cool Aid Society at housing sites that they operated in Victoria, B.C. Visiting nurses delivered services entirely within the housing sites to simplify access and remove barriers to hepatitis C care. In addition to homelessness and poverty, residents faced other barriers to health care related to substance use, mental health, stigma and trauma.
This program used a micro-elimination approach, ramping up testing and treatment in a specific setting for a specific population with a higher prevalence of hepatitis C as part of efforts to reach national hepatitis C elimination goals. In this case, the program was delivered in housing sites for people at risk of homelessness.
“Seek and treat” testing events
Nurses led multiple testing events at 13 supportive housing sites to engage residents and build awareness of the program. Snacks and refreshments were provided to draw residents for hepatitis C antibody testing. For those who tested antibody positive, nurses conducted full blood draws for follow-up RNA testing. The nurses also provided education for residents on hepatitis C and harm reduction, including clarifying myths and misconceptions about treatment. At one housing site, two individuals with previous experience of hepatitis C treatment acted as hepatitis C “treatment champions” to help recruit other residents.
Residents were encouraged to invite their partners, friends and family, especially people with whom they used drugs, to also receive testing and potentially treatment through the program. This helped to spread word-of-mouth awareness of the events and ultimately to prevent new cases among people at risk of transmitting hepatitis C to each other.
At subsequent visits to the housing sites, nurses shared laboratory test results with those who had had additional RNA testing. Individuals with a confirmed chronic hepatitis C infection testing worked with the nurses to begin treatment work-up. This included assessing liver injury, doing additional blood work and providing support for treatment coverage.
Flexible, network-based treatment options
Nurses worked with individuals to create personalized treatment plans, including how often medication was dispensed during the 12-week treatment course. Most individuals had medication delivered weekly by the nurse to their housing site. Individuals also had the option of having their medication given to housing staff, who then provided it daily to the individual to help with adherence. In some cases, medication was dispensed alongside opioid agonist therapy at community pharmacies. Where possible, people in the same social network started treatment on the same day to improve adherence and prevent future transmission, particularly if they used drugs together.
Nurses visited sites weekly to drop off medication and check in with individuals who were on treatment to support adherence and monitor any issues. Cool Aid housing staff were also trained to provide hepatitis C and harm reduction education as well as to provide reminders and check in with residents who were on treatment.
Incentives for completing care
Cash incentives of $5 were provided for returning a previous week’s blister pack, and $30 was provided for completing blood work at the end of treatment to confirm cure (sustained virologic response at 12 weeks, or SVR12). The weekly incentives helped encourage face-to-face contact and relationship building with the nurse and provided additional opportunities for education around preventing reinfection and addressing other healthcare concerns.
Results
Between February and December 2018, 180 people were tested for past exposure to hepatitis C (antibody testing). Of those, 72 (40%) were antibody positive, with 51 (28%) having a chronic hepatitis C infection. Of those with a chronic hepatitis C infection, 43 people started hepatitis C treatment. Individuals who did not start treatment either had other health issues that prevented treatment (e.g., cancer, severe alcohol use) or were lost to follow-up.
For those who started treatment and received at least one dose of medication:
- the average age was 53 years
- 40% were female
- 9% had an HIV co-infection
- 93% had a history of injection drug use, 58% of whom had injected drugs in the last six months
- 42% were currently on opioid agonist therapy
Overall, 91% of those who started treatment were cured. Reasons for not achieving cure were poor treatment adherence, reinfection before SVR12 testing and death due to other causes.
What does this mean for service providers?
This program took a targeted, person-centred approach to treating hepatitis C among people who use drugs and who are at risk of homelessness. It used a flexible, low-barrier approach to care that met people where they were at. Integrating care into an existing service created more accessible care that was delivered in a familiar, non-stigmatizing setting. Individuals had the autonomy to work with nurses to choose a treatment plan that worked for them, increasing the likelihood they would successfully complete treatment.
By ramping up testing and treatment in this specific setting, which had a high prevalence of hepatitis C, the program was able to effectively and efficiently reach the people at highest risk. In addition, the treatment of networks of individuals helped prevent transmission within the housing sites, particularly among people who used drugs together.
This study also demonstrates the value of housing to help a person successfully engage in care. Having a stable place of residence facilitated contact and follow-up by nurses. Of those who began treatment, none were lost to follow-up. For the individual, a stable residence can also increase safety and stability and reduce competing stressors, making it more likely that they will complete treatment. This program also provided opportunity to incorporate other STBBI and primary care services where people lived.
Related resources
Micro-elimination of hepatitis C: A pathway to achieve national elimination goals (CATIE)
From the Front Lines: Victoria Cool Aid Society (CATIE)
Cool Aid Community Health Centre: Mobile Outreach Clinic – video
Connecting with Care – Victoria, Canada - video
Reference
Selfridge M, Barnett T, Lundgren K et al. Treating people where they are: Nurse-led micro-elimination of hepatitis C in supported housing sites for networks of people who inject drugs in Victoria, Canada. Public Health Nursing. 2022.