This program delivered a flexible and mobile approach to hepatitis C care for people who were experiencing homelessness in South London. The program used a multidisciplinary team to provide education and testing, as well as treatment and follow-up support, for people with hepatitis C. Of the people identified as potential participants in the program, 99.3% (933 people) agreed to receive hepatitis C education and testing. Among those who were tested for hepatitis C, 17.4% (162 people) had a chronic hepatitis C infection, and of those, 70.4% (114 people) started hepatitis C treatment. Among those with chronic hepatitis C who initiated treatment, 72.8% (83 people) were cured.
Program description
The program used a “find and test” strategy that provided mobile hepatitis C education, testing and treatment for people who were experiencing homelessness, including people living in temporary housing (e.g., hostels, hotels) or living on the streets. The mobile aspect of the program allowed staff to move around to various “hot spot” locations, including venue-based (e.g., shelters, temporary housing, soup kitchens) and street-based (e.g., recognized sleeping sites, encampments) locations. Staff parked a mobile van adapted to provide all medical services on the streets at these locations and served clients from the van.
The program was created through a partnership between a peer-led hepatitis C organization and a hospital, with outreach services provided by peers. Community organizations (e.g., alcohol services, harm reduction centres, housing organizations) helped to identify potential participants.
A multidisciplinary team provided care including:
- prescribers (i.e., hepatologists)
- liver pharmacists
- hepatitis clinical nurse specialists
- peer workers
- project coordinators
Testing
Testing for hepatitis C was provided in a mobile van that visited various locations. There was a monetary incentive for testing; it was given to participants when they received their test results. A hepatitis C antibody test was performed on-site using a finger-prick rapid point-of-care test. A confirmatory RNA test was completed either on-site using the Cepheid GeneXpert or through a dried blood spot or venipuncture test that was sent to a laboratory at the partnered hospital for analysis.
A FibroScan was performed on the mobile van for clients who had a positive antibody test result.
People with a chronic hepatitis C infection were asked to complete blood tests to assess their liver function and to determine if they had other viral hepatitis infections; these blood samples were also sent to the laboratory at the partnered hospital for analysis.
Treatment
Treatment was approved remotely by the program's prescribers (i.e., hepatologists), and oral direct-acting antivirals (DAAs) and treatment instructions were delivered to patients in their location by program staff. The frequency of dispensing was determined by a nurse and peer workers and was adapted to needs of the individual participant.
Follow-up and referrals
Participants with a positive hepatitis C confirmatory test result were advised to have at least six appointments: a pre-treatment assessment, at treatment start, at treatment weeks 4 and 8, at the end of treatment and at post-treatment week 12 (to assess sustained virologic response [SVR12]) but they could have more frequent visits with program staff if necessary (e.g., daily, weekly or monthly). Visits with program staff could be conducted face to face at the mobile sites (e.g., a shelter) or by telephone and side effects, missed doses and the importance of adherence were discussed. If participants changed locations, the location of their follow-up appointments could also change to ensure continuity.
People with active substance or alcohol use were provided with counselling at the mobile sites and were linked to harm reduction services during treatment or at treatment follow-up (where possible). People who were actively injecting drugs were advised of their risk of reinfection and were invited for hepatitis C testing every six to 12 months. People could be retreated through the program if they were reinfected. Those with advanced liver fibrosis were linked to a liver cancer screening program every six months.
Results
The program took place from January 2018 to September 2021 in the South London area. Over 44 months, 940 people who experienced homelessness were identified for potential participation, and 99.3% (933 people) agreed to receive hepatitis C education and testing. Of those, 56.6% (528 people) were screened on the street or at soup kitchens and 43.4% (405) in temporary housing. Overall, 78.1% of study participants were male and 21.9% female; 62.2% identified as White, 20% as Black, 15% as multiracial, 2.8% as Asian and 0.1% as Hispanic.
Of those who participated in the program, 26.0% (243 people) tested positive for hepatitis C antibodies and 17.4% (162 people) had a chronic hepatitis C infection.
Participants with a chronic hepatitis C infection were more likely to have the following characteristics than those without a chronic hepatitis C infection:
- people taking opioid agonist therapy (OAT) (42.0% with a hepatitis C infection vs. 16.7% without)
- people with active drug use (40.7% vs. 27.8%)
- people with active alcohol consumption (49.4% vs. 34.7%)
- people with psychiatric disorders (42.6% vs. 22.2%)
Additionally, those with a chronic hepatitis C infection were significantly more likely than those without to have had previous treatment for hepatitis C (29.2% vs. 16.0%).
Of those with a chronic hepatitis C infection, 70.4% (114 people) started hepatitis C treatment and 72.8% (83 people) were cured.
Of the 48 people who did not start treatment, 47.9% could not be located, 25.0% refused treatment, 10.4% died before treatment initiation, 6.3% were in prison, 6.3% were treated in another area and 4.1% were on medication that could have caused serious drug interactions with DAA therapy.
In multivariate analyses:
- People screened in temporary housing were 3.2 times more likely to initiate treatment than those who were screened in street-based locations.
- People on OAT were 3.1 times more likely to initiate treatment than those not on OAT.
- People with better treatment adherence (>75%) were 26.6 times more likely to achieve cure than those with worse treatment adherence (<75%).
There was a 9.9% (16 people) mortality rate in people identified with a chronic hepatitis C infection; 56.3% (9 people) of deaths were non-liver related events, 25.0% (4 people) were for an unidentified reason and 18.8% (3 people) were liver related.
Implications for service providers
The study demonstrated that use of a flexible and mobile approach to hepatitis C education, testing and treatment can be useful in engaging people who are experiencing homelessness in hepatitis C care. This approach to hepatitis C testing and education was accepted by 99.3% of people identified; 70.4% of those found to have chronic hepatitis C initiated treatment. Although the treatment initiation rate in this study (70.4%) is comparable with treatment initiation rates in other studies with similar populations, the lower rate could be due to the lag time between testing and treatment initiation in this context (same-day treatment initiation was not possible because of policy limitations).
A strength of the program was the decentralized service delivery model, which allowed people to be tested and treated in temporary housing, daily soup kitchens, and street-based locations. This allowed the program to reach people in their usual locations, which may have helped to reduce barriers for this population. Additionally, use of reflex testing and monetary incentives may also have reduced barriers to testing. The multidisciplinary team, including peer workers who were experienced in serving this population, was also a strength of the program and may have reduced stigma and access barriers.
Results of the study indicate that many of the people with an active hepatitis C infection were more likely to be actively using alcohol and drugs and to have a mental health disorder, which highlights the multidisciplinary service needs (e.g., harm reduction, alcohol services) of the population served.
Related resources
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Reference
Veloz MFG, Han K, Oakes K et al. Results of a model of delivering hepatitis C care in a homeless metropolitan population in England. American Journal of Gastroenterology. 2022. Published online ahead of print.