A multidisciplinary team from the Vancouver Infectious Diseases Centre (VIDC) held weekly community pop-up clinics (CPCs) in various inner-city locations to engage people who use drugs in hepatitis C treatment. The VIDC leveraged community-based partnerships with housing societies and a local pharmacy to provide onsite point-of-care testing at CPCs, with follow-up rapid treatment initiation and linkage to wraparound services for people with a positive result. Of the 1,968 individuals evaluated during CPCs, 620 (31.5%) carried hepatitis C antibodies and 474 (76.5%) of these were RNA positive. Of the 387 individuals engaged in care, 326 (84.2%) started treatment; of those who started treatment, 304 (93.2%) completed treatment and 286 (94.1%) of those who finished treatment were cured (as measured by sustained virologic response at 12 weeks [SVR12])
Program description
In Vancouver’s inner city, people who use drugs face a high prevalence of hepatitis C and an elevated risk of transmission, resulting in a significant disease burden within this community. Many individuals are disconnected from care because of barriers like stigma, as well as social and structural factors that make it difficult to stay engaged in care (e.g., financial insecurity, housing instability). Observing a need for low-barrier, multidisciplinary care in this area, the Vancouver Infectious Diseases Centre (VIDC) developed community pop-up clinics (CPCs), which are held weekly in various inner-city locations. Partnerships between the VIDC and various housing societies, including Lu'ma Native Housing Society, Atira Women's Resource Society and Lookout Housing and Health Society, allow CPCs to be conducted at shelters, community service centres, modular housing facilities and single-room occupancy dwellings within inner-city Vancouver. Through a formal service agreement with Lookout Housing and Health Society, the VIDC has appointed a case manager nurse to coordinate outreach and follow-up for CPCs, improving engagement and retention in care among residents of these properties.
During each CPC, up to 30 individuals are offered point-of-care hepatitis C antibody testing over a three-hour period. All patients receive a $10 gift card for completing testing, regardless of the result. Those with a positive antibody result are offered an immediate consultation with a physician. If the patient consents, their medical records are reviewed in provincial laboratory databases before the physician consultation to confirm if they were previously diagnosed with or treated for hepatitis C. During the consultation, a comprehensive care plan is created, and patients can schedule a follow-up with a physician within one week at the VIDC or its satellite clinic, the Vancouver Urban Health Centre (VUHC).
Follow-up appointments include pre-treatment clinical assessments and evaluations (e.g., standard laboratory testing, FibroScan transient elastography) and connection to a variety of services to address other mental, social and addiction-related needs (e.g., assistance with housing paperwork, nutritional support, opioid agonist therapy [OAT]). This includes connecting patients to Indigenous-focused resources and incorporating cultural practices into care plans when requested. If patients choose to start treatment, they receive free medications through government-funded programs and patient support initiatives. The VIDC has partnered with Speciality Rx (SRx) Pharmacy, which is strategically located directly beneath the VUHC in the Downtown Eastside neighbourhood. This co-location reduces barriers and improves the accessibility of treatment for patients. SRx offers flexible dispensing schedules, pickup reminders and daily medication deliveries to support adherence to treatment plans. Patients may have additional follow-ups during treatment to address potential side effects and adherence issues, as well as other medical conditions. After finishing treatment, patients are monitored for treatment outcomes and offered continued access to the multidisciplinary care team.
Results
Between January 2021 and August 2023, 112 CPCs were conducted, with 1,968 individuals evaluated. Individuals included in analyses were 19 years or older, had an active untreated hepatitis C infection of any genotype and were either actively using or had used drugs in the previous three months. Those with cirrhosis or decompensated liver disease, hepatitis B coinfection or other factors preventing them from being able to give informed consent or engage in care were excluded from the analysis.
Among the 1,388 individuals who completed a demographic survey, the median age was 45 years; 34.9% of patients identified as female, 32.3% identified as Indigenous and 50% identified as Caucasian. Many participants had experienced housing insecurity (62.6%) and incarceration (58.9%), with 47.1% having experienced a recent drug overdose. When asked about drug use, 79.7% of individuals said they used opiates, 63.9% used amphetamines, 48.5% used cocaine, 22.8% used benzodiazepines and most indicated poly-substance use.
Out of 1,968 individuals included in the analysis, 620 (31.5%) were found to carry hepatitis C antibodies. Of those with hepatitis C antibodies, 474 (76.5%) were RNA positive. Of the people who were RNA positive, 387 (81.6%) were engaged in care.
Of the 387 individuals engaged in care:
- 326 (84.2%) started treatment, with 60 in the pre-treatment phase and one who died from an overdose in the pre-treatment phase.
Of the 326 individuals who started treatment:
- 304 (93.2%) completed it, with 18 still on treatment, three who stopped early because of side effects and one who died from an overdose during treatment.
Of the 304 people who completed treatment, 286 (94.1%) were cured (SVR12). This group included 16 people awaiting SVR testing, two who had a virologic relapse and one who was reinfected after achieving a cure. When those awaiting SVR testing were excluded, and only individuals with available SVR results were assessed, 286 out of 288 (99.3%) were cured. The median time from CPC attendance to hepatitis C treatment initiation was six weeks, and no patients were lost to follow-up.
What does this mean for service providers?
Findings from this program support the effectiveness of community-based approaches to engage people who use drugs in the cascade of hepatitis C care. This low-barrier, multidisciplinary approach improved access to care by minimizing traditional barriers experienced by people who use drugs (e.g., stigma, competing priorities like unstable housing or financial insecurity). Collaborative partnerships between the VIDC and several housing societies in inner-city Vancouver allowed for the systematic identification of individuals requiring treatment. Given that over 30% of individuals tested positive for hepatitis C antibodies, this approach was well targeted and it engaged an underserved population typically disconnected from care. Importantly, this program model showed high retention across the care cascade; while housing society partnerships improved outreach and access, the strategic partnership with SRx enhanced adherence to treatment. Given the high cure rates achieved through the CPCs, this program model is a promising approach for scaling up testing and treatment rates.
Although the primary focus of the CPCs was engaging people who use drugs in hepatitis C care, the program’s success was also driven by the wraparound services it offered. Patients received support for medical, mental health, social and substance use-related needs. In particular, access to substance use supports (e.g., OAT) may have helped with retention and adherence, as well as reduced risks for opioid overdose.
Related resources
People who inject drugs report unique barriers to hepatitis C treatment – CATIE News
What interventions can be used to improve hepatitis C testing and linkage to treatment? – Prevention in Focus
Reference
Yi S, Wiesmann C, Truong D et al. Community Pop‐Up Clinic: Cascade of care and HCV treatment of Vancouver's inner‐city PWID populations. Journal of Viral Hepatitis. 2024 Oct 19.