Program overview

Persons who are homeless and marginally housed have higher rates of serologic evidence of past or current hepatitis C virus (HCV) infection as compared to the general population. This demonstrated higher prevalence of HCV is partially explained by the coexistence of multiple, overlapping risk factors among the homeless population including injection drug use, non-injection illicit drug use, history of incarceration, and mental illness. Despite efforts to treat patients from this vulnerable population with highly effective direct acting antiviral therapy (DAA), gaps in the HCV treatment cascade persist. Data regarding scaling up HCV testing and treatment for this population in homeless shelters is not available.

This study aims to define and describe the facilitators and barriers to HCV testing and treatment among the homeless population and to implement a shelter-based testing and treatment protocol in our shelters across two large urban settings, building on existing facilitators and overcoming barriers to treat patients in this vulnerable population

Program results to date

Study team evaluated barriers and facilitators to implementing HCV care in homeless shelters among stakeholders. Focus group data was analyzed within the Health Behavior Framework and indicated multiple barriers and facilitators to the establishment of a universal HCV screening, testing and treatment protocol for patients accessing homeless shelters in San Francisco, CA and Minneapolis MN (Fokuo et al., Hepatology Communications 2020) https://doi.org/10.1002/hep4.1492.

Results:

• Societal-level barriers included lack of insurance, high out-of-pocket expenses, restriction of access to HCV treatment because of substance use, and paperwork required for HCV medication approval from payers.
• System level barriers identified were constraints on workforce, limited infrastructure, HCV stigma, sub-optimal knowledge of HCV treatment, and existing policies in homeless shelters.
• At the individual client level, barriers that were identified by stakeholders included competing priorities, concerns regarding behavioral health, and health attitudes.
• At the system level, facilitators to HCV care service integration within the shelter setting included linkage with social service providers and high acceptability and buy-in.
• Focus groups with homeless clients also indicated individual level and societal level barriers that negatively impacted homeless persons’ decisions to engage in HCV prevention and treatment (Masson et al., under review).

Based on the aforementioned findings, HCV rapid testing was offered to homeless clients in four large shelters in San Francisco and Minneapolis. (Khalili et al., Poster #633, Presented at AASLD Liver Meeting 2019)

Results:

• 479 clients (279 in SF, 200 in MN were tested.
• 94 clients (20%) were HCV antibody positive.
• 60 clients (63%) having detectable HCV RNA.
• 17 clients (28%) initiated HCV therapy.

HCV antibody positive patients were offered a formal 30 minute, comprehensive HCV education presented by a provider (Powell et al., Poster #735, Presented at AASLD Liver Meeting 2019).

•  94 antibody positive patients (63 in SF and 31 in MN) underwent HCV education.
•  Pre- and post-education assessment indicated that education resulted in a significant increase (P<0.05) in knowledge regarding methods of HCV transmission, the impacts of alcohol consumption on HCV-infected livers, progression of HCV to cirrhosis, and effectiveness of HCV therapy.
• Pre- and post-education assessment showed that education resulted in a significant increase (P<0.05) in patient confidence in methods to prevent HCV transmission, acceptance of HCV therapy, and understanding of the overall effect of HCV on general health.

Despite demonstrated success in amplifying HCV testing, increasing patient knowledge, and increasing desire for treatment, initiation of therapy remains challenging for this population, highlighting the critical need for the continued development of infrastructure for HCV testing, education, and linkage to therapy within shelters.

Successes and challenge

Over the past two years, the research teams in CA and MN have initiated shelter-based HCV screening and treatment in four large homeless shelters (2 in each study site). By first studying barriers and facilitators to initiating shelter-based testing and treatment, the research team was able to overcome barriers and take advantage of existing facilitators to implement a successful program that has enhanced HCV screening, access to therapy, and linkage to care among homeless patients in both CA and MN.

Active substance use continues to be a significant barrier to HCV treatment engagement. There is an urgent need to provide substance use disorder treatment either through active referrals or integration of addiction specialists onsite at shelters. Additionally, there is a need for dedicated stable housing for patients undergoing HCV treatment either through shelters, residential addiction treatment programs, or purchase of single room occupancy housing for the duration of the course of HCV treatment. Homeless patients are at times difficult to reach and may have significant comorbidities that complicate treatment, therefore a dynamic approach in which a wide variety of healthcare providers, outreach workers, shelter staff and program staff are involved is key to successfully testing, educating and treating patients.

Additional info

This project is ongoing and the research team looks forward to expanding on our existing work together with key collaborators to ensure the sustainability of our screening, treatment, and linkage to care program. The long-term impact of this project will be significant reductions in the forward transmission of HCV among this vulnerable population and the generation of a model that is applicable to other locales across the country. We look forward to sharing our model with others and extending our work to other interested programs both regionally and nationally.

Other references

• Adherence to Hepatitis C Therapy in a Shelter-Based Education and Treatment Model Among Persons Experiencing Homelessness

• Patient-reported experiences with direct acting antiviral therapy in an integrated model of hepatitis C care in homeless shelters

• Shelter-Based Integrated Model Is Effective in Scaling Up Hepatitis C Testing and Treatment in Persons Experiencing Homelessness