Recommendations for Implementing Hepatitis C Virus Care in Homeless Shelters: The Stakeholder Perspective

Exploring the Perspectives of Unhoused Adults and Providers Across the HCV Care Continuum

Hepatitis C virus (HCV), the most common blood-borne infection, disproportionately affects people experiencing homelessness (PEH); however, HCV interventions tailored for PEH are scarce. This study utilized a community-based participatory approach to assess perceptions of HCV treatment experiences among HCV-positive PEH, and homeless service providers (HSP) to develop and tailor the "I am HCV Free" intervention which integrates primary, secondary, and tertiary care to attain and maintain HCV cure. Four focus groups were conducted with PEH (N = 30, Mage = 51.76, standard deviation 11.49, range 22-69) and HSPs (n = 10) in Central City East (Skid Row) in Los Angeles, California. An iterative, thematic approach was used to ensure the trustworthiness of the data. Barriers and facilitators emerged from the data which have the potential to impact initiating HCV treatment and completion across the HCV care continuum. Understanding and addressing barriers and strengthening facilitators to HCV treatment will aid in HCV treatment completion and cure for PEH.

Hepatitis C treatment outcomes among people who inject drugs experiencing unstable versus stable housing: Systematic review and meta-analysis

BACKGROUND

The prevalence of hepatitis C virus (HCV) among people who inject drugs (PWID) is between 50-70%. Prior systematic reviews demonstrated that PWID have similar direct acting antiviral treatment outcomes compared to non-PWID; however, reviews have not examined treatment outcomes by housing status. Given the links between housing and health, identifying gaps in HCV treatment can guide future interventions.

METHODS

We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched six databases for articles from 2014 onward. Two reviewers conducted title/abstract screenings, full-text review, and data extraction. We extracted effect measures for treatment initiation, adherence, completion, success, and reinfection by housing status. Studies underwent quality and certainty assessments, and we performed meta-analyses as appropriate.

RESULTS

Our search yielded 473 studies, eight of which met inclusion criteria. Only the treatment initiation outcome had sufficient measures for meta-analysis. Using a random-effects model, we found those with unstable housing had 0.40 (0.26, 0.62) times the odds of initiating treatment compared to those with stable housing. Other outcomes were not amenable for meta-analysis due to a limited number of studies or differing outcome definitions.

CONCLUSIONS

Among PWID, unstable housing appears to be a barrier to HCV treatment initiation; however, the existing data is limited for treatment initiation and the other outcomes we examined. There is a need for more informative studies to better understand HCV treatment among those with unstable housing. Specifically, future studies should better define housing status beyond a binary, static measure to capture the nuances and complexity of housing and its subsequent impact on HCV treatment. Additionally, researchers should meaningfully consider whether the outcome(s) of interest are being accurately measured for individuals experiencing unstable housing.

Risk Factors Associated With Unsuccessful Linkage to Outpatient Hepatitis C Care

Background Modern direct-acting antivirals (DAAs) can treat and cure hepatitis C virus (HCV) infection. Treatment of HCV at a population level has the potential to decrease the prevalence of chronic HCV infection and sequela. Unfortunately, many patients fall off the HCV treatment cascade and do not complete HCV treatment. As social determinants of health (SDHs) affect HCV acquisition, we sought to evaluate factors that may limit successful linkage to outpatient HCV care. Methods We conducted a case-control study by matching patients who missed and those who attended their outpatient HCV visits in 2018. We matched cases in a 1:1 ratio using propensity scores. Results Of 1,539 patients, 161 (10.5%) did not attend their HCV clinic appointment. Factors associated with a missed HCV visit on bivariate testing included identifying as Black (p=0.03), housing instability (p<0.001), transportation difficulty (p<0.001), history of medication non-adherence (p<0.001), and undergoing screening during an inpatient admission (p<0.001). Multivariate testing found transportation difficulty (p<0.001) and inpatient admission (p=0.002) to be associated with missing their HCV appointment. Patients who attended their HCV visit were more likely to be alive by the end of 2018 (p=0.07). Conclusion Patients who missed an initial scheduled infectious disease (ID) clinic appointment for HCV treatment had higher rates of housing instability, transportation difficulties, and medication non-adherence. Patients diagnosed with HCV infection should be provided additional support as appropriate to address the social determinants of health that may limit linkage to outpatient HCV care.

A qualitative assessment of cleaning and hand hygiene practices at shelters serving people experiencing homelessness during the COVID-19 pandemic, Atlanta, GA - May-June, 2020

BACKGROUND

Cleaning practices and hand hygiene are important behaviors to prevent and control the spread of infectious disease, especially in congregate settings. This project explored hygiene- and cleaning-related experiences in shelters serving people experiencing homelessness (PEH) during May-June 2020 of the COVID-19 pandemic.

METHODS

We conducted qualitative, in-depth interviews by phone with 22 staff from six shelters in Atlanta, Georgia. The interview guide included questions about cleaning routines, cleaning barriers and facilitators, cleaning promotion, hand hygiene promotion, and hand hygiene barriers and facilitators. We analyzed interview transcripts using thematic analysis.

RESULTS

Multiple individuals, such as shelter individuals (clients), volunteers, and staff, played a role in shelter cleaning. Staff reported engaging in frequent hand hygiene and cleaning practices. Barriers to cleaning included staffing shortages and access to cleaning supplies. Staff reported barriers (e.g., differing perceptions of cleanliness) for clients who were often involved in cleaning activities. Barriers to hand hygiene included limited time to wash hands, forgetting, and inconvenient handwashing facilities. Specific guidance about when and how to clean, and what supplies to use, were requested.

CONCLUSION

During the early months of the COVID-19 pandemic, shelters serving PEH in the Atlanta-metro area needed resources and support to ensure sufficient staffing and supplies for cleaning activities. As part of future pandemic planning and outbreak prevention efforts, shelters serving PEH could benefit from specific guidance and training materials on cleaning and hand hygiene practices.

A systematic review of approaches to improve medication adherence in homeless adults with psychiatric disorders

Introduction

Medication non-adherence is a significant problem among homeless individuals with psychiatric disorders in the United States. We conducted a systematic review to identify strategies to improve psychiatric medication adherence among homeless individuals with psychiatric disorders, including substance use disorders.

Methods

We searched seven databases (MEDLINE, Embase, PsychInfo, Scopus, Web of Science, CDSR, and CENTRAL) and screened 664 studies by title and abstract followed by full-text review. Our inclusion criteria were studies that: involved an intervention for homeless adults with psychiatric disorders, reported a quantitative outcome of medication adherence, and were published in English in a peer-reviewed journal. We rated the relative effectiveness of strategies described in each study using a self-designed scale.

Results

Eleven peer-reviewed studies met criteria for inclusion in this review. Within these studies, there were seven different approaches to improve medication adherence in this population. Three studies were randomized controlled trials (RCTs) and the remaining were observational studies. Outpatient interventions included Assertive Community Treatment, Cell Phone-Assisted Monitoring, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Homeless-Designated Pharmacy Clinics. Residential, shelter-based, and inpatient interventions included use of the Housing First model, Modified Therapeutic Communities, and Homeless-Designated Inpatient Care. The approaches described in four of the eleven studies were rated as scoring a 3 or higher on a 5-point scale of effectiveness in improving medication adherence; none received 5 points.

Discussion

The interventions with the strongest evidence for improving medication adherence in this population were Assertive Community Treatment, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Housing First. Overall, studies on this topic required more rigor and focus on medication adherence as an outcome in this population. This review highlights several promising strategies and the need for larger RCTs to determine effective and diverse ways to improve medication adherence among homeless adults with psychiatric disorders.

Exploring Frontline Shelter Staff Perspectives on the Healthcare Needs of Clients Experiencing Homelessness

PURPOSE

To examine healthcare service development needs for persons experiencing homelessness from the perspective of frontline staff at a homeless shelter in Montreal, Quebec.

DESIGN

Qualitative descriptive design.

METHODS

Purposive sampling, semi-structured interviews with frontline shelter staff (n = 8), and thematic analysis.

FINDINGS

Themes included: 1) Challenges meeting healthcare service needs in a shelter environment. 2) Visions for improving healthcare services while accounting for health issues and barriers to care. 3) Participants' own knowledge gaps around health and healthcare services.

CONCLUSIONS

Future research should emphasize this group's crucial role in homelessness healthcare services development.

Exploratory assessment: Nurse-led community health worker delivered HCV intervention for people experiencing homelessness

BACKGROUND

Getting and maintaining Hepatitis C Virus (HCV) cure is challenging among people experiencing homelessness (PEH) as a result of critical social determinants of health such as unstable housing, mental health disorders, and drug and alcohol use.

OBJECTIVES

The purpose of this exploratory pilot study was to compare a registered nurse/community health worker (RN/CHW)-led HCV intervention tailored for PEH, "I am HCV Free," with a clinic-based standard of care (cbSOC) for treating HCV. Efficacy was measured by sustained virological response at 12 weeks after stopping antivirals (SVR12), and improvement in mental health, drug and alcohol use, and access to healthcare.

METHODS

An exploratory randomized controlled trial design was used to assign PEH recruited from partner sites in the Skid Row Area of Los Angeles, California, to the RN/CHW or cbSOC programs. All received direct-acting antivirals. The RN/CHW group received directly observed therapy in community-based settings, incentives for taking HCV medications, and wrap-around services, including connection to additional healthcare services, housing support, and referral to other community services. For all PEH, drug and alcohol use and mental health symptoms were measured at month 2 or 3 and 5 or 6 follow-up, depending on HCV medication type, while SVR12 was measured at month 5 or 6 follow-up.

RESULTS

Among PEH in the RN/CHW group, 75% (3 of 4) completed SVR12 and all three attained undetectable viral load. This was compared with 66.7% (n = 4 of 6) of the cbSOC group who completed SVR12; all four attained undetectable viral load. The RN/CHW group, as compared to the cbSOC, also showed greater improvements in mental health, and significant improvement in drug use, and access to healthcare services.

DISCUSSION

While this study shows significant improvements in drug use and health service access among the RN/-CHW group, the sample size of the study limits the validity and generalizability of the results. Further studies using larger sample sizes are necessitated.

Identifying barriers and facilitators along the hepatitis C care cascade to inform human-centered design of contextualized treatment protocols for vulnerable populations in Austin, Texas: a qualitative study

BACKGROUND

Hepatitis C virus (HCV) is a leading cause of liver-related mortality and morbidity. Despite effective direct acting antivirals and a simplified treatment algorithm, limited access to HCV treatment in vulnerable populations, including people experiencing homelessness (PEH) and people who inject drugs (PWID), hinders global elimination. Adapting the evidence-based, simplified HCV treatment algorithm to the organizational and contextual realities of non-traditional clinic settings serving vulnerable populations can help overcome specific barriers to HCV care. The first phase of the Erase Hep C study aimed to identify barriers and facilitators specific to these vulnerable populations to design the site-specific, simplified treatment protocols.

METHODS

Forty-two semi-structured qualitative interviews, guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework, were conducted with clinic staff, community-based organizations providing screening and linkage to care, and patients diagnosed with HCV, to identify contextual barriers and facilitators to treatment at a local community health center's Health Care for the Homeless program in Austin, Texas. Audio-recorded interviews were systematically analyzed using thematic analysis informed by the PRISM framework and design thinking, to anchor barriers and facilitators along the HCV care cascade. Findings were fed into human-centered design workshops to co-design, with clinic staff, site-specific, simplified HCV treatment protocols.

RESULTS

The specific needs of PEH and PWID patient populations informed barriers and facilitators of HCV care. Barriers included tracking patients who miss critical appointments or labs, medication access and adherence, and patient HCV knowledge. Clinical teams leveraged existing facilitators and incorporated solutions to barriers into clinic workflows to improve care coordination and medication access. Actionable solutions included augmenting existing staff roles, employing HCV care navigation throughout the cascade, and standardizing medication adherence counseling.

CONCLUSIONS

Clinic staff identified HCV care facilitators to leverage, and designed actionable solutions to address barriers, to incorporate into site-specific treatment protocols to improve patient HCV outcomes. Methods used to incorporate staff and patient experiential knowledge into the design of contextualized treatment protocols in non-traditional clinic settings could serve as a model for future implementation research. The next phase of the study is protocol implementation and patient enrollment into a single-arm trial to achieve HCV cure.

Health disparities in chronic liver disease

The syndemic of hazardous alcohol consumption, opioid use, and obesity has led to important changes in liver disease epidemiology that have exacerbated health disparities. Health disparities occur when plausibly avoidable health differences are experienced by socially disadvantaged populations. Highlighting health disparities, their sources, and consequences in chronic liver disease is fundamental to improving liver health outcomes. There have been large increases in alcohol use disorder in women, racial and ethnic minorities, and those experiencing poverty in the context of poor access to alcohol treatment, leading to increasing rates of alcohol-associated liver diseases. Rising rates of NAFLD and associated fibrosis have been observed in Hispanic persons, women aged > 50, and individuals experiencing food insecurity. Access to viral hepatitis screening and linkage to treatment are suboptimal for racial and ethnic minorities and individuals who are uninsured or underinsured, resulting in greater liver-related mortality and later-stage diagnoses of HCC. Data from more diverse cohorts on autoimmune and cholestatic liver diseases are lacking, supporting the need to study the contemporary epidemiology of these disorders in greater detail. Herein, we review the existing literature on racial and ethnic, gender, and socioeconomic disparities in chronic liver diseases using a social determinants of health framework to better understand how social and structural factors cause health disparities and affect chronic liver disease outcomes. We also propose potential solutions to eliminate disparities, outlining health-policy, health-system, community, and individual solutions to promote equity and improve health outcomes.

Innovative Approaches to Engaging Homeless and Marginally Housed Patients in Care: a Case Study of Hepatitis C

BACKGROUND

Homeless and marginally housed (HAMH) individuals experience significant health disparities compared to housed counterparts, including higher hepatitis C virus (HCV) rates. New direct-acting antiviral (DAA) medications dramatically increased screening and treatment rates for HCV overall, but inequities persist for HAMH populations.

OBJECTIVE

This study examines the range of policies, practices, adaptations, and innovations implemented by Veteran Affairs Medical Centers (VAMCs) in response to Veterans Health Administration (VHA)'s 2016 HCV funding allocation to expand provision of HCV care.

DESIGN

Ethnographic site visits to six US VAMCs varying in size, location, and availability of Homeless Patient-Aligned Care Teams. Semi-structured qualitative interviews informed by the HCV care continuum were conducted with providers, staff, and HAMH patients to elicit experiences providing and receiving HCV care. Semi-structured field note templates captured clinical care observations. Interview and observation data were analyzed to identify cross-cutting themes and strategies supporting tailored HCV care for HAMH patients.

PARTICIPANTS

Fifty-six providers and staff working in HCV and/or homelessness care (e.g., infectious disease providers, primary care providers, social workers). Twenty-five patients with varying homeless experiences, including currently, formerly, or at risk of homelessness (n=20) and stably housed (n=5).

KEY RESULTS

All sites experienced challenges with continued engagement of HAMH individuals in HCV care, which led to the implementation of targeted care strategies to better meet their needs. Across sites, we identified 35 unique strategies used to find, engage, and retain HAMH individuals in HCV care.

CONCLUSIONS

Despite highly effective, widely available HCV treatments, HAMH individuals continue to experience challenges accessing HCV care. VHA's 2016 HCV funding allocation resulted in rapid adoption of strategies to engage and retain vulnerable patients in HCV treatment. The strategies identified here can help healthcare institutions tailor and target approaches to provide sustainable, high-quality, equitable care to HAMH individuals living with HCV and other chronic illnesses.

A qualitative investigation of the barriers and facilitators to Hepatitis C virus (HCV) screening among individuals experiencing homelessness in Houston, Texas

BACKGROUND

Individuals experiencing homelessness may be at a higher risk for hepatitis C infection because many are vulnerable to risk factors related to HCV. Screening is the very first step in the HCV care continuum, but it remains unclear how to improve HCV screening among this hard-to-reach population. Thus, the present study investigated the barriers and facilitators to HCV screening from the perspective of individuals experiencing homelessness within a non-residential social service setting.

METHODS

Individuals experiencing homelessness (aged 18+) were approached while they were seeking services at two community-based organizations in Houston, Texas, during August 2020. Participants (N = 31) completed an interviewer-administered demographic survey and a semi-structured interview about their experiences with healthcare, homelessness, and HCV screening. Following transcript coding and content analysis, a thematic analysis was conducted to identify HCV screening barriers and facilitators discussed by participants.

RESULTS

Participants were predominantly male (n = 25, 80.6%), and almost 40% of participants had no form of medical insurance. Participants identified the following as barriers to HCV screening: mistrust of the healthcare system and professionals and lack of knowledge of HCV prevention, harm reduction, and complications. Participants identified the following as facilitators to HCV screening: providing incentives and increasing access and convenience to HCV screening.

CONCLUSION

Community-based HCV screening programs may wish to account for the lived experiences of individuals experiencing homelessness in order to minimize barriers to screening. Client-centered strategies that reduce wait times and incentivize participation should be considered to eliminate barriers and increase convenience for this high-risk population.

Integrating Management of Hepatitis C Infection into Primary Care: the Key to Hepatitis C Elimination Efforts

Elimination of hepatitis C virus (HCV), a leading cause of liver disease in the USA and globally, has been made possible with the advent of highly efficacious direct acting antivirals (DAAs). DAA regimens offer cure of HCV with 8-12 weeks of a well-tolerated once daily therapy. With increasingly straightforward diagnostic and treatment algorithms, HCV infection can be managed not only by specialists, but also by primary care providers. Engaging primary care providers greatly increases capacity to diagnose and treat chronic HCV and ultimately make HCV elimination a reality. However, barriers remain at each step in the HCV cascade of care from screening to evaluation and treatment. Since primary care is at the forefront of patient contact, it represents the ideal place to concentrate efforts to identify barriers and implement solutions to achieve universal HCV screening and increase curative treatment.

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

To achieve the World Health Organization's goal of eliminating hepatitis C (HCV) by 2030 requires enhanced HCV testing and treatment among people who use drugs (PWUD). Micro-elimination of HCV is a strategy to target HCV testing and treatment efforts to specific segments of the population. From February to December 2018 nurses initiated a "seek & treat" micro-elimination approach, increasing outreach and removing barriers to accessing HCV treatment in a clinic setting by testing and treating individuals, including PWUD, where they live. The aim of this study was to evaluate the proportion of clients with HCV antibodies and HCV RNA and the response to direct acting agent (DAA therapy) among people who live at or have social connections to local supportive housing sites through this nurse-led micro-elimination project in Victoria, Canada. A chart review of electronic medical records and case management documentation was used to collect relevant data of participants treated with DAA therapy, identified through specific housing site testing and outreach interventions. In total, 180 people were tested for HCV antibodies, 72 (40%) were antibody positive: 51 (28%) were RNA positive, 13 (7%) had spontaneously cleared and 8 (4%) had been previously treated. Of the 51 that were currently living with HCV, 43 people were started on treatment, 39 have achieved sustained virologic response (SVR). By providing treatment to clients in their homes and with their friends, clinicians have been able to treat clients, including those with limited contact with the health care system.

Gaps in Hepatitis A and Hepatitis B Vaccination Among Hepatitis C Antibody-Positive Individuals Experiencing Homelessness

Vaccination for both hepatitis A (HAV) and hepatitis B (HBV) is recommended in hepatitis C infection (HCV). Among HCV antibody-positive persons experiencing homelessness, we identified high rates of HAV (34%) and HBV vaccine (35%) eligibility, highlighting critical gaps in HCV preventative services. Following education, 54% and 72% underwent HAV and HBV vaccination, respectively.

Formal Hepatitis C education increases willingness to receive therapy in an onsite shelter-based HCV model of care in persons experiencing homelessness

Background

To evaluate the effectiveness of formal Hepatitis C (HCV) education on engagement in therapy in persons experiencing homelessness in an onsite shelter-based model of care. As policies to eliminate Medicaid access restrictions to HCV treatment are expanded, patient education is paramount to achieving HCV elimination targets in difficult to engage populations including persons experiencing homelessness.

Methods

This prospective study was conducted at four shelters in San Francisco and Minneapolis from August 2018 to January 2021. Of the 162 HCV Ab positive participants, 150 participated in a 30-minute HCV education session. Post-education changes in knowledge, beliefs, barriers to care and willingness to accept therapy scores were assessed.

Results

Following education, knowledge scores (mean change 4.4 ± 4.4, p&lt;0.001) and willingness to accept therapy (70% to 86% p=0.0002) increased. Perceived barriers to HCV care decreased (mean change -0.8 ± 5.2 p=0.001). Higher baseline knowledge was associated with lesser gain in knowledge following education (coef. -0.7, p&lt;0.001). Post-education knowledge (OR 1.2, p=0.008) was associated with willingness to accept therapy.

Conclusions

An HCV educational intervention successfully increased willingness to engage in HCV therapy in persons experiencing homelessness in an onsite shelter-based HCV model of care.

Barriers and facilitators to hepatitis C screening and treatment for people with lived experience of homelessness: A mixed-methods systematic review

BACKGROUND

People experiencing homelessness have an increased risk of hepatitis C virus (HCV) infection, with rates higher than the general population. However, their access to HCV diagnosis is limited and treatment uptake is low.

OBJECTIVES

To identify and describe the barriers and facilitators for HCV screening and treatment for adults with lived experience of homelessness in highly developed countries.

METHODS

Bibliographic databases (Embase, MEDLINE, CINAHL and SocINDEX) and grey literature (Google, EThOS, the Health Foundation, Social Care Online, the World Health Organisation, Shelter, Crisis and Pathway) were searched. Two reviewers independently screened and appraised all studies. The Critical Appraisal Skills Programme tool and the Joanna Briggs Institute checklist were used. The analysis involved a three-stage process: coding, theme generation and theme mapping under Penchansky and Thomas's modified access model.

RESULTS

Twelve papers/reports were included in the review. Several interacting factors influence access of people with lived experience of homelessness to HCV testing and treatment. Some mirror those identified for the general population. The precarious conditions associated with the lived experience of homelessness along with the rigidity of hospital settings and lack of awareness emerged as dominant barriers. Flexibility, outreach, effective communication, tailoring and integration of services were found to be important facilitators. Evidence from Black, Asian and minority ethnic groups is limited.

CONCLUSIONS

People experiencing homelessness face multiple barriers in accessing and completing HCV treatment, relating to both their lived experience and characteristics of health systems. Although some barriers are readily amenable to change, others are more difficult to modify. The facilitators identified could inform future targeted measures to improve HCV diagnosis and treatment for people experiencing homelessness. Research is warranted into successful models to promote screening, diagnosis and treatment.

PATIENT OR PUBLIC CONTRIBUTION

Our team includes a peer advocate, a hepatology nurse and a community volunteer, all with significant experience in promoting and engaging in HCV care and outreach for people experiencing homelessness. They contributed to the protocol, interpretation and reporting of the review findings.

Differences in the hepatitis C virus cascade of care and time to initiation of therapy among vulnerable subpopulations using a mobile unit as point-of-care

BACKGROUND AND AIMS

People who inject drugs (PWID) and other marginalized populations with high hepatitis C virus (HCV) infection rates represent a unique challenge for treatment initiation due to health, administrative and social barriers. We analysed the HCV cascade of care (CoC) in some vulnerable subpopulations in Madrid, Spain, when using a mobile point-of-care (PoC).

METHODS

From 2019 to 2021, a mobile unit was used to screen active HCV using a linkage-to-care and two-step PoC-based strategy. Viremic participants were grouped into four subgroups: PWID, homeless individuals and people with a mental health disorder (MHD) and alcohol use disorder (AUD). Logistic regression, and Cox and Aalen's additive models were used to analyse associated factors and differences between groups.

RESULTS

A prospectively recruited cohort of 214 HCV-infected individuals (73 PWID, 141 homeless, 57 with a MHD and 91 with AUD) participated in the study. The overall HCV CoC analysis found that 178 (83.1%) attended a hospital, 164 (76.6%) initiated direct-acting antiviral therapy and 141 (65.8%) completed therapy, of which 99 (95.2%) achieved sustained virological response (SVR). PWID were significantly less likely to initiate treatment, whereas individuals with AUD waited longer before starting the treatment. Both people with AUD and PWID were significantly less likely to complete HCV treatment.

CONCLUSIONS

Overall, SVR was achieved in the majority of the participants treated. However, PWID need better linkage to care and treatment, whereas PWID and AUD need more support for treatment completion.

Hepatitis C virus: Its prevalence, risk factors and genotype distribution in Pakistan

Hepatitis C is a dangerous liver disease transmitted by Hepatitis C virus (HCV). HCV constitutes an important health issue in Pakistan. In Pakistani setting HCV is found frequently and is recognized as an alarming health problem. In this cross sectional study we reviewed published data regarding the seroprevalence of hepatitis C in general community, blood donors and pregnant females and risk factors linked with its occurrence in Pakistan. Data retrieved from163 studies published from 2001 to 2022 was utilized and weighted mean was calculated. Data of 1,875,232 individuals was collected and arranged into three groups, depending upon the population type such as (1) general population, (2) pregnant women, (3) blood donors. General population (765,426) and blood donors (973,260) formed the most of population. Mean Hepatitis C virus prevalence in general public and blood donors was 16.47% and 8.2% respectively. In pregnant females (136,546) the mean frequency was 9.3%. This study exhibits that the frequency of Hepatitis C in general population, pregnant females and blood donors groups was 11.32%. The data suggested that risks factors for transmitting HCV infection in Pakistan include unsterilized needle use, blood transfusions, shaving by barbers, lack of trained staff, needle stick injuries, injection drug users, household contacts/spousal transmission, unsterilized dental and surgical Instruments, improper disposal of hospital waste, poor infra-structure and others. The frequency of HCV infection is distressing in Pakistan. Health education and awareness programs are needed for decreasing Hepatitis C infection in Pakistan. The data necessitate the implementation of preventive and remedial approaches to decrease the disease load and mortality in Pakistan.

Real-world evidence of sofosbuvir/velpatasvir as an effective and simple hepatitis C virus treatment and elimination tool in homeless populations

Background: People experiencing homelessness are disproportionately affected by hepatitis C virus (HCV) and can face specific barriers to care. Simple treatment algorithms could increase linkage to care in this population. Methods: This retrospective real-world analysis pooling data from 15 clinical cohorts evaluated effectiveness of a once-daily sofosbuvir/velpatasvir (SOF/VEL) regimen in HCV-infected people experiencing homelessness. The primary outcome was sustained virological response (SVR) in the effectiveness population (patients with confirmed SVR status). Secondary outcomes included reasons for not achieving SVR, adherence and time between diagnosis and SOF/VEL treatment start. Results: Of 153 patients treated with SOF/VEL for 12 weeks without ribavirin, SVR was 100% in the effectiveness population (n = 122), irrespective of various baseline factors including active injecting drug use and presence of mental health disorders. Conclusion: HCV-infected people experiencing homelessness can successfully be treated with SOF/VEL. SOF/VEL enables implementation of simple treatment algorithms and can support test-and-treat strategies through rapid treatment starts and minimal monitoring.

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

Background

Medication adherence is a common reason for treatment deferment in persons experiencing homelessness. We evaluated adherence to hepatitis C virus (HCV) therapy following HCV education in a shelter-based care model.

Methods

Prospective study conducted at 4 homeless shelters in Minneapolis, Minnesota and San Francisco, California from November 2018 to January 2021. Sixty-three patients underwent HCV education and treatment. Multivariable modeling evaluated factors associated with (1) medication and (2) overall (composite score of medication, laboratory, and clinic visit) adherence.

Results

Median age was 56 years; 73% of participants were male, 43% were Black, 52% had psychiatric illness, and 81% used illicit drugs and 60% used alcohol in the past year. Following education, 52% were extremely confident in their ability to be adherent to HCV therapy. Medication adherence by patient and provider report was 88% and 48%, respectively, and 81% achieved HCV cure. Active alcohol use was associated with less confidence in medication adherence (43% vs 78%, P = .04). Older age was positively (coefficient = 0.3) associated with overall adherence to HCV treatment whereas prior therapy was associated with both medication (odds ratio, 0.08) and overall treatment (coefficient = -0.87) nonadherence.

Conclusions

Despite imperfect adherence, sustained virologic response rates were still high. Expanding opportunities to treat persons experiencing homelessness in a structured and supportive setting is critical to HCV elimination efforts.

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

Hepatitis C virus (HCV) prevalence is high among people experiencing homelessness, but barriers to scaling up HCV testing and treatment persist. We aimed to implement onsite HCV testing and education and evaluate the effectiveness of low‐barrier linkage to HCV therapy among individuals accessing homeless shelters. HCV rapid testing was performed at four large shelters in San Francisco (SF) and Minneapolis (MN). Sociodemographic status, HCV risk, barriers to testing, and interest in therapy were captured. Participants received information about HCV. Those testing positive underwent formal HCV education and onsite therapy. Multivariable modeling assessed predictors of receipt of HCV therapy and sustained virologic response (SVR). A total of 766 clients were tested. Median age was 53.7 years, 68.2% were male participants, 46.3% were Black, 27.5% were White, 13.2% were Hispanic, and 57.7% had high school education or less; 162 (21.1%) were HCV antibody positive, 107 (66.0%) had detectable HCV RNA (82.1% with active drug use, 53.8% history of psychiatric illness), 66 (61.7%) received HCV therapy, and 81.8% achieved SVR. On multivariate analysis, shelter location (MN vs. SF, odds ratio [OR], 0.3; P = 0.01) and having a health care provider (OR, 4.1; P = 0.02) were associated with receipt of therapy. On intention to treat analysis, the only predictor of SVR when adjusted for age, sex, and race was HCV medication adherence (OR, 14.5; P = 0.01). Conclusion: Leveraging existing homeless shelter infrastructure was successful in enhancing HCV testing and treatment uptake. Despite high rates of active substance use, psychiatric illness, and suboptimal adherence, over 80% achieved HCV cure. This highlights the critical importance of integrated models in HCV elimination efforts in people experiencing homelessness that can be applied to other shelter settings.

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

BACKGROUND AND AIM:

Patient reported experience (PRE) is critical for engagement in hepatitis C (HCV) therapy in hard to reach populations. However, there is no data on patient reported experience with DAA therapy among homeless patients accessing shelters. We assessed PRE with DAA treatment following implementation of HCV therapy within homeless shelters in two diverse regions in the United States.

METHODS:

In a study of integrated HCV testing and treatment in four homeless shelters in San Francisco (SF) and Minnesota (MN), 66 patients received DAA therapy from 11/2018–4/2020. PREs were assessed at the end of therapy with constructs: satisfaction with communication with their HCV treatment provider, receipt of social support during therapy, perceived stigma associated with HCV infection, and their overall satisfaction with DAA therapy. Descriptive statistics and factors associated with satisfaction with HCV therapy were assessed.

RESULTS:

At end of therapy, 41 patients completed the questionnaire (response rate was 62%). Median age was 56 years, 74.4% were men, 44% White (45% Black, 6% Latino), 35% had more than a high school diploma, 65% had a history of IV drug use, 56% had received SUD treatment, and 12% were co-infected with HIV. During DAA treatment, the majority of patients lived in shelters, 37% used illicit drugs, 24% consumed alcohol, and 14% received psychiatric treatment. Patient reported experience with DAA therapy were as follows: 100% agreed or strongly agreed that HCV providers seemed non-judgmental, 98% reported that their provider seemed to care about them, 98% reported that people close to them had been supportive of their care, and 98% were satisfied with their HCV treatment. There were no patient level or clinical predictors associated with PREs of stigma, perceived lack of social support or satisfaction with DAA treatment.

CONCLUSIONS:

Nearly all (>95%) homeless patients receiving integrated HCV testing and therapy within homeless shelters felt supported and reported favorable views toward their providers and a high level of satisfaction with DAA treatment. As patient reported experience is key for engagement in HCV therapy, our onsite treatment intervention within shelters can serve as a model of HCV care to enhance treatment uptake in patients experiencing homelessness.

Engaging the Community in Designing a Hepatitis C Virus Treatment Program for Adults Experiencing Homelessness

Despite the availability of cure for hepatitis C virus (HCV), people experiencing homelessness (PEH) are challenged with initiating and completing HCV treatment. The design of culturally sensitive HCV treatment programs is lacking. The objective was to employ community-based participatory research methods to understand perceptions of HCV-positive PEH, and providers, on the design and delivery of a culturally sensitive, nurse-led community health worker (RN/CHW) HCV initiation and completion program. Four focus group sessions were conducted with HCV-positive PEH (n = 30) as well as homeless service providers (HSP; n = 7) in Skid Row, Los Angeles. An iterative, thematic approach provided the themes of essentials of successful participant engagement and retention: Role of nurse-Led CHW in promoting: (a) tangible and emotional support; (b) cognitive and behavioral support; and (c) financial and structural resources. The goal of this study is to provide the groundwork for future research of HCV program design to support HCV cure among homeless populations.

HIV screening and retention in care in people who use drugs in Madrid, Spain: a prospective study

Background

The burden of human immunodeficiency virus (HIV) infection in people who use drugs (PWUD) is significant. We aimed to screen HIV infection among PWUD and describe their retention in HIV care. Besides, we also screen for hepatitis C virus (HCV) infection among HIV-seropositive PWUD and describe their linkage to care.

Methods

We conducted a prospective study in 529 PWUD who visited the “Cañada Real Galiana” (Madrid, Spain). The study period was from June 1, 2017, to May 31, 2018. HIV diagnosis was performed with a rapid antibody screening test at the point-of-care (POC) and HCV diagnosis with immunoassay and PCR tests on dried blood spot (DBS) in a central laboratory. Positive PWUD were referred to the hospital. We used the Chi-square or Fisher’s exact tests, as appropriate, to compare rates between groups.

Results

Thirty-five (6.6%) participants were positive HIV antibodies, but 34 reported previous HIV diagnoses, and 27 (76%) had prior antiretroviral therapy. Among patients with a positive HIV antibody test, we also found a higher prevalence of homeless (P < 0.001) and injection drug use (PWID) (P < 0.001), and more decades of drug use (P = 0.002). All participants received HIV test results at the POC. Of the 35 HIV positives, 28 (80%) were retained in HIV medical care at the end of the HIV screening study (2018), and only 22 (62.9%) at the end of 2020. Moreover, 12/35 (34.3%) were positive for the HCV RNA test. Of the latter, 10/12 (83.3%) were contacted to deliver the HCV results test (delivery time of 19 days), 5/12 (41.7%) had an appointment and were attended at the hospital and started HCV therapy, and only 4/12 (33.3%) cleared HCV.

Conclusions

We found almost no new HIV-infected PWUD, but their cascade of HIV care was low and remains a challenge in this population at risk. The high frequency of active hepatitis C in HIV-infected PWUD reflects the need for HCV screening and reinforcing the link to care.

Hepatitis C in homeless people: reaching a hard-to-reach population

OBJECTIVE

the aim of this study was to analyze the process of detection and treatment of hepatitis C in individuals experiencing homelessness (IEH).

METHODS

an analytical cross-sectional study was performed in a Primary Care center. The center screened and registered patients with a positive hepatitis C antibody test and referred them to the Digestive Service.

RESULTS

finally, 8.3 % presented with a positive HCV antibody test, of which six were patients who had already received treatment. Of those who had not received treatment, one patient was successfully treated; 30.8 % of the total could not be located or did not wish to participate.

CONCLUSION

community coordination and the use of rapid tests would improve detection.

A Feasibility Study to Increase Chronic Hepatitis C Virus RNA Testing and Linkage to Care among Clients Attending Homeless Services in Amsterdam, The Netherlands

People who inject drugs (PWID) are disproportionately affected by hepatitis C virus (HCV) infections and are frequently homeless. To improve HCV case finding in these individuals, we examined the feasibility of rapid HCV RNA testing in homeless services in Amsterdam. In 2020, we provided a comprehensive service to homeless facilities, which included workshops on HCV for personnel, a “hepatitis ambassador” at each facility, a rapid, onsite HCV RNA fingerstick test service, and assistance with linkage to care. Risk factors for HCV RNA-positive status were examined using Bayesian logistic regression. Of the 152 participants enrolled, 150 (87% men; median age: 47 years) accepted rapid HCV testing. Seven tested HCV RNA positive (4.7%, 95%CrI = 1.31–8.09; 7/150). Of these, five (71%) were linked to care, of whom four (57%, 4/7) initiated treatment and one (14%, 1/7) delayed treatment due to a drug–drug interaction. Of these four people, two completed treatment (50%), of whom one (25%) achieved sustained virologic response after 12 weeks. HCV RNA-positive individuals were more likely to originate from Eastern Europe (posterior-odds ratio (OR) = 3.59 (95% credible interval (CrI) = 1.27–10.04)) and to inject drugs (ever: posterior-OR = 3.89 (95% CrI = 1.37–11.09); recent: posterior-OR = 3.94 (95% CrI = 1.29–11.71)). We identified HCV RNA-positive individuals and linkage to care was relatively high. Screening in homeless services with rapid testing is feasible and could improve HCV case finding for PWID who do not regularly attend primary care or other harm reduction services for people who use drugs.

Exploring how hospitalization can alter hepatitis c virus treatment prioritization and trajectories in people who use drugs: A qualitative analysis

Background: People who use drugs (PWUD) have high rates of hepatitis C virus (HCV) infection. Hospitalization can be a time for PWUD to engage in addiction treatment, but little is known about how hospitalization shapes HCV treatment readiness. We aimed to describe how hospitalization and addiction medicine consult service (AMCS) can alter HCV prioritization of inpatient PWUD with HCV. Methods: We conducted a qualitative study consisting of semi-structured interviews (n = 27) of hospitalized adults with addiction and HCV infection seen by an AMCS at a single, urban, academic center. Interviews were audio-recorded, transcribed, and coded iteratively at the semantic level, and analyzed for themes. Results: Of the 27 participants, most identified as Caucasian (85%), male gender (67%), and they primarily used opioids (78%); approximately half (48%) reported HCV diagnosis over 5 years ago. We identified three main themes around hospitalization altering the prioritizations and HCV treatment preferences for PWUD: (1) HCV treatment non-engaged (2) HCV treatment urgency, and (3) HCV treatment in the future. Those wanting to treat HCV-whether urgently or in the future-shared the overlapping theme of hospitalization as a reachable moment for their addiction and HCV. These participants recognized the long-term benefits of addressing HCV and connected their hospitalization to substance use. Conclusion: In our study, PWUD with HCV expressed varying and competing priorities and life circumstances contributing to three main HCV treatment trajectories. Our results suggest ways hospitalization can serve as an HCV touchpoint for PWUD, especially in the context of addressing substance use, and could be used when designing and implementing targeted interventions to improve the HCV care continuum for PWUD.