Engagement in the Hepatitis C Care Cascade Among Homeless Veterans, 2015

Factors Associated with Sustained Virologic Response to Hepatitis C Treatment in a Homeless-Experienced Cohort in Boston, 2014-2020

BACKGROUND

Engaging people experiencing homelessness or unstable housing in hepatitis C virus (HCV) treatment is critical to achieving HCV elimination.

OBJECTIVE

To describe HCV treatment outcomes, including factors associated with retention through the treatment cascade, for a cohort of individuals treated in a homeless health center in Boston.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All individuals who initiated HCV treatment with Boston Health Care for the Homeless Program's HCV treatment program between January 2014 and March 2020 (N = 867).

OUTCOME MEASURES

The primary outcome was sustained virologic response (SVR), defined as an HCV ribonucleic acid (RNA) level ≤ 15 IU/mL at least 12 weeks after treatment completion. We used multivariable logistic regression to examine the association between baseline variables and SVR. Process-oriented outcomes included treatment completion, assessment for SVR, and achievement of SVR.

RESULTS

Of 867 individuals who started HCV treatment, 796 (91.8%) completed treatment, 678 (78.2%) were assessed for SVR, and 607 (70.0%) achieved SVR. In adjusted analysis, residing in stable housing (OR 3.83, 95% CI 1.85-7.90) and age > 45 years old (OR 1.53, 95% CI 1.04-2.26) were associated with a greater likelihood of achieving SVR. Recent drug use (OR 0.63, 95% CI 0.41-0.95) was associated with a lower likelihood of SVR. Age, housing status, and drug use status impacted retention at every step in the treatment cascade.

CONCLUSION

A large proportion of homeless-experienced individuals engaging in HCV treatment in a homeless health center achieved SVR, but enhanced approaches are needed to engage and retain younger individuals, those with recent or ongoing substance use, or those experiencing homelessness or unstable housing. Efforts to achieve HCV elimination in this population should consider the complex and overlapping challenges experienced by this population and aim to address the fundamental harm of homelessness itself.

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.

Results of a Model of Delivering Hepatitis C Care in a Homeless Metropolitan Population in England

INTRODUCTION

Given the hepatitis C virus (HCV) burden and despite curative treatments, more efforts focused on scaling-up testing and treatment in homeless populations are needed. This project aimed to implement education and flexible on-site HCV testing, treatment, and follow-up for a homeless population in south London and to evaluate engagement, therapy initiation, and cure rates.

METHODS

A mobile unit (van) for on-site HCV education, screening, treatment, and follow-up was placed on the street in a well-known homeless population areas from January 2018 to September 2021. Homeless was defined as living in temporary housing (hostel/hotel-based) or living on the street (street-based). Sociodemographic status, risk factors, comorbidities, concomitant medication, and data related with HCV treatment were recorded. Univariable and multivariable modeling were performed for treatment initiation and sustained virological response (SVR).

RESULTS

Nine hundred forty homeless people were identified and 99.3% participated. 56.2% were street-based, 243 (26%) tested positive for HCV antibody, and 162 (17.4%) were viremic. Those with detectable HCV RNA had significantly more frequent psychiatric disorders, active substance use disorders, were on opioid agonist treatment, had advanced fibrosis, and had lower rates of previous treatment in comparison with undetectable HCV RNA. Overall treatment initiation was 70.4% and SVR was 72.8%. In the multivariable analysis, being screened in temporary housing (odds ratio [OR] 3.166; P = 0.002) and having opioid agonist treatment (OR 3.137; P = 0.004) were positively associated with treatment initiation. HCV treatment adherence (OR 26.552; P < 0.001) was the only factor associated with achieving SVR.

DISCUSSION

Promoting education and having flexible and reflex mobile on-site testing and treatment for HCV in the homeless population improve engagement with the health care system, meaning higher rates of treatment initiation and SVR. However, street-based homeless population not linked with harm reduction services are less likely to initiate HCV treatment, highlighting an urgent need for a broad health inclusion system.

Is the Availability of Direct-Acting Antivirals Associated with Increased Access to Hepatitis C Treatment for Homeless and Unstably Housed Veterans?

OBJECTIVE

Hepatitis C virus (HCV) treatment has experienced a rapid transformation in the USA. New direct-acting antiviral (DAA) medications make treatment easier, less toxic, and more successful (90% or greater viral cure) than prior, interferon-based HCV medications. We sought to determine whether DAAs may have improved access to HCV treatment for hard-to-reach populations such as the homeless.

METHODS

In a retrospective study of VA electronic medical record data, a cohort was created of 63,586 veterans with a positive HCV RNA or genotype test taken at any point from January 1, 2012, through December 31, 2016. Patient data were examined for up to 5 years using a discrete time survival model to assess the relationship between their housing status and receipt of HCV medications in 6-month time periods in both the interferon and DAA eras.

RESULTS

In the interferon era, the probability of HCV treatment in a given 6-month window among housed veterans, at 6.2% (95% CI: 5.3-7.1%) was significantly higher than among veterans who were homeless or unstably housed; for example, among currently homeless veterans, the probability of treatment initiation, in a given 6-month window, was 2.6% (95% CI: 1.9-3.3%). With the arrival of DAAs, each housing category had an increased probability of treatment initiation. For housed veterans, the probability was 8.6% (95% CI: 8.3-8.9%) while for currently homeless veterans, it was 6.3% (95% CI: 5.7-6.9%).

CONCLUSIONS

We found a clear indication that the likelihood of treatment initiation was greater for all veterans in the DAA era as compared to the interferon era. However, disparities in treatment initiation rates between housed and homeless veterans that were observed in the interferon era persisted in the DAA era.

Chronic liver disease in homeless individuals and performance of non-invasive liver fibrosis and injury markers: VALID study

BACKGROUND/AIMS

Community-based assessment and management of chronic liver disease (CLD) in people who are homeless (PWAH) remain poorly described. We aimed to determine prevalence/predictors of CLD in PWAH and assess the performance of non-invasive liver fibrosis and injury markers.

METHODS

The Vulnerable Adult LIver Disease (VALID) study provided a "one-stop" liver service based at homeless hostels. Our primary outcome was the prevalence of clinically significant hepatic fibrosis (CSHF; liver stiffness measurement (LSM) ≥8 kPa).

RESULTS

Total individuals recruited were 127, mean ± SD age 47 ± 9.4 years, 50% (95% CI 41%-59%) and 39% (95% CI 31%-48%) having alcohol dependence and a positive HCV RNA respectively. CSHF was detected in 26% (95% CI 17%-35%), independent predictors being total alcohol unit/week (OR 1.01, 95% CI 1.00-1.02, P = .002) and HCV RNA positivity (OR 2.93, 95% CI 1.12-7.66, P = .029). There was moderate agreement between LSM and Enhanced Liver Fibrosis (ELF) score (kappa 0.536, P < .001) for CSHF as assessed by LSM ≥8 kPa. Those with CSHF had significantly higher levels of IFN-γ (P = .002), IL-6 (P = .001), MMP-2 (P = .006), ccCK-18 (P < .001) and ELF biomarkers (P < .001), compared to those without CSHF. Service uptake was ≥95%. Direct acting antiviral (DAA) treatment completion was 93% (95% CI 77%-99%), sustained virological response (SVR) being 83% (95% CI 64%-94%).

CONCLUSION

There is a significant liver disease burden from HCV and alcohol in PWAH. Non-invasive liver fibrosis and injury markers can help in identifying such individuals in the community. Despite a challenging cohort, excellent service uptake and high DAA-based SVRs can be achieved.

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.

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.

Hepatitis C virus care cascade in persons experiencing homelessness in the United States in the era of direct-acting antiviral agents: A scoping review

The hepatitis C virus (HCV) care cascade has been well characterized in the general United States population and other subpopulations since curative medications have been available. However, information is limited on care cascade outcomes in persons experiencing homelessness. The main objective of this study was to map the available evidence on HCV care cascade outcomes in people experiencing homelessness in the U.S. in the era of direct-acting antiviral agents (DAAs). Primary and secondary outcomes included linkage to care (evaluation by a provider that can treat HCV) and sustained virologic response (SVR) or cure. Exploratory outcomes included other cascade data, like treatment initiation, which precedes SVR. PubMed was the primary database accessed for this scoping review. We characterized the HCV care cascade in people experiencing homelessness using sources of evidence published in 2014 onwards that reported the proportions of persons who were linked to care, achieved SVR, and completed other cascade steps. We synthesized our results into a scoping review. The proportion of persons linked to care among chronically infected cohorts with unstable housing ranged from 29.3% to 88.7%. Among those chronically infected, 5%-58.8% were started on DAAs and 5%-50% achieved SVR. In conclusion, these results show that persons experiencing homelessness achieve high rates of linkage to care in non-specialist community-based settings compared to the general U.S. population pre-DAAs. However, DAA initiation was found to be a rate-limiting step along the care cascade, resulting in commensurate low rates of cure.

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.

Global cascade of care for chronic hepatitis C virus infection: A systematic review and meta-analysis

The World Health Organization 2030 targets for hepatitis C virus (HCV) elimination include diagnosing 90% of people with HCV and treating 80% of people diagnosed with HCV. This systematic review assessed reported data on the HCV care cascade in various countries and populations, with a focus on direct-acting antiviral (DAA) treatment uptake. Bibliographic databases and conference presentations were searched for studies reporting the HCV care cascade (DAA treatment uptake was a requirement) among the overall population with HCV or sub-populations at greater risk of HCV. Population-based studies, with participants representative of a city, province/state or country were eligible. Twenty eligible studies were included, reporting HCV care cascade in 28 populations/sub-populations from 11 countries. DAA treatment uptake at national levels was reported from Iceland (95%), Egypt (92%), Georgia (79%), Norway (18%) and Sweden (8%), and at sub-national levels from the Netherlands (52%), Canada (50%), the United States (29%) and Denmark (5%). Among people with HIV-HCV co-infection, DAA treatment uptake was 62% in Canada, 44% in the Netherlands, 21% in Switzerland and 18% in the United States. Among people who inject drugs, DAA treatment uptake was 50% in Georgia, 40% in Canada, 37% in Australia and 13% in the United States. Data among people experiencing homelessness were only available from the United States (treatment uptake: 12%-14%). We found no eligible study reporting HCV care cascade data in prisons. Relatively few countries reported HCV care cascade at the national level. DAA treatment uptake was widely varied across populations/sub-populations, with higher rates reported in recent years.

Evaluation of Risk Factors for Hepatitis C Virus Infection Among Philadelphia's Shelter-Bound, Homeless Population: Data from a Student-Run Hepatitis C Virus Screening Initiative

The objective was to assess risk factors for HCV specific to the shelter-bound homeless population of Philadelphia, Pennsylvania. This is a retrospective analysis of data obtained from 306 patients who received HCV antibody testing at 4 homeless shelters in Philadelphia between March 2017 and June 2019. Risk factors for HCV infection specific to this population were analyzed using Fischer exact tests. Fourteen (4.6%) of 306 patients screened positive for HCV infection. Risk factors for HCV infection among this shelter-bound homeless population included injection drug use, inhalation drug use, and tattoos obtained while incarcerated. Although an estimated 2.8% of the population of Philadelphia is infected with HCV, 4.6% of those screened in this program tested positive, highlighting the increased prevalence of HCV among the shelter-bound homeless population and the importance of assessing risks for HCV infection inherent to this specific population.

Outcomes of Hepatitis C Virus Treatment in the New York City Jail Population: Successes and Challenges Facing Scale up of Care

BACKGROUND

The population detained in the New York City (NYC) jail system bears a high burden of hepatitis C virus (HCV) infection. Challenges to scaling up treatment include short and unpredictable lengths of stay. We report on the clinical outcomes of direct-acting antiviral (DAA) treatment delivered by NYC Health + Hospitals/Correctional Health Services in NYC jails from 2014 to 2017.

METHODS

We performed a retrospective observational cohort study of HCV patients with detectable HCV ribonucleic acid treated with DAA therapy while in NYC jails. Some patients initiated treatment in jail, whereas others initiated treatment in the community and were later incarcerated. Our primary outcome was sustained virologic response at 12 weeks (SVR12).

RESULTS

There were 269 patients included in our cohort, with 181 (67%) initiating treatment in jail and 88 (33%) continuing treatment started in the community. The SVR12 virologic outcome data were available for 195 (72%) individuals. Of these, 172 (88%) achieved SVR12. Patients who completed treatment in jail were more likely to achieve SVR12 relative to those who were released on treatment (adjusted risk ratio, 2.93; 95% confidence interval, 1.35-6.34). Of those who achieved SVR12, 114 (66%) had a subsequent viral load checked. We detected recurrent viremia in 18 (16%) of these individuals, which corresponded to 10.6 cases per 100 person-years of follow-up.

CONCLUSIONS

Hepatitis C virus treatment with DAA therapy is effective in a jail environment. Future work should address challenges related to discharging patients while they are on treatment, loss to follow-up, and a high incidence of probable reinfection.

Provider Perceptions of Hepatitis C Treatment Adherence and Initiation

BACKGROUND

Significant disparities in hepatitis C (HCV) treatment existed in the interferon treatment era, such that patients with mental health and substance use disorders were less likely to be treated. We aimed to evaluate whether these perceptions continue to influence HCV treatment decisions.

METHODS

We e-mailed HCV providers a survey to assess their perceptions of barriers to HCV treatment adherence and initiation. We assessed the frequency of perceived barriers and willingness to initiate HCV treatment in patients with these barriers. We identified a group of providers more willing to treat patients with perceived barriers to adherence and determined the associated provider characteristics using Spearman's rho and Wilcoxon rank-sum tests.

RESULTS

A total of 103 providers (29%) responded to the survey. The most commonly endorsed perceived barriers to adherence were homelessness (65%), ongoing drug (58%), and ongoing alcohol use (33%). However, 90%, 68%, and 90% of providers were still willing to treat patients with these comorbidities, respectively. Ongoing drug use was the most common reason providers were never or rarely willing to initiate HCV treatment. Providers who were less willing to initiate treatment more frequently endorsed patient-related determinants of adherence, while providers who were more willing to initiate treatment more frequently endorsed provider-based barriers to adherence (e.g., communication).

CONCLUSIONS

Most responding providers were willing to initiate HCV treatment in all patients, despite the presence of perceived barriers to adherence or previous contraindications to interferon-based treatments. Ongoing substance use remains the most prominent influencer in the decision not to treat.

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

Compared with the general population, homeless individuals are at higher risk of hepatitis C infection (HCV) and may face unique barriers in receipt of HCV care. This study sought the perspectives of key stakeholders toward establishing a universal HCV screening, testing, and treatment protocol for individuals accessing homeless shelters. Four focus groups were conducted with homeless shelter staff, practice providers, and social service outreach workers (n = 27) in San Francisco, California, and Minneapolis, Minnesota. Focus groups evaluated key societal, system, and individual-level facilitators and barriers to HCV testing and management. Interviews were transcribed and analyzed thematically. The societal-level barriers identified were lack of insurance, high-out-of-pocket expenses, restriction of access to HCV treatment due to active drug and/or alcohol use, and excessive paperwork required for HCV treatment authorization from payers. System-level barriers included workforce constraints and limited health care infrastructure, HCV stigma, low knowledge of HCV treatment, and existing shelter policies. At the individual level, client barriers included competing priorities, behavioral health concerns, and health attitudes. Facilitators at the system level for HCV care service integration in the shelter setting included high acceptability and buy in, and linkage with social service providers. Conclusion: Despite societal, system, and individual-level barriers identified with respect to the scale-up of HCV services in homeless shelters, there was broad support from key stakeholders for increasing capacity for the provision of HCV services in shelter settings. Recommendations for the scale-up of HCV services in homeless shelter settings are discussed.

Community Screening, Identification, and Referral to Primary Care, for Hepatitis C, B, and HIV Among Homeless Persons in Los Angeles

People experiencing homelessness are disproportionally affected by drug and alcohol use and by their serious health consequences. In this study, 137 adults from the "UCLA/ARG/RAND Homeless Hepatitis Study" who were sampled from shelters and meal programs in the Skid Row of Los Angeles and screened for HIV or HCV or HBV infection. Those who tested positive for these infections were counseled about their infections and referred to primary care. They were followed-up at 1 month with interviews to identify rates, and predictors, of seeking primary care. Participants were 87.5% male, mean age of 48.6 years (SD: 8.2); most were Black (77.4%) and were chronically homeless (> 12 months). A majority (70%) had a regular source of care; 78% were lifetime marijuana users, 56% were lifetime cocaine users and 51% had injected intravenously during the past year. Among this sample, 118 participants (86.1%) tested seropositive for HCV infection, 79 (57.7%) HBV infection and 18 (13.1%) HIV infection. At 1-month follow-up, 102 participants (74.5%) attended the clinic they were referred to. The only variable associated with attending the clinic was having slept in a shelter during the previous night versus other sleeping conditions [Odds ratio (95% CI): 3 .0 (1.07-8.42), p = 0.03]. This model offers a simple and efficacious approach to seeking, testing, counseling, and referral to treatment of community-based adults experiencing homelessness with HIV, HCV and/or HBV infection and linking them to primary care. Being sheltered may be the key facilitator for homeless seeking primary care.

The Hepatitis C Virus Care Continuum: Linkage to Hepatitis C Virus Care and Treatment Among Patients at an Urban Health Network, Philadelphia, PA

Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five federally qualified health centers (FQHCs) in Philadelphia, PA, where a testing and linkage to care program had been established. Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a "test and treat" site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012 to 2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. Of 885 chronically infected patients, 92.2% received their RNA-positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.82-4.17) and to undergo liver disease staging (aOR, 1.92; 95% CI, 1.02-2.86) than patients at the other FQHCs combined. Conclusion: In this US urban setting, over two thirds of HCV-infected patients were linked to care; although treatment uptake was low overall, it was highest at the test and treat site; scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum.

Quantitative evaluation of an integrated nurse model of care providing hepatitis C treatment to people attending homeless services in Melbourne, Australia

BACKGROUND

The prevalence of hepatitis C virus (HCV) has been reported to be high among people experiencing homelessness. People who are homeless often have multiple needs that may take precedence over HCV testing and treatment. We quantitatively evaluated the outcomes of a service providing HCV treatment to people attending homeless services.

METHODS

Clients attending homeless services were referred to a nurse specialising in HCV-related care. The nurse provided HCV testing, education and case-management while prescriptions were provided by an affiliated doctor. Logistic regression was used to explore factors associated with treatment commencement.

RESULTS

Fifty-two clients referred (78%) underwent testing, thirty-nine were HCV-RNA positive among whom 18 (46%) reported sleeping rough and 29 (74%) reported injecting drug use; 66% had injected less than three months ago. Twenty-four (62%) clients commenced treatment, of whom thirteen (54%) had a sustained virological response test; all were cured. Treatment commencement was lower among people who reported sleeping rough (aOR 0.15, 95%CI 0.029-0.73). There was no difference in treatment commencement based on injecting drugs (aOR 1.06, 95%CI 0.21-5.2).

CONCLUSION

Most clients' commenced treatment and the majority were successfully cured using a dedicated nursing service. Clients who reported sleeping rough may still face personal and/or system level barriers to HCV treatment.

A Novel Measure to Assess Variation in Hepatitis C Prevalence Among Homeless and Unstably Housed Veterans, 2011-2016

We constructed a novel measure of homelessness to examine differences in hepatitis C virus (HCV) prevalence across 3 categories of unstably housed and homeless veterans and across US Department of Veterans Affairs Medical Center facilities. We used Veterans Affairs administrative data to classify a cohort of 434 240 veterans as at risk of homelessness, currently homeless, or formerly homeless, and we examined variation in HCV prevalence by using descriptive measures and mixed-effect logistic regression models. HCV prevalence was highest among veterans who were formerly homeless (16.7%; 32 490 of 195 000), followed by currently homeless (12.4%; 22 050 of 178 056) and at risk of homelessness (8.2%; 5015 of 61 184). Veterans Affairs Medical Center-level prevalence ranged from 5.4% to 21.5%. Differences in HCV prevalence were significant by sex, race/ethnicity, and age. Targeting specific populations of homeless veterans for tailored HCV interventions and allocating additional resources to certain Veterans Affairs Medical Centers may be warranted.

Hepatitis C Care in the Department of Veterans Affairs: Building a Foundation for Success

The Department of Veterans Affairs (VA) has made significant progress in treating hepatitis C virus, experiencing more than a 75% reduction in veterans remaining to be treated since the availability of oral direct-acting antivirals. Hepatitis C Innovation Teams use lean process improvement and system redesign, resulting in practice models that address gaps in care. The key to success is creative improvements in veteran access to providers, including expanded use of nonphysician providers, video telehealth, and electronic technologies. Population health management tools monitor and identify trends in care, helping the VA tailor care and address barriers.

A Surveillance-Based Hepatitis C Care Cascade, New York City, 2017

OBJECTIVES

The care cascade, a method for tracking population-level progression from diagnosis to cure, is an important tool in addressing and monitoring the hepatitis C virus (HCV) epidemic. However, little agreement exists on appropriate care cascade steps or how best to measure them. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) sought to construct a care cascade by using laboratory surveillance data with clinically relevant categories that can be readily updated over time.

METHODS

We identified all NYC residents ever reported to the DOHMH surveillance registry with HCV through June 30, 2017 (n = 175 896). To account for outmigration, death, or treatment before negative RNA results became reportable to the health department, we limited the population to people with any test reported since July 1, 2014. Of these residents, we identified the proportion with a reported positive RNA test and estimated the proportion treated and cured since July 2014 by using DOHMH-developed surveillance-based algorithms.

RESULTS

Of 78 886 NYC residents ever receiving a diagnosis of HCV and tested since July 1, 2014, a total of 70 397 (89.2%) had ever been reported as RNA positive through June 30, 2017; 36 875 (46.7%) had initiated treatment since July 1, 2014, and 23 766 (30.1%) appeared cured during the same period.

CONCLUSION

A substantial gap exists between confirming HCV infection and initiating treatment, even in the era of direct-acting antivirals. Using this cascade, we will monitor progress in improved treatment and cure of HCV in NYC.

Monitoring the hepatitis C care cascade using administrative claims data

OBJECTIVES

With the availability of curative therapies, it is important to ensure that individuals infected with hepatitis C virus (HCV) receive recommended testing, care, and treatment. We sought to evaluate insurance claims data as a source for monitoring progression along the HCV care cascade.

STUDY DESIGN

Longitudinal evaluation of disease progression, from diagnosis to treatment, among commercially insured enrollees with chronic HCV.

METHODS

We validated and used algorithms derived from standardized procedure and diagnosis codes to identify enrollees with chronic HCV in large insurance claims databases to describe the HCV care cascade, including the proportion engaged in HCV-specific care (13 possible definitions), the proportion prescribed HCV treatment, and the proportion who received an HCV RNA test 30 or more days after initiating treatment.

RESULTS

Approximately 90% of individuals with an HCV RNA test procedure code followed by either 3 or more chronic HCV diagnosis codes on different service dates or 2 or more chronic HCV diagnosis codes separated by more than 60 days truly had chronic HCV. Using these algorithms, we identified 5791 HCV cases from January 1, 2013, to June 30, 2014. Among enrollees with HCV, 95% were engaged in HCV care, but only 49% initiated treatment and 43% received a follow-up HCV RNA test 30 or more days after initiating treatment.

CONCLUSIONS

With validated case-finding algorithms, insurance claims data can be used to describe and monitor portions of the HCV care cascade. Although nearly all enrollees with HCV were engaged in HCV care, only half received treatment, indicating that even commercially insured enrollees may find it challenging to access treatment.