The HepCare peer intervention project: morbidity, mortality and linkage to care in a homeless population at risk of hepatitis C

Background:

Homeless populations are at high risk of unsafe injecting, leading to a higher risk of HCV infection, and re-infection, skin and soft tissue infections, and accidental drug overdose (ref). High rates of alcohol consumption increase the risk of liver disease, cirrhosis and death. This pattern of multiple morbidities reinforces the adverse health consequences of social exclusion. ? Treating homeless populations for HCV is possible if services reach-out into the community however morbidity and mortality can remain disproportionately high compared with the general population. We studied the morbidity and mortality rates of homeless and underserved individuals infected with HCV. We then used peer support workers to link individuals into care and HCV treatment.

Methods: The HepCare project, co-funded by the European Commission, outreaches HCV screening to at-risk underserved populations. In London, we worked alongside the Find&Treat team’s mobile health unit, using HCV point-of-care tests and a portable Fibroscan to determine liver fibrosis, to individuals accessing homeless and drug services. Peer support workers were trained alongside the clinical team to screen individuals and improve linkage to care with incentives and accompanied appointments. Chronically infected HCV individuals and those with severe fibrosis or cirrhosis were referred and supported into specialist care. Information was gathered on demographics and risk factors, plus linkage to care, treatment outcomes, SVR and all-cause mortality

Results: Over 20 months 461 individuals attending homeless or drug services in London were screened, the majority (78.7%) were male; the median age was 45.7 years (IQR 39-52); most were UK born (76.6%) and a total of 197 people (42.7%) were found to be chronically infected with HCV. Drug use was common with 329 (71.4%) having ever injected and 125 (27.1%) currently injecting. Problem alcohol use was high with a third (33.6%) consuming more than 50 units per week. Fibroscan was carried out on 283 individuals and over 1 in 4 (22.7%) had advanced fibrosis or liver cirrhosis (>F3). We found that the age-standardised all-cause mortality rate for our cohort was much higher than the general population (SMR 3.8, 95% CI 1.8 – 8). Of the 197 with chronic HCV all received peer support with 104 (52.8%) individuals successfully engaged with treatment centres. Of these 89 (85.6%) started treatment and 76 (85.4%) had a favourable outcome. Factors associated with not being approved for treatment were recent homelessness, younger age, current crack cocaine injecting.

Conclusions: There is a high burden of morbidity and mortality in this group compared with the general population. It is also likely that the above estimate is conservative as follow-up data was not available to all screened individuals. Peer support workers achieved high rates of engagement with treatment services and treatment completion amongst a population with complex needs. Strategies to improve health in PWEH, who are one of the most marginalised groups in society, will help to reduce health inequalities in society. However, HCV elimination strategies may concentrate on eliminating the pathogen and not address the other health and behavioural causes of adverse health events of a marginalised population.