Service Integration: accessing HCV treatment for homeless PWIDs/ex-PWIDs attending community OST
Background: Ireland has up to 30,000 HCV patients, of whom just over 3000 have been treated, mostly in hospital-based settings. Approximately 10% of those are actively injecting drugs, so treatment to date has focused on the ‘low transmitters. We present the results of our Shared Care Programme, attempting to link the hospital with the community, a challenge in all settings. We describe initial results and future plans. By developing new models to target ‘high HCV transmitters’ we can meet WHO targets for treatment and elimination by 2030.
Objectives: The Dublin Community/Shared Care HCV Treatment Programme aimed to develop a shared model of care across community and acute hospital settings to facilitate the treatment of HCV positive patients from homeless/substance abuse populations. Our protocol enables ‘hard to reach’ patients to receive Direct Acting Antivirals (DAA’s) alongside their opioid substitution therapy (OST).
Methods: A pilot project of community HCV treatment was implemented, targeting patients who were homeless and with active addiction issues. Exclusion criteria included: co-infection with HIV or Hepatitis B, previous HCV treatment and decompensated liver disease. Patients were pre-assessed with full blood testing and FibroScan evaluation, and had just one hospital located appointment; with all subsequent appointments delivered through their community clinic. DAA consumption was linked to daily supervised OST.
Results: To date 25 have been treated with DAA therapy (M=21, F=4), age range (29-56 years). Genotype distribution (G1a=17, G1b =1, G3=5, G3a=1. G4=1). Side effects included 4 patients requiring ribavirin reductions due to anaemia, 1 experiencing nausea and poor appetite. 2 did not complete treatment, one due to drug addiction issues and the other due to severe personal distress as her children being placed in foster care during her treatment. All patients who had end of treatment bloods have undetectable HCV viral loads.
Conclusion: Despite high levels of substance misuse, with support and regular engagement by our team, patients were cured of HCV. This cohort of patients’ lives often consists of transient lifestyle, moving to different homeless services, and has frequent and repeated incarcerations. Peer support workers continue to engage with this cohort to facilitate attendance. Going forward we are targeting PWIDs who are not engaged in OST or NSP programmes, an even more important group who need linkage to testing, treatment and cure for HCV.