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

Abstract

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 individuallevel 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. (Hepatology Communications 2020;4:646-656).H epatitis C virus (HCV) prevalence is underestimated in underserved populations, including people experiencing homelessness who are at increased risk of HCV infection. (1) According to a recent systematic review of infectious disease prevalence studies, the prevalence of HCV among homeless adults ranges from 9.8% to 52.5%. (2) Among people experiencing homelessness, substance use and mental health disorders are common, and are risk factors for HCV infection. (3,4) Moreover, homelessness has consistently been associated with injection drug use, (5) and engaging in unsafe injection drug-use practices likely drives the high rates of HCV infection documented among this population.

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

“…In an earlier pilot study in homeless centers (67%; [ 12 ]) and in studies from the USA, linkage ranged from 66% for inpatient and 58% for outpatient populations to 23% for people visiting the emergency department. This finding suggests that the guidance provided by the hepatitis ambassadors and hospital staff was successful, thereby supporting earlier recommendations [ 13 , 27 ]. A qualitative study among homeless people in the USA has suggested that a designated HCV coordinator, an incentive for clients to continue follow-up appointments, reduced treatment periods (to a maximum 2 months), education of personnel and HCV-positive patients, and peer support for HCV patients are needed to promote linkage to care [ 27 ].…”

“…A qualitative study among homeless people in the USA has suggested that a designated HCV coordinator, an incentive for clients to continue follow-up appointments, reduced treatment periods (to a maximum 2 months), education of personnel and HCV-positive patients, and peer support for HCV patients are needed to promote linkage to care [ 27 ]. Unstable accommodation in particular is a major barrier for HCV treatment uptake [ 28 , 29 , 30 ], which could be overcome by extending shelter stays for HCV-positive clients [ 27 , 31 ].…”

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

“…Homelessness in itself is also a risk factor for HIV infection [ 26 ]. This could be explained because independent risk factors, such as injection drug use, engaging in unsafe injection drug‐use practices, mental health disorders, and a history of incarceration, are common in this population [ 27 , 28 ]. Our study is in accordance with previous estimates of HIV prevalence among PWUD in Western and Central Europe [ 29 ], and confirms the higher HIV prevalence in homeless PWUD screened and people with a longer drug injection duration.…”

The Extent of Prevailing Stigma Among Hepatitis C Patients in Peshawar Khyber Pukhtunkhwa Pakistan

“…It reduces the quality of sound health and significantly contributes to mortality and morbidity as well. The virus is responsible for transfusion-associated non-A non-B Hepatitis was identified and later named with Hepatitis C (HCV) in 1989 (Fokuo et al 2020).…”