Novel care model may increase HCV testing uptake in vulnerable populations

Hepatitis C testing uptake was high and treatment outcomes were good among patients seen at a homeless outreach service in a primary care center in London, according to a study presented at The Liver Meeting Digital Experience.

“New direct-acting antivirals (DAAs) offer a cure in more than 95% of treated patients and are widely available and free of charge through the U.K.’s National Health Service. However, despite the availability of free and effective treatments, many marginalized patients still face significant barriers in accessing the HCV cascade of care,” Yura Shin, a medical student at University College London in the United Kingdom, said during a virtual poster presentation.

A combination of patient circumstances and these barriers – which can include multiple appointments for diagnostic tests, monitoring and follow-up tests and awaiting referral to a multidisciplinary team for a treatment decision – can place vulnerable patient populations, such as people experiencing homelessness, at risk for “falling through the cracks in the treatment pathway,” Shin said.

“Where primary care and homeless outreach services are co-located, there are opportunities to treat patients early in the care cascade and potential to lower the number of patients lost in the various steps,” Shin said.

Shin and colleagues conducted a retrospective chart review to evaluate the uptake of HCV testing and care outcomes among patients attending a homeless outreach service located in a central London primary care center. They also sought to identify factors that predict effective screening and treatment of HCV. They collected data on age, sex, ethnicity, reported mental health diagnoses, substance use and previous prison sentences as well as analyzed HCV antibody opt-out testing uptake, HCV RNA positivity, and referral and treatment outcomes from all patients seen from 2018 to 2019.

Of 807 patients who attended the outreach service, 90.3% received testing for HCV antibodies. Of these patients, 21.5% were positive and 9.7% were PCR-positive. The majority (88.7%) of viremic patients had no fixed abode, 85.9% reported drug use and 43.7% were recorded as people who inject drugs.

In terms of treatment, 59 of 71 viremic patients were referred for treatment at the time of the analysis. Of these patients, 22 were successfully treated with a DAA and achieved sustained virologic response after 12 weeks of treatment. One had treatment failure, one had not attended an SVR 12 follow-up visit after completion of therapy and nine were receiving ongoing treatment.

Of the other patients, 20 had been approved for but had not yet started treatment and six declined treatment, were lost to follow-up or had died. At the time of analysis, the remaining 12 patients were waiting for treatment approval.

“This model of care with homeless outreach located in primary care service offers a novel model of care with opt-out HCV antibody testing for all attending patients,” Shin said.

This model, Shin noted, not only resulted in high testing uptake, but over a 2-year period, 46.5% of patients had been treated or started therapy with a further 28.2% approved to start therapy. Moreover, of those who completed treatments and had SVR measured at 12 weeks, 95.7% had been cured.

“Therefore, we conclude that testing at-risk patients in primary care settings offers a high yield for uptake and detection of viremia. However, a delay in starting treatments after a positive PCR test may lead to a lost opportunity for a cure,” Shin said. “We suggest that a same-day test-and-treat approach at homeless outreach services in primary care settings for vulnerable patients would potentially increase treatment initiation and cure among vulnerable groups.”