If you’re homeless and have no symptoms, testing for hep C is probably low on the list of priorities. Aaron considered himself pretty clued in about blood-borne virus risk; he’d been injecting drugs for many years and was an expert in technique, always using clean equipment.
He was keen to go on treatment straight away and was indeed referred immediately to get started.
Viral Hepatitis Nurse, Lucy Ralton said Aaron later told her that he had seen his GP due to persistent fatigue but hadn’t been screened for an HCV infection at the time. “He was very glad he got talked into having a test that day and said he only did so because he was asked,” she said.
The testing clinic at the Hutt Street Centre was part of the PROMPt study where a nurse and a Hepatitis SA peer worker together and directly approach individuals to invite them to have a test. Anyone with a positive result was referred to the community Viral Hepatitis Nurses for treatment.
What programs like this has shown is the importance of connections and support for community and health workers who provide services to clients who are homeless and at risk of hepatitis C.
Rates of hepatitis C prevalence are higher in people who are homeless compared to the general population. Studies, including a recent South Australian study, have found that frequent injecting drug use and hepatitis C prevalence are associated with homelessness.
Knowing that they can contact a local organisation … and get all the information they need … will empower them to … be part of the effort to eliminate hepatitis C…
Despite this, Nurse Ralton said, many of those working with people who are homeless may not be aware of how easy and effective hepatitis C treatment is or of the benefits to the client and where to turn for information and support.
“Health workers often have key relationships with clients who are homeless and at risk of hepatitis C. They are ideally placed to encourage individuals to get tested and to support them during treatment.
“Knowing that they can contact a local organisation such as Hepatitis SA and get all the information they need including local specialist service contact details will empower them to see that they can be part of the effort to eliminate hepatitis C and improve the health of their clients.”
She explained that there is a clear association between homelessness and hepatitis C risk factors such as injecting drug use. “Given the overlap between homelessness and injecting drug use, homelessness services will inevitably find that many of their clients have or are at risk of acquiring hepatitis C and they may not know what to do,” she said.
“Studies have found that people who are homeless face many barriers to hepatitis C testing and treatment including not knowing what support exists, incarceration, ineffective healthcare communication methods (including the referral process and telephone coordination) and difficulty keeping appointments.
“Drug misuse is a factor that can lead to homelessness, however homelessness can also cause drug misuse or worsen an existing problem.
“Scaling up hepatitis C prevention, screening and treatment to address hepatitis C transmission among the homeless within existing community-based services and primary care is a priority if Australia is to realise the goal of eliminating hepatitis C by 2030.”
One way to improve access to hepatitis C care for this vulnerable group, is to bring together different services to explore ways of working together to make the process as simple as possible for both service providers and clients.
New models of care that integrate peers and healthcare workers have demonstrated that community-based screening, point of care testing and on the spot prescribing by either a nurse practitioner or GP in a non-judgmental and friendly environment can improve screening and treatment uptake. PROMPt – the project which helped Aaron get cured of his hepatitis C – was one example of such a model.
C the Whole Story was an online forum hosted by ASHM to discuss this challenge to provide participants with the tools, contacts and confidence to be able to discuss HCV screening and treatment with their clients, as well as create the opportunity for people to connect and explore ways for services to work together. To enquire about forum recordings or similar upcoming events, contact ASHM at ashm@ashm.org.au.
*Name changed to protect privacy
]]>Opioid substitution treatment (OST) clinics are considered ideal locations for providing treatment for people with chronic hepatitis C virus infection who inject drugs, a vital priority group for achieving the goal of HCV elimination. But despite the availability of highly effective treatments with relatively few side effects, treatment uptake is yet to reach the level needed to achieve elimination.
Research led by Heidi Coupland, of Drug Health Services in the Sydney Local Health District, explored competing priorities among clients, clinic staff and policy makers, and the resulting barriers to beginning HCV treatment in OSTs.
Coupland’s team conducted in-depth interviews with clients and staff from two hospital-based opioid substitution treatment clinics in Sydney. The interviews were then thematically and rigorously analysed.
For the majority of clients—more than three quarters—HCV treatment was not a priority and many preferred to postpone treatment. Work and family obligations, health problems, focusing on drug treatment issues, and perceptions that HCV was an additional and unwanted commitment and responsibility, shaped clients’ decision-making. “I’ll have hep C treatment eventually,” was the overall theme.
Clients also identified concerns about side-effects and the barriers posed by the multiple steps involved in pre-treatment testing and getting scripts filled. Many clients (69%) reported that clinic staff strongly encouraged them to commence treatment, and they perceived staff to have a clear agenda during their interactions.
OST clinics are required to harness considerable resources to make testing and treatment more accessible for clients, given their existing staff capacity and both institutional and prescribing-related barriers. Data gathered from the interviews highlighted the need for adequate staff and appropriate record-keeping systems for capturing and storing relevant tracking data to facilitate client linkage to treatment, and for reporting progress.
The study found that eliminating HCV in Australia’’s resource-constrained OST settings requires a marked reorientation of the available resources. Given the disparities between the priorities of clients and staff regarding treatment uptake, real challenges persist in maintaining client-centred service provision for a population with multiple health and social needs.
With liberal access to direct acting antivirals in Australia, and recommendations for all people living with HCV to be treated, most people accessing clinical services should be treated. A study led by Rosie Gilliver of the Kirketon Road Centre in Sydney’s Kings Cross describes a cohort of individuals aware of their HCV diagnosis but who have yet to initiate treatment despite its recommendation.
The results showed that clients receiving Opioid Substitution Treatment were no more likely to initiate treatment than those not receiving OST: 81% versus 77%. Those experiencing homelessness were significantly less likely to initiate treatment than those who were not homeless: 78% versus 89%. Those reporting recent injecting drug use were equally likely to initiate treatment as those reporting no recent use: 73% versus 69%.
Every Kirketon Road Centre client with detectable HCV RNA who was worked up for DAA therapy between March 2016 and March 2019 was included in the study, though clients known to have been treated at another service were excluded. Demographic, behavioural, attendance and clinical variables were factored into the results. Clients known to the service for less than a month prior to their HCV assessment were considered existing clients.
During the 3-year timeframe, 456 individuals were diagnosed and assessed for DAA treatment. Of these, 328 individuals commenced DAAs at Kirketon Road, with 128 clients remaining untreated. Overall treatment uptake was therefore 72%.
No other demographic factors, including gender, Aboriginality, or other variables such as attendance at outreach or main site locations or duration of relationship with the service were significantly associated with lower treatment uptake.
So, homelessness was shown to be the most notable factor in affecting the client’s going onto treatment. But it’s important to note that those clients who are housed and who attend Kirketon Road are still often highly socially disadvantaged, and it is clearly important that someone’s current housing status does not lead to an assumption of likely engagement in care.
Despite high overall treatment uptake, a significant proportion of clients remain untreated. Many still attend the service, but have not commenced treatment despite it being offered. Significant social instability compromised Kirketon Road’s capacity to work up and initiate treatment with these clients.
]]>