Despite high rates of hepatitis C virus (HCV) infection among people who use street drugs, access to treatment for HCV is very low for this population. Studies in Canada and the U.S. have shown that less than 1% of people with HCV who inject drugs access treatment.
A number of barriers to HCV treatment have been documented for people who use drugs, including a lack of knowledge about HCV infection and its impact on health, past negative experiences with healthcare providers, competing issues such as unstable housing or other health problems, and specialists who are not willing to treat people who use drugs.
In order to address barriers to HCV treatment for people who use drugs, the Toronto Community Hepatitis C Program (TCHCP) has developed a low-barrier community-based multidisciplinary team model for providing HCV care. Previous research on this program demonstrated cure rates for HCV treatment among the program’s clients that were similar to those seen in people in clinical trials.
The current study goes beyond HCV cure rates to examine the impact of TCHCP on clients’ physical and mental health, substance use, housing, income supports and access to healthcare. It found that access to housing, income supports and healthcare improved over the course of the study. There was no change in participants’ perception of their overall health.
The TCHCP
TCHCP consists of multidisciplinary teams based in three primary healthcare settings that receive support from hospital-based medical specialists who offer appointments onsite. The program provides low-barrier HCV treatment and support to people who use drugs or have mental health issues, or both.
The anchor of the program is a two-hour weekly support group meeting. Each support group cycle lasts 16 to 18 weeks and people can participate in multiple cycles.
This support group is designed to be a low-barrier way for people who may avoid healthcare due to stigma and discrimination to be linked to HCV care and treatment. This group is the base through which they are connected to HCV nurses, doctors and specialists.
To encourage access to the group, participants receive a meal during the meeting as well as transit fare and an honorarium. During the support group, people receive and share information about HCV and how to take care of their health.
Appointments with HCV nurses, doctors and specialists take place while the group meets, allowing for easier access to these healthcare providers. Outside of the group, participants can also receive case management, counselling and further peer support.
Abstinence from drugs and alcohol or participation in an opiate substitution program or addiction treatment program is not a requirement for joining the program.
About the study
The goal of the study was to evaluate the health and psychosocial outcomes of TCHCP participants over time.
Starting in 2011, all new participants in the program were invited to join the study. Participants were interviewed at three time points: upon joining the program, at the end of the first support group cycle they attended, and one year after they finished their first support group cycle. This study is ongoing and will end in 2016, when the last group finishes its one-year anniversary interviews.
Interviews consist of standardized questionnaires that measure overall health status, physical and mental health, drug and/or alcohol use and healthcare utilization. Questions are also asked about housing, income and history of incarceration.
Results—A highly marginalized population
There were 78 participants in the study. Three participants died during the study (for reasons unrelated to the study), 13 participants did not complete the study and four participants withdrew.
Participants in the study were a highly marginalized group:
- 85% reported a history of incarceration, with an average of six years spent in prison
- 82% relied on social assistance as their primary income
- 49% were living in unstable housing, such as a shelter, motel, rooming house or public place
- 49% had an elementary school education or less
- 71% reported a history of physical abuse
- 46% reported a history of sexual abuse
Many participants also had medical issues other than HCV infection, including the following:
- 78% reported at least one additional chronic health problem
- 58% reported anxiety in the past month
- 45% reported depression in the past month
- 41% reported having been in the hospital for a mental health issue
- 4% reported having HIV
The majority of participants (nearly 90%) had a history of injecting street drugs; 11 had injected drugs in the past month. Half of the participants also used crack cocaine (non-injection) in the past six months and 68% used alcohol in the same time period.
Access to HCV care improved
Prior to starting the program, the majority of participants (85%) had a primary care doctor, however, only 15% had seen an HCV specialist. After one year of follow up, access to an HCV specialist had significantly increased, with 54% of participants seeing a specialist. Additionally, almost all participants (93%) also had a visit with the program’s HCV primary care doctor and all participants had seen an HCV treatment nurse.
By the end of the study period, participants had also received HCV assessments and related care, including:
- 95% had lab tests of their blood samples
- 77% received an ultrasound of the liver
- 58% had an assessment of liver injury
- 86% received vaccinations against hepatitis A and B viruses
Prior to the study, only 4% of participants had previously started HCV treatment. After one year of monitoring, 19% (15 people) had started treatment and 12% (nine people) had completed treatment. Thirteen participants wished to start treatment but did not meet the criteria for government funding for treatment, and 10 participants reported the need to address other health issues as the main reason for not starting HCV treatment.
Access to housing and income improved
Access to housing and income supports improved significantly for participants during the study.
At the beginning of the study, 54% of participants reported stable housing, and this increased to 76% by the end of the study period.
Similarly, the number of participants receiving provincial government disability benefits increased from 55% at the beginning of the study to 75% at the end.
Accessing disability supports was considered the marker of income improvement because these benefits are higher than other social benefit programs in Ontario. Several medical assessments are necessary to be approved for benefits and the team supports people to get these assessments done.
Housing and income have been shown to be linked to better health outcomes and improved use of healthcare.
No changes in overall health
Just over half of the participants reported their overall health as poor or fair at the beginning of the study, and this did not change over the study period.
The researchers theorized that this might be because the majority of participants were dealing with major health challenges and a high degree of marginalization in their lives. Therefore, a positive shift in self-perceived health may not occur until a longer period has elapsed.
Limitations
One limitation of this study was its small sample size; however, it represents the largest sample in a prospective study (a study that follows people over time) of highly marginalized people with HCV who use drugs and receive support in a primary healthcare setting.
As well, the program used a holistic approach, and participants could have been impacted by a number of interventions. The study wasn’t designed to determine which interventions were responsible for which outcomes, making interpretation of results more difficult.
Finally, participants may have received healthcare services or support from outside of the program and it was not possible to control for the effect of this support.
Conclusions
TCHCP was able to improve access to housing, income supports and HCV-related healthcare for people who are highly marginalized and offer support in these and other areas prior to starting HCV treatment.
Furthermore, these improvements in care, treatment and support lay the groundwork for improvements in health beyond HCV.
The results of the TCHCP study provide evidence for organizations that serve highly marginalized people with HCV who use drugs that this type of program can improve key factors that affect health for this population.
Resources
Toronto Community Hep C Program Guide Book
—Scott Anderson
References
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