Programming Connection

Project HEAL Hepatitis C screening and linkage to care program 


San Francisco, California, USA
2021

Project HEAL (Hepatitis C Engagement and Accessible Linkage) tested and treated homeless or underhoused individuals who accessed services at a network of community health centres, shelters and harm reduction centres. Using a full-time care coordinator and nurse practitioner, this program successfully engaged marginalized individuals in hepatitis C care. Of the 6,767 people tested, 6.5% were found to have a current infection. Of those, 85% were linked to care. This study suggests that homeless people are more likely to engage in hepatitis C care when it is integrated with services they are already accessing in their community. 

Program description

Project HEAL was launched by the Los Angeles Christian Health Centers, an organization that operates a network of clinics and satellite sites that provide health services to low-income neighbourhoods in the Metro Los Angeles area. Project HEAL was created to provide hepatitis C testing, treatment and care coordination services at 11 sites in underserved communities that serve predominately homeless or underhoused individuals. These sites were linked to other community services such as shelters, harm reduction centres and clinics for people recently released from prison. 

Between October 2016 and March 2019, all eligible people visiting the health centres were provided with one-time testing for hepatitis C on the basis of recommendations from the US Centers for Disease Control and Prevention. Eligibility included being born between 1945 and 1965 and having risk factors for hepatitis C such as substance use. When an individual screened positively for hepatitis C by the testing laboratory, their sample automatically underwent confirmatory testing.

For individuals with confirmed, active hepatitis C, an electronic medical record system sent an automated alert to a full-time care coordinator. The care coordinator contacted each individual who tested positive by phone within three days to set up a medical appointment. If a person was not reachable by phone, the care coordinator sent up to two letters to the address provided by the person (sometimes a post office box or shelter address). The care coordinator also visited local shelters to attempt to connect with individuals who were not reachable by phone or mail.

At the medical appointment, the clinic assessed individuals for treatment eligibility and readiness. They also addressed issues around insurance and provider coverage. Treatment was overseen by a nurse practitioner, who provided treatment work-up such as liver assessment, hepatitis A and B vaccination, and additional blood testing. Clients requiring more complicated treatment courses, such as those with decompensated cirrhosis or co-infection with hepatitis B, were referred to a liver or digestive system specialist outside of the program.

During treatment, the care coordinator contacted clients by phone every two weeks to monitor adherence and assist with refilling prescriptions. They also scheduled appointments to have their viral load tested at four, eight and 12 weeks of treatment. People who did not have a phone were instructed to return to the clinic every two weeks and were given an appointment card indicating a date to return for testing at the end of a treatment. When necessary, clients could pick up medication refills at the clinic during their biweekly visits.  

Results

Testing and linkage to care

Between October 2016 and March 2019, Project HEAL screened 6,767 people from 11 sites, with 11% (769/6,767) testing positive for hepatitis C antibodies. Those who tested positive were primarily male (73%) and either black (34%) or Hispanic (38%).

Of those who tested positive, 58% (443/769) had a confirmed, current hepatitis C infection. Approximately 85% (375/443) of these individuals returned for their laboratory results and were linked to care. Of those who were linked to care, 46% (173/375) were previously unaware of their hepatitis C status.

Treatment

The treatment program ran from March 2017 until March 2019, with 59 clients starting treatment. Of those who started treatment, 90% had previously not undergone hepatitis C treatment. Thirty-nine percent had previously used injection drugs (none used drugs during the study). Of those who started treatment, 95% (56/59) completed treatment; one person discontinued treatment and two others were lost to follow-up.

Among the clients who completed treatment, 49 were confirmed to be cured following treatment. Seven people were lost to follow-up before post-treatment cure was confirmed, although they all showed viral suppression throughout the duration of treatment.

There was a relatively large difference between the number of people who were linked to care and the number who started treatment (only 59 of the 375 who were linked to care started treatment). The authors attributed this difference to limitations in the number of providers trained in hepatitis C treatment and issues around eligibility for treatment coverage through Medicaid.

What does this mean for service providers?

This study shows that community-based hepatitis C care is effective to engage and cure homeless or underhoused populations. Key to this success was a full-time care coordinator who was able to successfully engage individuals and support them throughout treatment. Many homeless or underhoused individuals may not be readily reachable by phone or mail, so additional outreach at community sites, like shelters, is important.

Integrating hepatitis C care with harm reduction, community health and shelter services is also effective. Marginalized individuals at high risk of hepatitis C are often not engaged in the healthcare system and might not otherwise be reached. Integrating hepatitis C care can increase convenience and decrease the stigma individuals face in other healthcare settings. Widespread screening was also important, as many clients were not aware of their hepatitis C status and may not otherwise have chosen to be tested.

Despite this, a relatively low number of people began treatment in this study (59 of the 375 people who were linked to care). This was partly due to a lack of providers trained in hepatitis C treatment. However, solutions such as sharing providers between sites and increasing the number of nonspecialist providers (e.g., nurse practitioners) being trained in hepatitis C treatment may help change this.

Additionally, the low number of people who began treatment was due to public insurance only covering those with advanced liver damage. However, since this study took place, many regions are easing restrictions, opening up eligibility for more individuals to be treated. In Canada, treatment is now covered through public health insurance plans for most people.

Related resources

Check Hep C – evidence brief

Linkage to hepatitis C care using a nurse navigator at the University of Virginia Infectious Diseases Hepatitis C Clinic – evidence brief

Ahtahkakoop Know Your Status Hepatitis C Program – case study

Peer outreach point-of-care testing for hepatitis C – evidence brief

Reference

Benitaz T, Fernando S, Amini C et al. Geographically focused collocated hepatitis C screening and treatment in Los Angeles’s Skid Row. Digestive Diseases and Sciences. 2020;65:3023–3031.