Single-visit hepatitis C testing and linkage to care through a mobile unit
A single-visit hepatitis C testing and linkage program used a mobile unit staffed by a nurse and a navigator/educator to visit locations in Madrid, Spain, where there were people at high risk for hepatitis C (i.e., hot spots). Staff performed a point-of-care (POC) antibody test. If the result was positive, they performed an on-site POC RNA test (the PoC Xpert HCV VL) to confirm if people had an active hepatitis C infection. Those who had an active infection were immediately linked to a hospital to begin hepatitis C treatment if they were interested. Combining screening and confirmatory testing into a single visit resulted in 93% of people with an active hepatitis C infection being seen by a physician in hospital and 77% starting hepatitis C treatment.
A mobile unit (mobile van and satellite car) visited hot spots in Madrid on a predefined schedule and tested people at risk for hepatitis C. The program worked with mobile harm reduction units and visited organizations that provided social assistance, public areas, homeless shelters and places where sex work took place.
A nurse and a navigator/educator staffed the mobile unit. The navigator/educator was a social worker trained in infectious disease screening and had experience working with people who use drugs.
Staff completed hepatitis C screening using the OraQuick HCV Rapid Antibody Test; it took approximately 20 minutes to complete the test and obtain test results. Individuals with negative results received counselling from the navigator/educator on ways to prevent getting hepatitis C. People with a positive result were offered immediate hepatitis C RNA (i.e., confirmatory) testing. The PoC Xpert HCV VL was used for RNA testing; samples were analyzed on the mobile unit and results were available within 60 minutes. The PoC Xpert HCV VL is a piece of equipment that allows for on-site hepatitis C RNA testing and uses a finger-stick blood sample. The PoC Xpert HCV VL is not currently approved for diagnostics in Canada, but it has been used in research contexts. While people waited, they were provided information on hepatitis C prevention and harm reduction.
Hepatitis C treatment in Spain can only be prescribed by specialists in hospitals. People who had a positive hepatitis C confirmatory test result were offered a referral to a hospital the same day. If they accepted, they were transported by car to the hospital, accompanied by the navigator/educator. Once at the hospital, people were examined by a physician who could prescribe hepatitis C treatment the same day. People who started hepatitis C treatment were given an appointment to confirm whether their hepatitis C was cured (i.e., if they attained a sustained virological response [SVR]) 12 weeks after their planned treatment completion date.
If a person with a positive hepatitis C confirmatory test result did not agree to a same-day hospital referral, they were contacted later to try to arrange another time.
An observational study was completed from February 1, 2019, to March 15, 2020. There were 2001 people from at-risk populations screened for hepatitis C during this time. The majority of the participants (68%) were males, 48% were migrants, 58% had no income and 66% were homeless. Of those screened, 43% were people who use drugs and of those, 50% were people who inject drugs (33% of people in the latter group had injected drugs in the previous year).
Of those screened, 380 people (19%) tested positive for hepatitis C antibodies and 136 (7%) had an active hepatitis C infection. Of those who had an active infection:
- 134 (99%) received their hepatitis C screening results
- 133 (98%) had an appointment made at a hospital
- 126 (93%) were seen by a physician once they were at the hospital
- 105 (77%) started hepatitis C treatment
Being over 50 years old and a person who uses drugs was directly associated with active hepatitis C infection. People with recent injection drug use had the lowest rates of attendance at the hospital (89%) and starting hepatitis C treatment (70%).
Although the study was set up to measure linkage to care, SVR (i.e., cure) data were available for 67% (70/105) of the people who started treatment. Of this group, 94% (66/70) were cured of hepatitis C following their treatment.
What does this mean for service providers?
This study showed that a program that integrated screening and confirmatory testing into a single visit through a mobile unit and provided navigation services was successful in diagnosing a large number of people with an active hepatitis C infection and linking them to a physician who could prescribe same-day treatment initiation. The ability to screen and diagnose people with hepatitis C in a single visit has major implications for streamlining the start of hepatitis C treatment. Although the PoC Xpert HCV VL is not currently approved for diagnostic use in Canada, research studies have used it. The study demonstrated that in addition to bringing services to where people are and decreasing the number of visits required to start treatment, use of a navigator may help to increase linkage to hepatitis C care in marginalized populations (e.g., people who use drugs).
Although the focus of the current study was hepatitis C testing and linkage to care, it is important to consider how to continue to engage with the people reached through this type of program to potentially link them to other needed health and social services and to confirm SVR.
Ryan P, Valencia J, Cuevas G et al. Detection of active hepatitis C in a single visit and linkage to care among marginalized people using a mobile unit in Madrid, Spain. International Journal of Drug Policy. 2021;96:103424.