Community Screening, Identification, and Referral to Primary Care, for Hepatitis C, B, and HIV Among Homeless Persons in Los Angeles

HBV and HCV testing outcomes among marginalized communities in Italy, 2019-2024: a prospective study

BACKGROUND

The health of the marginalized populations is crucial for public health and inequalities. The World Health Organization (WHO) Global Hepatitis Report 2024 stated that over 304 million people were living with Hepatitis B Virus (HBV)/Hepatitis C Virus (HCV) infection in 2022. We performed HBV/HCV screenings among marginalized communities to reveal hidden infections and link-to-care positive participants.

METHODS

From January 2019 to May 2024, finger-prick tests were used to conduct on-site screenings at non-profit organizations in Tuscany, Italy. Positive participants were referred to the closest outpatient clinic.

FINDINGS

Eighty/1812 (4.4%) participants were Hepatitis B surface Antigen (HBsAg)+, mostly men (p < 0.001) and non-Italian natives compared to those HBsAg- (p < 0.001). Fifty-two/1812 (2.9%) were anti-HCV+ with a higher proportion of Italians (p < 0.001) and lower education level (p < 0.01) compared to the anti-HCV-. Intravenous drug use was an independent factor for being anti-HCV+ (p < 0.0001). Among the HBsAg + individuals, 66.3% (53/80) were linked and 90.4% (48/53) retained in care (treated/monitored). Of the anti-HCV participants requiring clinical evaluation, 37.8% (14/37) were linked to care, and all the 11/14 (88.6%) viremic patients were successfully treated.

INTERPRETATION

We found higher HBV/HCV positivity compared to national prevalences. Participation and linkage to care were successful. The young mean age (33.6 yrs) of HBsAg + individuals, primarily from regions with low vaccinal adherence, indicated geographical origin as a key risk factor. HCV positivity was associated with extreme marginality. The results stress the need to implement marginalized groups screening to target HBV/HCV hidden infections, reducing disparities in healthcare and advancing towards the WHO 2030 elimination goal.

FUNDING

Gilead Sciences; Fondazione Cassa di Risparmio di Pistoia e Pescia; Regione Toscana.

Global elimination of HBV: Is it really achievable?

Hepatitis B virus (HBV) infection is a major cause of premature death worldwide. In 2016, the World Health Organization (WHO) called for HBV elimination and set up very ambitious elimination targets. The development of effective vaccines, accurate diagnostic tools and safe antiviral drugs make HBV elimination a realistic goal. However, the most constrained-resource regions, which bear the highest burden of HBV, are facing major challenges in implementing strategies to reduce HBV incidence and mortality. Developing simplified approaches adapted to resource-limited settings and scaling up interventions for the prevention and control of HBV globally are urgently needed. Whether HBV elimination will be achieved in an equitable manner and in a reasonable timeframe remains highly uncertain.

Assessing the Feasibility, Acceptability, and Effectiveness of a Pilot Hepatitis C Screening Program at Food Distribution Sites in Cherokee Nation, Oklahoma

Compared with other racial and ethnic groups in the United States, American Indian and Alaska Native (AI/AN) people experience the highest incidence of acute hepatitis c (HCV). Cherokee Nation Health Services (CNHS) implemented a pilot health screening program from January through May 2019 to assess whether conducting HCV and other preventive health screenings at food distribution sites is a feasible, acceptable, and effective strategy to increase health screening among underserved community members. Data were collected among 340 eligible participants. Most (76%) participants reported being very comfortable receiving health screenings at food distribution sites and that getting screened at food distribution sites is very easy (75.4%). Most (92.1%, n = 313) participants received HCV screening, with 11 (3.5%) individuals testing positive for HCV antibodies. Of the 11 HCV seropositive individuals, six were confirmed to have active HCV infection of which four initiated treatment. Most (55.7%) participants exhibited a body mass index in the obese range, 33.1% exhibited high hemoglobin A1C (> 6.0), 24.5% exhibited high (> 200) cholesterol, 44.6% exhibited high blood pressure ( > = 140/90), and 54.8% did not have a current primary care provider. This project demonstrated that conducting HCV and other health screenings at food distribution sites within Cherokee Nation was an effective strategy to engage AI/AN people in preventive health screenings. Future programs are needed to scale-up preventive health screenings outside of traditional medical facilities as these types of screenings may help to decrease the HCV disparities among AI/AN people.

Pharmacist-Led Implementation of Brief Tobacco Cessation Interventions during Mobile Health Access Events

To address gaps in care for individuals from under-resourced communities disproportionately affected by tobacco use, this pharmacist-led demonstration project evaluated the feasibility of implementing tobacco use screening and brief cessation interventions during mobile health access events. A brief tobacco use survey was administered verbally during events at two food pantries and one homeless shelter in Indiana to assess the interest and potential demand for tobacco cessation assistance. Individuals currently using tobacco were advised to quit, assessed for their readiness to quit, and, if interested, offered a tobacco quitline card. Data were logged prospectively, analyzed using descriptive statistics, and group differences were assessed by site type (pantry versus shelter). Across 11 events (7 at food pantries and 4 at the homeless shelter), 639 individuals were assessed for tobacco use (n = 552 at food pantries; n = 87 at the homeless shelter). Among these, 189 self-reported current use (29.6%); 23.7% at food pantries, and 66.7% at the homeless shelter (p < 0.0001). About half indicated readiness to quit within 2 months; of these, 9 out of 10 accepted a tobacco quitline card. The results suggest that pharmacist-led health events at sites serving populations that are under-resourced afford unique opportunities to interface with and provide brief interventions for people who use tobacco.

Care and Complexity in Emergency Housing: an Examination of the COVID-19 Shelter-in-Place (SIP) Hotel Program to House People Experiencing Homelessness in San Francisco

In this study, we consider the patient, provider, and public health repercussions of San Francisco's (SF) COVID-related response to homelessness using tourist hotels to house people experiencing homelessness (PEH). We describe the demographics, medical comorbidities, and healthcare utilization patterns of a subset of PEH who accessed the shelter-in-place (SIP) hotel sites during the 2020-2021 pandemic. We focus on how SIP hotels impacted connection to outpatient care and higher-cost emergency utilization. Our mixed methods study integrates qualitative and quantitative data to consider the impact of this temporary housing initiative among a medically complex cohort in a time of increased morbidity and mortality related to substance use. We found that temporary SIP housing increased outpatient care and reduced higher-cost hospital utilization. Our results can inform the future design and implementation of integrated supportive housing models to reduce mortality and promote wellness for PEH.

A qualitative investigation of the barriers and facilitators to Hepatitis C virus (HCV) screening among individuals experiencing homelessness in Houston, Texas

BACKGROUND

Individuals experiencing homelessness may be at a higher risk for hepatitis C infection because many are vulnerable to risk factors related to HCV. Screening is the very first step in the HCV care continuum, but it remains unclear how to improve HCV screening among this hard-to-reach population. Thus, the present study investigated the barriers and facilitators to HCV screening from the perspective of individuals experiencing homelessness within a non-residential social service setting.

METHODS

Individuals experiencing homelessness (aged 18+) were approached while they were seeking services at two community-based organizations in Houston, Texas, during August 2020. Participants (N = 31) completed an interviewer-administered demographic survey and a semi-structured interview about their experiences with healthcare, homelessness, and HCV screening. Following transcript coding and content analysis, a thematic analysis was conducted to identify HCV screening barriers and facilitators discussed by participants.

RESULTS

Participants were predominantly male (n = 25, 80.6%), and almost 40% of participants had no form of medical insurance. Participants identified the following as barriers to HCV screening: mistrust of the healthcare system and professionals and lack of knowledge of HCV prevention, harm reduction, and complications. Participants identified the following as facilitators to HCV screening: providing incentives and increasing access and convenience to HCV screening.

CONCLUSION

Community-based HCV screening programs may wish to account for the lived experiences of individuals experiencing homelessness in order to minimize barriers to screening. Client-centered strategies that reduce wait times and incentivize participation should be considered to eliminate barriers and increase convenience for this high-risk population.

A qualitative investigation of organizational challenges and facilitators to screening individuals experiencing homelessness for hepatitis C virus (HCV) in Houston, Texas

Background

Individuals experiencing homelessness may be at a disproportionately high risk for hepatitis C (HCV) because they may be more likely to engage in HCV risk behaviors. Community organizations that provide services to these vulnerable individuals can effectively screen, diagnose, and navigate them into HCV care. However, screening people experiencing homelessness for HCV at such organizations is limited by various challenges that remain understudied, including budgetary considerations and strategies to improve teamwork and communication. Accordingly, this study investigated the organizational challenges and facilitators to HCV screening of individuals experiencing homelessness as reported by homeless services providers.

Methods

Staff (N = 21) at two community organizations in Houston, Texas, completed an interviewer-administered survey and a semi-structured interview in August 2020 to assess the challenges and facilitators to screening people experiencing homelessness for HCV. Interviews were coded, and a thematic analysis was conducted to identify challenges as well as facilitators to HCV screening among individuals experiencing homelessness.

Results

Almost half of participants were employed in social services (42.86%; n = 9), while the remainder were employed in management/administration and health services. Barriers to HCV screening included funding, logistics, and resource-related challenges; and limited communication and collaboration around HCV screening. Facilitators to HCV screening included providing HCV education and training for all staff; and incentivizing, formalizing, and funding HCV screening.

Conclusions

Community organizations can help minimize barriers to HCV screening among individuals experiencing homelessness by providing staff with training specific to HCV, client education around HCV and the screening process, and providing clients with incentives for participation, as well as by maximizing community and clinic partnerships to provide linkage to care and services to this high-risk population.

Viral blood-borne infections testing and linkage to care cascade among persons who experience homelessness in the United States: a systematic review and meta-analysis

BACKGROUND

Persons who experience homelessness remain at increased risk for three viral blood-borne infections: human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). We assessed the yield of testing and linkage to care programs targeting this population for these infections in the United States (US).

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Central for peer-reviewed articles through August 27, 2020. Additionally, we searched the grey literature. Two individuals independently reviewed all relevant studies to check for eligibility and extracted data for each step in the care cascade. We used random-effects model to generate weighted pooled proportions to assess yield at each step. Cumulative proportions were calculated as products of adjacent-step pooled proportions. We quantitatively synthesized data from the studies that focused on non-drug injecting individuals.

RESULTS

We identified 24 studies published between 1996-2019 conducted in 19 US states. Seventeen studies screened for HIV, 12 for HCV, and two screened for HBV. For HIV, 72% of approached were recruited, 64% had valid results, 4% tested positive, 2% were given results, and 1% were referred and attended follow-up. Of positives, 25% were referred to treatment and started care. For HCV, 69% of approached were recruited, 63% had valid results, 16% tested positive, 14% were given results, and 3% attended follow-up. Of positives, 30% were referred for treatment and 19% started care. The yield at each care cascade step differs widely by recruitment strategy (for example, for HIV: 71.6% recruited of reached under service-based with zero yield under healthcare facility-based and outreach).

CONCLUSIONS

A very large proportion of this population reached for HIV and HCV care were lost in the follow-up steps and never received treatment. Future programs should examine drop-out reasons and intervene to reduce health disparities in this population.

Formal Hepatitis C education increases willingness to receive therapy in an onsite shelter-based HCV model of care in persons experiencing homelessness

Background

To evaluate the effectiveness of formal Hepatitis C (HCV) education on engagement in therapy in persons experiencing homelessness in an onsite shelter-based model of care. As policies to eliminate Medicaid access restrictions to HCV treatment are expanded, patient education is paramount to achieving HCV elimination targets in difficult to engage populations including persons experiencing homelessness.

Methods

This prospective study was conducted at four shelters in San Francisco and Minneapolis from August 2018 to January 2021. Of the 162 HCV Ab positive participants, 150 participated in a 30-minute HCV education session. Post-education changes in knowledge, beliefs, barriers to care and willingness to accept therapy scores were assessed.

Results

Following education, knowledge scores (mean change 4.4 ± 4.4, p&lt;0.001) and willingness to accept therapy (70% to 86% p=0.0002) increased. Perceived barriers to HCV care decreased (mean change -0.8 ± 5.2 p=0.001). Higher baseline knowledge was associated with lesser gain in knowledge following education (coef. -0.7, p&lt;0.001). Post-education knowledge (OR 1.2, p=0.008) was associated with willingness to accept therapy.

Conclusions

An HCV educational intervention successfully increased willingness to engage in HCV therapy in persons experiencing homelessness in an onsite shelter-based HCV model of care.

Hepatitis C in homeless people: reaching a hard-to-reach population

OBJECTIVE

the aim of this study was to analyze the process of detection and treatment of hepatitis C in individuals experiencing homelessness (IEH).

METHODS

an analytical cross-sectional study was performed in a Primary Care center. The center screened and registered patients with a positive hepatitis C antibody test and referred them to the Digestive Service.

RESULTS

finally, 8.3 % presented with a positive HCV antibody test, of which six were patients who had already received treatment. Of those who had not received treatment, one patient was successfully treated; 30.8 % of the total could not be located or did not wish to participate.

CONCLUSION

community coordination and the use of rapid tests would improve detection.

Human Immunodeficiency Virus and Hepatitis C Linkage-to-Care Initiative for New Orleans Residents Experiencing Homelessness During the COVID-19 Pandemic

BACKGROUND

People experiencing homelessness are disproportionately infected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). In response to COVID-19, cities nationwide temporarily housed people experiencing homelessness in unused hotels. One such initiative in New Orleans also enacted a screening, counseling, and linkage-to-care model for HIV and HCV treatment for this temporarily housed population between May and July 2020.

METHODS

A nonconcurrent cohort study was performed assessing follow up in the treatment of HIV and HCV for this population. Outcome data were collected on seropositive patients' electronic medical record to assess patient progression through the treatment cascade.

RESULTS

Of 102 unhoused residents, 25 (24.5%) tested HCV seropositive. Of the HCV positive 21/25 (84%) were connected to the associated clinic for follow up care and 10 (40%) obtained HCV treatment medication. Furthermore, all 3 patients who tested seropositive for HIV either started or re-initiated antiviral treatment. The greatest barrier to providing medication for the HCV seropositive patients, once care was initiated, was loss-to-follow-up.

CONCLUSIONS

Targeting homeless persons living in temporary residences for HCV and HIV screening can be effective at promoting access to care for those infected due to this population's high HCV seropositivity especially significant if the patient has a history of intravenous drug use or is older than 40 years. However, continued outreach strategies are needed to assist patients in retention of care.

Vaccine-preventable diseases other than tuberculosis, and homelessness: A scoping review of the published literature, 1980 to 2020

BACKGROUND

Homelessness may result in the breakdown of regular health services, including routine vaccination programmes. A scoping review was conducted to describe vaccine-preventable diseases (VPD) other than tuberculosis in people experiencing homelessness (PEH).

METHODS

We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We searched peer-reviewed literature published in English, French, Spanish or Portuguese reporting the outbreak of VPD or VPD prevalence in both infant and adult homeless populations published between 1980 and 2020, using PubMed/Medline, SciELO, Google Scholar, and Web of Science databases. Relevant information from the studies was charted in Microsoft Excel and results were summarised using a descriptive analytical method.

RESULTS

Eighty-one articles were included. A high prevalence of past hepatitis B virus (HBV) and hepatitis A virus (HAV) infections were observed through serosurveys, mostly in high income countries or high-middle income countries (USA, Canada, France, Iran or Brazil). Ten outbreaks of HAV infection were also reported, with lethality rates ranging from 0 to 4.8%. The studies identified numerous risk factors positively associated with HBV infection, including older age, homosexual or bisexual practice, injected drug use (IDU), and, with HAV infection including IDU, having sexual partner(s) with a history of unspecified hepatitis, insertive anal penetration, or originating from a country with a high prevalence of anti-HAV antibody. Eleven outbreaks of pneumococcal infection affecting PEH were reported in Canada and USA, with lethality rates from 0 to 15.6%. Six diphtheria outbreaks were reported. Vaccination status was rarely documented in these studies.

CONCLUSIONS

The literature suggests that homeless populations generally experience a high VPD burden suggesting the need for a national vaccination programme and planning for delivering vaccines in this population.

Identifying Missed Opportunities for Routine Vaccination among People Who Use Drugs

In the US, adult immunization coverage remains low, especially among vulnerable populations, as recent hepatitis A outbreaks have demonstrated. We studied the vaccination history variation among the US adults who use drugs by implementing a community-engaged research survey to identify reported immunization coverage, missed opportunities (MO), and places where immunizations might be delivered. Our analysis of a sample of 1127 participants recruited at community syringe exchanges in three cities identified higher overall vaccination receipt in Los Angeles compared to Atlanta or Las Vegas (e.g., HAV receipt 52.2% LA, 42.1% LV, 41.4% Atlanta). Overall, fewer participants reported having received HAV (45.9%), HBV (47.5%), or influenza (47.6%) vaccines than MMR (57.1%) or Td/Tdap (61.1%). Across sites, HAV receipt was higher for participants incarcerated ≥ 5 years (54.2% vs. 43.6% for those incarcerated < 5 years, 49.4% no incarceration history, p = 0.02). HBV receipt was higher among participants who were not intravenous drug users (56.1% vs. 46.0%, p = 0.03). Additionally, income >$20k predicted higher rates of MMR receipt (67.0% vs. 56.5%, p = 0.009), as did stable housing (62.8% vs. 54.3%, p = 0.01). To address the need to expand vaccine coverage among vulnerable adults, delivering vaccine at sites where persons who use drugs access services, or in correctional facilities, may be warranted.

Epidemiological serosurvey and molecular characterization of sexually transmitted infections among 1890 sheltered homeless people in Marseille: Cross-sectional one day-surveys (2000-2015)

OBJECTIVES

We observed the prevalence and distribution of potential risk factors for sexually transmitted infections (STIs) among Marseille homeless population.

METHODS

Over the 2000-2015 period, we enrolled 1890 sheltered homeless adults and collected serum samples. Markers of hepatitis B and C viruses (HBV, HCV) and Treponema pallidum were searched using the CMIA testing. Positive HBsAg or anti-HCV samples underwent sequencing; positive anti-T. pallidum sera were subjected to the RPR test.

RESULTS

The overall prevalence of HBsAg, anti-HBs, anti-HBc, anti-HCV and anti-T. pallidum (by CMIA and RPR) was 4.1%, 22.9%, 35.5%, 5.3% and (6.8%, 1.0%), respectively. We found a significantly higher prevalence of HBsAg and anti-T. pallidum among individuals born in sub-Saharan Africa (or Asia) compared to those born in Europe. Being older (>42 years), toxicomania status, cannabis use and underweight status (compared to normal status) were independent factors associated with HCV seropositivity. Using sequencing, we obtained a substantial diversity of HBV and HCV genotypes. One HCV sequence harbouring a L31M substitution in the NS5a protein may be associated with reduced drug sensitivity.

CONCLUSIONS

The positive relationship between toxicomania and HCV suggests the need for effective prevention programmes including health education activities and addiction treatment.

Clients' perceptions of barriers and facilitators to implementing hepatitis C virus care in homeless shelters

Background

Hepatitis C virus (HCV) is highly prevalent among homeless persons, yet barriers continue to impede HCV testing and treatment in this population. We studied the experiences of homeless individuals related to accessing HCV care to inform the design of a shelter-based HCV prevention and treatment program.

Methods

Homeless shelter clients (10 women and 10 men) of a large shelter in San Francisco participated in gender segregated focus groups. Focus groups followed a semi-structured interview format, which assessed individual, program/system, and societal-level barriers and facilitators to universal HCV testing and linkage to HCV care. Focus group interviews were transcribed, coded, and analyzed using thematic analysis.

Results

We identified key barriers to HCV testing and treatment at the individual level (limited knowledge and misconceptions about HCV infection, mistrust of health care providers, co-morbid conditions of substance use, psychiatric and chronic medical conditions), system level (limited advocacy for HCV services by shelter staff), and social level (stigma of homelessness). Individual, system, and social facilitators to HCV care described by participants included internal motivation, financial incentives, prior experiences with rapid HCV testing, and availability of affordable direct acting antiviral (DAA) treatment, respectively.

Conclusions

Interrelated individual- and social-level factors were the predominant barriers affecting homeless persons’ decisions to engage in HCV prevention and treatment. Integrated models of care for homeless persons at risk for or living with HCV address many of these factors, and should include interventions to improve patient knowledge of HCV and the availability of effective treatments.

Recommendations for Implementing Hepatitis C Virus Care in Homeless Shelters: The Stakeholder Perspective

Compared with the general population, homeless individuals are at higher risk of hepatitis C infection (HCV) and may face unique barriers in receipt of HCV care. This study sought the perspectives of key stakeholders toward establishing a universal HCV screening, testing, and treatment protocol for individuals accessing homeless shelters. Four focus groups were conducted with homeless shelter staff, practice providers, and social service outreach workers (n = 27) in San Francisco, California, and Minneapolis, Minnesota. Focus groups evaluated key societal, system, and individual-level facilitators and barriers to HCV testing and management. Interviews were transcribed and analyzed thematically. The societal-level barriers identified were lack of insurance, high-out-of-pocket expenses, restriction of access to HCV treatment due to active drug and/or alcohol use, and excessive paperwork required for HCV treatment authorization from payers. System-level barriers included workforce constraints and limited health care infrastructure, HCV stigma, low knowledge of HCV treatment, and existing shelter policies. At the individual level, client barriers included competing priorities, behavioral health concerns, and health attitudes. Facilitators at the system level for HCV care service integration in the shelter setting included high acceptability and buy in, and linkage with social service providers. Conclusion: Despite societal, system, and individual-level barriers identified with respect to the scale-up of HCV services in homeless shelters, there was broad support from key stakeholders for increasing capacity for the provision of HCV services in shelter settings. Recommendations for the scale-up of HCV services in homeless shelter settings are discussed.