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Outreach to homeless in England achieved large-scale testing for hepatitis C during the COVID-19 lockdown

Keith Alcorn
25 March 2021
Image: Ev/Unsplash

Outreach to homeless people in England housed in temporary accommodation during the COVID-19 pandemic led to over 1200 to be tested for hepatitis C, one in ten to test positive for active infection and at least 83 to begin direct-acting antiviral treatment during 2020, researchers from the University of Southampton and Public Health England report in Clinical Liver Disease.

A similar number were tested and diagnosed in London in the same period, according to a report by the London Joint Working Group on Substance Use and Hepatitis C.

On 16 March 2020, the Ministry of Housing, Communities and Local Government wrote to local authorities in England asking them to take steps to provide temporary accommodation to people sleeping on the streets, to reduce the risk of widespread COVID-19 infections and deaths among homeless people. A national lockdown began a week later.

Some hepatitis C care providers took the opportunity to offer hepatitis C testing and linkage to care for homeless people in temporary accommodation. A survey of regional peer support leads employed by the Hepatitis C Trust showed that they undertook outreach work in 63 locations outside London by July 2020. Most outreach work took place in hostels and hotels.

Outreach work led to 1263 people being tested for hepatitis C. Of these, 224 (17.7%) tested positive for hepatitis C virus (HCV) antibodies and 133 (10.5%) also tested HCV RNA positive, indicating chronic infection. The study authors say that the prevalence of chronic infection matches a survey of homeless people in London between 2011 and 2013.

In 32 settings where up-to-date information was available on the number of homeless people being housed, 63% of residents were tested for hepatitis C.

Ninety-two people (69% of those who tested RNA positive) had been offered treatment and 83 had started treatment, but few had completed treatment by the time the report was compiled.

In London, 1082 people were tested at 98 testing events at hotels and hostels. Eleven per cent tested positive for hepatitis C antibodies and 7% tested positive for HCV RNA. Out of 72 people with active infection, 42 had started treatment by the time of reporting in December 2020. People were also offered testing for hepatitis B and HIV. Twenty-two tested positive for HIV, of whom 12 were previously undiagnosed. Five people were diagnosed with active hepatitis B. In the 22 settings where up-to-date information on numbers housed was available, 37% of residents were tested for at least one blood-borne virus.

The two reports offer common lessons on 'test and treat' initiatives among the homeless:

  • COVID-19 offered an opportunity for a rapid reconfiguration of services to address the needs of a previously hard-to-reach group. Innovation in service delivery will be critical for achieving elimination of hepatitis C, especially in marginalised groups.
  • Use of oral tests or dried blood spots was preferable to venous blood sampling due to issues with vein health in long-term injectors. Rapid point-of-care testing kept people engaged.
  • Clients generally appreciated testing and saw it as an opportunity to re-engage with health care or support their own recovery from drug use. Other health checks were offered. A whole-person health approach encouraged engagement with testing.
  • The stability provided by temporary accommodation and lockdown allowed people who tested positive to focus on taking a course of medication. As in other settings, meeting basic needs for food and shelter allowed people to take care of their health.
  • Peer supporters were crucial to the successful delivery of testing. They were able to talk to people about treatment and dispel myths, as well as sharing their own experiences. It was important to use language and content that the target audience did not find stigmatising.
  • Due to COVID-19 restrictions, diagnosed people were often given a full course of medication and followed up by peer supporters.
  • Interventions proved successful due to multi-agency partnerships. Clinical services worked with peer support groups, rough sleeping agencies and homeless outreach workers in ways that broke down boundaries between services and laid the ground for improved collaboration in the future.

“The project has turbocharged joint working between organisations, enabling us to offer a variety of tests and support to people who are homeless,” said Julian Surey, of University College Hospital’s Find and Treat team.