Peer-led outreach improves uptake of hepatitis C care among homeless and people who use drugs

Intensive peer support during engagement with hepatitis C care was associated with a high level of engagement in care among vulnerable people including recently homeless people and people who inject drugs in London, HepCare Europe researchers report in the Journal of Antimicrobial Chemotherapy.

The evidence comes from the London arm of the HepCare study, which investigated screening methods to improve linkage to care for people diagnosed with hepatitis C. The London arm was designed to study the impact of specialist outreach to vulnerable groups including the homeless and people who use drugs. This outreach work included the use of peer support.

The London study was part of a larger project funded by a grant from the European Commission to investigate models of care that can link primary, secondary and community care and outreach services for populations at risk of hepatitis C.

The London study focused on efforts to engage in care people with a history of injecting drug use who may be homeless or recently homeless. These vulnerable groups have a high prevalence of hepatitis C but may not have been screened or may be disengaged from medical care.

Testing for hepatitis C was offered through a peer advocacy organisation for homeless people, Groundswell. Peer advocates were trained in hepatitis C awareness, testing and the use of Fibroscan for liver fibrosis testing. They worked with outreach nurses until they were ready to work on their own. Peer workers carried out outreach activities at sites selected by the Find & Treat Mobile Health service based at University College Hospital. They publicised the screening programme and accompanied people diagnosed with hepatitis C to clinical appointments.

People were approached for testing by members of the Find & Treat clinical team and underwent oral mouth swab antibody testing. People who tested positive for hepatitis C virus (HCV) antibodies received confirmatory testing for chronic infection, with results provided seven days later.

Peer outreach workers also provided money to cover travel costs to appointments, provided food and drink while waiting at appointments and a mobile phone top-up credit to ensure that people diagnosed with hepatitis C could stay in touch with their peer support worker.

Four hundred and sixty-one people were screened in London between 2016 and 2018. Over half were recently homeless (59%), 78% were male and the median age was 45 years. More than half reported a previous positive antibody test but were disengaged from care, 92% had a previous history of injecting drug use, 33% were currently injecting and 73% were receiving opioid substitution therapy.

A high proportion of those tested had chronic HCV infection (42%). Eighty-nine per cent were referred to specialist care (the remainder were either lost to follow-up or already in care). Just over half (104, 52%) attended two appointments, underwent Fibroscan and had blood tests to assess fibrosis. People who had a history of rough sleeping or living in a homeless hostel in the previous year were significantly less likely to complete treatment assessment and be approved to start treatment (odds ratio 0.53), as were people currently injecting crack cocaine (OR 0.49).

Eighty-nine out of 104 who completed treatment assessment went on to start treatment, and by the time the study findings were submitted for publication 63 had completed treatment and 13 were still on treatment. The investigators say that this represents 36% of those identified with chronic HCV infection. Thirteen out of 89 people who started treatment did not complete it, four because of death, five interrupted treatment for medical or social reasons, three abandoned treatment and in two people, treatment failed to cure hepatitis C.

The investigators note that despite peer support, the loss to follow-up rate was high. Nearly half of people diagnosed with chronic hepatitis C infection did not reach the stage of treatment initiation and 43 people were lost between initial engagement with services and completion of treatment assessment.

Peer support workers continue to work to engage people with chronic HCV in care through visiting homeless hostels and further research is underway to understand the reasons why people choose not to engage with treatment services.

The high number of people identified with hepatitis C suggests that “there is still a large pool of people who are disengaged from treatment services. This pool of 'known positives' highlights the need for an enhanced case management approach that is better tailored to the complex social needs of the individual,” the study authors conclude.

They stress the importance of peer support workers in helping homeless people and people who use drugs to overcome barriers to healthcare and to advocate with health professionals regarding the readiness of clients for treatment.