A novel multisite model to facilitate hepatitis C virus elimination in people experiencing homelessness

Abstract

Background & Aims

Only a handful of countries are on target to achieve elimination of HCV by 2030. People experiencing homelessness (PEH) remain an important HCV reservoir. The END C study evaluated clinical, patient reported, and health economic outcomes of a decentralised integrated model.

Methods

This prospective study assessed a decentralised regional service based at multiple homeless sites in southeast England. Novel linkage-care strategies were used. We assessed generic and liver specific health-related quality of life (HRQoL) (SF-12v2; EQ-5D-5L, and SFLDQol) pre-/post-HCV treatment, and cost per HCV case detected and cured. The primary outcome was sustained virological response (SVR12) in the intention-to-treat (ITT) population.

Results

We recruited 418 individuals with mean age 44.45 ± 10.6 years, 78% were male, 74% were currently homeless, current injecting drug use or alcohol use was 25% and 65%, respectively. Prevalence of cirrhosis (liver stiffness measurement ≥12 kPa) was 12%. A total of 28% (n = 116) were HCV PCR-positive of whom 105 individuals received direct acting antiviral treatment. The ITT SVR12 rates were 81% (95% CI 72%–88%), the only predictor of SVR12 was >80% treatment adherence (OR 20.69, 95% CI 6.227–68.772, p <0.001). HRQoL improved significantly after SVR12: SF-12v2 (General Health, Mental Health, Social Functioning, Mental Health Composite Score p <0.049); SFLDQoL (Symptoms/Effects of Liver Disease, Distress, Loneliness p <0.004) and EQ-5D-5L (Index Score, Visual Analog Scale p <0.001). Costs (British pound 2022) per HCV case detected and per case cured were £359 and £257, respectively. Reinfection rates were 6.82/100 person years.

Conclusion

The END C study endorses a multisite decentralised service for PEH enabling excellent linkage to care, high SVR12 rates, and significant improvements in generic and liver specific HRQoL, all being achieved at modest costs. Such services are paramount to help achieve HCV elimination.

Impact and implications:

In people experiencing homeless, we found a high prevalence of HCV, alcohol, and substance misuse including overdoses and mental health issues. Despite this, an integrated and decentralised service resulted in excellent linkage to care with high SVR12 rates. Even in this complex cohort with multiple comorbidities, SVR12 was associated with significant improvements in both generic and liver specific HRQoL. This was all achieved at modest costs in a community setting. Such models of care are feasible, easy to replicate, and essential if we are to achieve HCV elimination.