This is the first study in Ireland to specifically target and characterise homeless individuals and their prevalence of HCV and experiences of the HCV care pathway. The study presents a unique Irish profile of HCV burden among homeless patients accessing primary care services in Dublin, Ireland, and illustrates the complexities around provision of an intensified screening programme for HCV for homeless populations. The strengths of the study include the selection of a particularly hard to reach group of homeless individuals in Dublin, who are a HCV risk population who need to be studied and intervened with in order to better understand how to improve their experiences of HCV assessment and treatment.
The study highlights the complexities around provision of HCV cascade of care to homeless individuals living in Dublin. Not having stable accommodation is a major barrier to screening and treatment retention. Studies elsewhere in Europe have indicated how structural factors impede HCV screening and treatment access, with key barriers centring on social stigma, housing, criminalisation, healthcare systems, and gender .
As highlighted previously, hospital-based appointments are the only model of care available in Ireland. This study demonstrates that standard referral methods are inadequate in engaging this population. The current referral process exacerbates barriers to treatment engagement. Due to the transient nature of the cohort there are difficulties in contacting and sending reminders for appointments. To compound this further, not all participants had access to a keyworker to facilitate the referral process.
The opportunistic community-based screening uncovered concerning numbers of HCV Ab positive individuals in those accessing SafetyNet services, with 37% of individuals testing positive for HCV antibodies. Of note is that over half were ‘new positives’ and just under half were ‘known positives’, which underscores the need to enhance patient engagement with the HCV cascade of care, and to completion. Studies in Dublin have pointed to the issues around other disease morbidities in this population where symptoms of alcohol or drug withdrawals may mask HCV symptoms . This highlights that symptom-based testing for HCV is futile, further emphasising the necessity for broad risk-based and network-based strategies in effectively identifying cases [5, 29].
The study supports Crowley et al. (2017) by emphasising the need to consistently target homeless individuals, particularly those who are actively using or have a history of injecting drug use, for HCV screening and treatment. Marginalised injecting drug users, especially those who are without stable accommodation are a hard to reach group and are less likely to access health care due to fear of discrimination, stigma, low health literacy, and health professional misunderstanding of their needs [20, 30,31,32]. Homeless patient characteristics in our study are equally complex in terms of physical and mental health problems such as continued drug/alcohol use, being on drug treatment, and experiencing forgetfulness, depression and anxiety, respiratory and dental conditions, all of which confound the HCV treatment care pathway. Reasons for non-attendance of HCV care such as active drug use, being incarcerated, fear of HCV treatment side effects and forgetfulness are similar to those reported by Crowley et al. (2017) in their study of Irish patient characteristics and barriers to Hepatitis C treatment in patients on opioid substitution treatment (OST) attending a community-based clinic where Fibroscans were performed.
Scaling up of HCV prevention, screening and treatment to address HCV transmission among the homeless, particularly those injecting drugs within existing community-based infrastructures and primary care are warranted [20, 31,32,33]. Of note is that among Phase 2 participants, 42% saw a GP once a week. This suggests a potential for high engagement within community-based primary care settings. A recent study by Barocas et al. (2017) describes excellent responses to community-based HCV treatment within a primary care program in a cohort of homeless and marginally housed adults, demonstrating that despite barriers and competing priorities, outcomes similar to those of clinical trials and other cohorts are possible for this traditionally difficult to treat group . Similarly, Grebely et al. (2017) describes an effective implementation of point-of-care HCV RNA testing in people attending drug health and homelessness services in Australia, showing potential for improved screening, linkage to care and treatment retention .
We recognise that whilst community-based screening intervention can determine the prevalence of HCV in homeless populations, referrals to / attendance at secondary care remains a challenge for this cohort. Psychosocial factors are at the core of why patients do not attend secondary care for HCV management and in this study, the interplay between addiction, mental health and homelessness were especially problematic. With this in mind, community-based health services such as Safetynet are ideally placed to support HCV screening and facilitate vulnerable individuals in accessing the treatment and care pathway. This study demonstrates that the current hospital-based model of care is inadequate in addressing the specific needs of this population, reflected in only 2 of the 199 individuals testing positive accessing treatment and cure. This emphasises the need for a community-based treatment approach.
A notable limitation of this study is missing data. Participating services were highly burdened, with a large volume of people accessing primary care and although there was high uptake of screening, a high number of questionnaires were incomplete as immediate health concerns took precedence in the limited consultation time. This meant that we were not as fully able to explore patient characteristics and barriers to access.
It is important to note that the HepCheck study was carried out during a homelessness crisis in Dublin. Sourcing accommodation on a nightly basis was an unfortunate reality for many of the participants in this study.