Delivery of liver services within primary care can improve treatment outcomes in persons experiencing homelessness

ABSTRACT

BackgroundPersons experiencing homelessness (PEH) often have complex health needs compounded by difficulty accessing healthcare. Liver disease is the third commonest cause for death in PEH after accidents and suicides. Some studies have identified chronic hepatitis C (CHC) in up to 50% of this population. Alcohol disorders are also extremely common.MethodsFrom June 2018, a weekly Hepatology clinic was co-located with a primary care clinic serving a population of 2,500 PEH. Blood borne virus testing, near patient HCV RNA testing, transient elastography and anti-viral drug dispensing for Hepatitis B and C was introduced. All patients with HCV were treated in line with national guidelines.ResultsBetween the period of June 2018 and November 2020, 326 patients were reviewed within the Hepatology clinic. A total of 1,236 appointments were offered with 632 attendances (51.1%).241 patients were referred due to a positive HCV Ab test. 193 were RNA positive (80%), 30 RNA negative (12.4%) and 19 had unknown HCV RNA status. Transient elastography was performed on 138 with 31 having advanced fibrosis.Treatment was initiated on 101/193 HCV RNA positive patients. 93 patients were receiving opiate substitution therapy. 65% had a co-existing mental health diagnosis whilst 24% had a significant alcohol intake, 2% were co-infected with Hepatitis B and C and 3% were co-infected with both Hepatitis C and HIV. The genotypes were 44 G1a;3 G1b;6 G2;34 G3;1 G4 and 13 unknown.There is a high rate of sustained virological response (SVR) being achieved with 61 patients having achieved SVR (82%). 13 patients needed to re-start treatment. 37 have SVR 12 pending. 3 patients have relapsed.Of the remaining 92 known RNA positive patients within the clinic, 40 identified within our service have been treated elsewhere during the peak of the Covid-19 pandemic. 24 SVR blood tests were performed for the patients treated in other locations. 21 patients are approved to start treatment. 9 are awaiting genotyping and transient elastography. 5 are no longer patients of the primary care clinic and attempts have been made to arrange onward referrals to Hepatology services in their new locations and 5 patients have died.ConclusionPersons experiencing homelessness often have difficulty accessing healthcare. By facilitating access to Hepatology services tailored to their needs at a site where they access primary care and receive opiate substitution therapy, favourable SVR rates can be achieved with significant risk reduction.