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“One of the biggest barriers for homeless people is having to attend the service, I feel it’s almost impossible to test while on outreach because of unsanitary conditions. I have encountered on more than one occasion people avoiding testing because of fears they had another BBV (HIV).”
Testing requires a whole team approach, and staff need to be flexible and offer testing to people when attending drop-in sessions, and not just those people who are on their caseloads. Deb highlighted some risks faced by people who are homeless who inject drugs such as using substances outdoors and the lack of equipment to hand. Deb suggested that people are often aware they shouldn’t share needles and syringes, but may lack awareness of the risks around the sharing of washes (used filters from cooking up heroin), or using “half a hit” (when an amount of drug is prepared in one syringe and then decanted into another syringe) as they may not know if the original syringe was sterile.
Needle litter can also be problematic and pose a risk of coming into contact with hepatitis C. Needle stick injuries can occur from discarded equipment on waste ground or poorly lit areas that people frequent, and injuries from poorly stored IV equipment.
Staff not being able to test on the street or in non-clinical environments can limit the opportunities for testing, with some staff only testing in the service. Outreach staff can carry out testing at local hostels and shared accommodation for people who find it difficult to attend structured settings such as a drug and alcohol service. Deb reported that being flexible to the needs of people she works with helps to break down the barriers and builds a solid working relationship.
Sometimes people are more likely to test on entry to services using the opt-out method of testing. Follow-up testing often receives a better level of engagement when done through an event delivered in partnership with other agencies (such as the Hepatitis C Trust), offering incentives such as food, hot and cold drinks, access to telephones and vouchers.
Andy said “stigma still plays a big part in the barriers to testing and treating people, I have lived experience of both injecting drug use and Hep C, and being willing to talk about it is a great engagement tool.” Andy helps the local recovery service in the delivery of testing events and holds regular testing clinics. Andy also added “drop in clinics have been successful with the homeless drug using community, a hot drink, some food and a voucher is great at not only getting people tested but also getting people engaged or re-engaged with the local drug service.”
“We are so focussed on eliminating Hepatitis C we have to remain aware this is OUR focus and not always the service user’s most important priority! Whenever we see someone on our outreach bus there are so many other issues they have to face such as housing, money, food, registering with GP/appointments, health problems, domestic violence and cuckooing. We often have to try and support with these issues before we can start to deal with hepatitis C and continue this support throughout their treatment.”
The Inclusion Hants P2P service have recently started a Homeless Outreach Project – this is a joint project with Inclusion Hants P2P and Two Saints – providers of homeless housing in and around Gosport, Havant and Fareham.
The project is headed up by Alan, along with a Two Saints Hep C Assertive Outreach Worker. The purpose of this project is to test, diagnose and treat people within the homeless populations in these areas. Due to there being areas of high deprivation, there is a prevalence of homelessness and hepatitis C that has been identified through existing joint working.
Alan said “Having already good working relationships established with Two Saints, having existing (regular) hepatology outreach clinics in place in these areas, and the provision of the clinical vans, will enable us to reach and engage individuals that may otherwise not be engaged.”
“Due to Covid 19 and the temporary housing of people who are homeless, we have started this project by offering testing to all those at risk that are housed in Two Saints homeless hostels in these areas and through Two Saints engaging individuals through their Assertive Outreach programme.”
Testing is being incentivised with vouchers and they will be using peers with lived experience to support the project. In addition to this, they will be using the Hepatitis C Trust to deliver ‘Talk & Test’ events across locations in these areas.
Nicola said “Since coming into my post we have set up clinics at several local authority housing units in partnership with key workers and venue staff and local peers from the Hep C Trust, antibody testing is carried at in the clinics and if a person is identified as antibody positive another appointment for follow up bloodwork can be made.”
“The main barrier I have found is conveying the importance of the testing process and if diagnosed as Hep C positive the importance of treatment and the impact of not being treated on the persons quality of life.” Nicola stated that her past work as a homeless outreach worker has been valuable moving into this new role as she has experience working with the homeless community and has a good relationship with people she has engaged with in the past. Nicola identified that through engaging people in testing for hepatitis C an individual can be signposted into other areas of support such as housing, physical health, and substance use support services.
It’s clear that people affected by homelessness are faced with multiple barriers and issues. Our role in this is to provide people with the support they need. It is essential that we work with compassion and understanding, creating flexible opportunities for people to access hepatitis C testing and treatment if needed, and working with individuals to support them in tackling the many barriers that may exist for them.
Missed part 1 of this blog? access it here.