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People who are affected by homelessness or unstable housing could possibly fall into what is described as one of the highest risk categories for coming into contact with hepatitis C.
Since Hepatitis C elimination programs have begun the number of people living with an infection has dropped dramatically as we test and treat more people, however those still living with the virus are mostly considered to be in groups that are at high risk of infection, such as people who inject drugs.
In this blog we will explore some of the barriers to engagement in testing, referrals to treatment, medication and follow-up post treatment completion for those affected by homelessness or unstable housing.
One of the main barriers for engaging people into testing, especially for those people who are injecting drugs and rough sleeping, is the transient nature of being street homeless. A person may very rarely be in the same place twice, may not be in structured treatment in drug treatment services, and if they are, they may disengage on a regular basis.
Needles, syringes, used filters, shared water and spoons used to ‘cook’ the drugs, can all carry hepatitis C infected blood. Research shows that the virus can live on a hard surface for up to 5 days, and longer in a used syringe. Many people know that it is not safe to share needles, but some may not realise that the sharing of other equipment used to inject drugs carries its own risks.
The first step to eliminating hepatitis C amongst people affected by homelessness is to engage people in hepatitis C testing and infection prevention awareness.
Hepatitis C, being on the most part an asymptomatic illness, has a part to play in people not worrying about the virus, it can be seen as low priority by some people who have other issues to deal with on a daily basis such as securing food, shelter and funding their dependency to drugs or alcohol.
It is crucial the staff are up to date with the latest innovations in hepatitis C engagement, testing and treatment and be confident in the delivery of test results including the referral pathways into treatment. Training is available from a number of sources, and individual organisation’s own internal training programs, Hep C U Later (for NHS APA members) and the Hepatitis C Trust.
In the past, treatments for hepatitis C were Interferon based which led to quite un-desirable side effects, and longer treatment times including the person having to inject themselves with medication. These older treatments were less effective against the virus with clearance rates ranging from 40-80% and much longer treatment regimens of 6-12 months.
These treatments are a thing of the past.
The development of newer Direct Acting Antivirals (DAAs) has resulted in a greater ability to cure the hepatitis C virus, and much fewer side effects – with a cure rate of over 95%. However, some people are not aware these newer treatments exist.
People who are rough sleeping or vulnerably housed can be hard to locate as they may be sleeping in different locations. It requires extra effort from staff in drug treatment services to locate people and maintain a meaningful professional relationship with a person who is affected by homelessness. Drug service homeless outreach teams are essential in the process of building relationships with people affected by homelessness and unstable housing. Some local authorities have partnership meetings that share information each morning on locations of people believed to be ‘sleeping rough’ which can be invaluable in locating and engaging people.
Wellbeing days or testing events are a great way to engage people, especially people who may be homeless.
What makes a testing event a successful tool in engaging people? Food and refreshments are popular, as well as incentives for attending and engaging in testing such as £5 or £10 gift vouchers. Vouchers are often available through partner agencies such as the Hepatitis C Trust, Hep C U Later, drug treatment services, or operational delivery networks. Equally, inviting peer workers with lived experience can be an excellent way to engage people who access drug and alcohol services.
Incentives are also available as a way to engage people from several sources such as the UKHSA-Unlinked Anonymised Monitoring Survey of People Who Inject Drugs. This is a survey that can be completed by people who attend drug and alcohol services or needle and syringe provision services. Those who complete the survey will also complete a DBST (dry blood spot test) for HIV and viral hepatitis and the person completing the test receives a £10 voucher as a thank you.
It is well-known that people who use drugs, engage well with people with lived experience, this can be for many reasons including the fact that shared experience encompasses an understanding of marginalisation, discrimination and stigma. People with lived experience can often give reassurance that they have walked the a similar path to someone by sharing their own experience of drug use, living with hepatitis C, and their journey through the test and treat process, and are often a credible source for dispelling myths.
This peer support can come from a service peer/volunteer programme within drug treatment services, or through organisations such as the Hepatitis C Trust. The Hepatitis C Trust have both paid and unpaid peer staff who support services in the engagement of people who use drugs into testing for blood borne viruses, and help engage then into treatment and support them through the treatment process.
Organisations such as the Hep C trust are a great place for people who have used drugs or have been affected by hepatitis C to begin their journey into volunteering, sharing their experiences and beginning to support others.
Some areas have access to clinical vans. This resource is an excellent tool for engaging people with unmet need, including those who are affected by homelessness by taking the testing into the community where they are. Vans can be used in partnership with drug treatment or other healthcare services and local hostels to coordinate events.
Clinical vans in some areas are funded by the local operational delivery networks and NHSE, and can act as a ‘one stop shop’ for hepatitis C testing and treatment, often with Cepheid GeneXpert point of care testing machines and fibro-scanners on-board. If a person tests positive for hepatitis C a referral can be made to the hepatology clinic for treatment, or in some cases, a person can be assessed for treatment on a clinical van.
Many localities deliver regular open access clinics at hostels and homeless centres where residents and people who are affected by homelessness can drop-in and have a test completed. Clinics are often delivered in partnership with clinical nursing teams, local drug treatment services and the Hepatitis C Trust.
It has been identified that medication adherence can be an issue amongst people who are affected by homelessness and who use drugs. DAA (Direct Acting Antivirals) are not a short course of medication, the course will last for 8 to 12 weeks. For people experiencing homelessness the storage of medication can be an issue. In the past, up 12 weeks of treatment has been given to a person when the medication was first prescribed. This often led to expensive medication being misplaced or lost, leading to a poor level of medication regime adherence.
On speaking to practitioners from several locations around the UK they have informed me that medication has begun to be prescribed and dispensed on a monthly basis, therefore reducing the risk of medication being lost.
Please follow the link here, to read part 2 of this blog which explores good practice examples of those working with people experiencing homelessness.