Clients’ perceptions of barriers and facilitators to implementing hepatitis C virus care in homeless shelters

Abstract

Background: Hepatitis C virus (HCV) is highly prevalent among homeless persons, yet barriers continue to impede HCV testing and treatment in this population. We studied the experiences of homeless individuals related to accessing HCV care to inform the design of a shelter-based HCV prevention and treatment program. Methods: Homeless shelter clients (10 women and 10 men) of a large shelter in San Francisco participated in gender segregated focus groups. Focus groups followed a semi-structured interview format, which assessed individual, program/system, and societal-level barriers and facilitators to universal HCV testing and linkage to HCV care. Focus group interviews were transcribed, coded, and analyzed using thematic analysis. Results: We identified key barriers to HCV testing and treatment at the individual level (limited knowledge and misconceptions about HCV infection, mistrust of health care providers, co-morbid conditions of substance use, psychiatric and chronic medical conditions), system level (limited advocacy for HCV services by shelter staff), and social level (stigma of homelessness). Individual, system, and social facilitators to HCV care described by participants included internal motivation, financial incentives, prior experiences with rapid HCV testing, and availability of affordable direct acting antiviral (DAA) treatment, respectively. Conclusions: Interrelated individual-and social-level factors were the predominant barriers affecting homeless persons' decisions to engage in HCV prevention and treatment. Integrated models of care for homeless persons at risk for or living with HCV address many of these factors, and should include interventions to improve patient knowledge of HCV and the availability of effective treatments.

Hepatitis C virus care cascade in persons experiencing homelessness in the United States in the era of direct‐acting antiviral agents: A scoping review

“…This study employed multiple resources in an effort to engage patients including centralized identification of viremic patients, staged outreach and group classes where patients could also undergo labs and imaging. Importantly, patients were informed of curative medications, a knowledge barrier that keeps homeless persons from seeking treatment 7 . In logistic regression, they identified homelessness to be a statistically independent factor associated with non‐engagement in HCV care.…”

“…In addition to the high prevalence rate, persons experiencing homelessness encounter many barriers to treatment. Masson et al 7 stratified these barriers into individual, system, and social‐level barriers. Identified barriers on the individual level included comorbid medical and psychiatric conditions as well as misconceptions about HCV.…”

Patient‐reported experiences with direct acting antiviral therapy in an integrated model of hepatitis C care in homeless shelters

“…1 While direct-acting antiviral (DAA) therapy is highly effective for HCV treatment, there are barriers to DAA treatment uptake among persons experiencing homelessness related to access to medication, substance use problems and difficulty with engaging in on-going care, among others. 2 Patient-reported experiences (PREs) measure patients' perspectives of their general health, quality of life and psychosocial experiences relating to their disease and its management. 3 These factors are critical in addressing patient concerns during HCV therapy and scaling DAA therapy in hard to engage populations.…”

“…4 In this study, we aimed to assess PREs in patients experiencing homelessness during HCV daa therapy in an integrated homeless shelter-based model of HCV care that was implemented following assessment of key stakeholders' perspectives. 2,5 1) associated with PREs were evaluated using univariable and multivariable logistic regression models. Statistical significance was defined at p-value of <.05 (two-sided).…”

Reply

“…Indeed, we have shown that despite near universal screening for HCV in a birth cohort receiving care within a safety net health system, less than a quarter of patients infected with HCV were started on HCV treatment. ( 1 ) Structured and multidisciplinary approaches to HCV care with input from key stakeholders, including patients, ( 2 ) are therefore required to meet the needs of the homeless populations infected with HCV. Based on these findings, we have successfully implemented an integrated model of on‐site shelter‐based HCV testing, education, and treatment to scale up HCV care in the homeless shelters across two urban and geographically diverse cities.…”