Cascade of care for chronic hcv infection in a large homeless metropolitan population

Introduction

Persons experiencing homelessness (PEH) have a high risk of chronic hepatitis C infection (HCV). Liver disease is the 3rd most common cause of death in this population. PEH have difficulties accessing both primary and secondary care. We hypothesised that delivery of a hepatology clinic co-located within a GP surgery dedicated to the primary care of PEH would improve the uptake and outcomes of HCV treatment. We also sought to identify how close we are to micro-elimination in the largest population of PEH in London using a cascade of care model.

Methods

All patients within the practice were identified. Their records were examined for previous testing for HCV Ab. All patients with a positive HCV Ab were invited to attend a weekly hepatology clinic providing Fibroscan, near-patient testing for HCV RNA and pan-genotypic therapy. A cascade of care was identified for all those with a positive HCV Ab to determine whether they had achieved a sustained virological response at 12 weeks (SVR12). This was achieved using the local electronic health records in both primary care and secondary care and both the UKHSA look-back exercise and the NHS England treatment register.

Results

1099 of the 2315 patients registered within the practice have been tested for HCV Ab. There were 582 positive tests (prevalence 53.2%). The HCV Ab positive population was predominantly male (84%) with a mean age of 46 years. The prevalence of cirrhosis within the HCV population was 15%. 403 patients were HCV RNA positive and treatment was delivered to 325 patients. The majority of treatment was within primary care (147/325). The cascade of care is shown in figure 1. The intention-to-treat SVR12 was 66.7% whilst the per-protocol SVR12 was 91.9%.

Conclusions

Treatment within a primary care service has enabled large numbers to be treated successfully. This study has been able to identify the gaps in the cascade of care and identification those at ongoing risk of liver disease due to chronic HCV. The key to this is the use of this data to help drive this decision making and case-finding. For micro-elimination to be achieved in this population, individualized treatment plans are likely to be required with the involvement of multiple agencies in testing and treating this cohort of patients.