The HepCheck study sought to investigate the characterization of hepatitis C (HCV) burden among individuals who attended an intensified screening programme for hepatitis C in homeless services in Dublin.
HepCheck Dublin was undertaken as part of a larger European initiative called HepCare Europe. HepCare Europe is an EU-funded service innovation project and feasibility study, rolled out in four European cities (Dublin, London, Seville and Bucharest), and aimed at developing, implementing and evaluating interventions to enhance identification and treatment of hepatitis C among vulnerable populations.
Homelessness is associated with an increased prevalence of risk factors for hepatitis C such as injecting drug use. Facing pressing needs such as food, warmth and shelter, homeless individuals \ tend to delay reaching out to health services. This means they frequently wait until symptoms have become acute requiring emergency care and hospitalisation. Late diagnosis and treatment can be all the more frequent in the case of hepatitis C, whose early symptoms are not easily detectable without adequate screening.
The target population of the study was homeless individuals accessing the SafetyNet Primary Care services in Dublin. Individuals using homeless services and hostels were informed of screening for hepatitis C in SafetyNet clinics and encouraged to attend. Those who reported having already been diagnosed with hepatitis C were advised to attend a SafetyNet clinic for assessment and referral for treatment if appropriate.
Screening took place in 11 SafetyNet affiliated GP practices, as well as SafetyNet in-reach locations such as coffee shops, needle exchanges, hostels, drop-in centres, and the SafetyNet mobile health unit. The process consisted of three phases. These included:
- Offering of a blood or rapid oral hepatitis C test,
- An in-depth questionnaire for those who reported positive that explored health and social risk factors, with the objective of identifying barriers to follow up, as well as
Monitoring along the care pathway to ensure that the appropriate care was received.
This study demonstrates that standard referral methods (such as hospital-based appointments) are inadequate to engage the homeless population and even exacerbate barriers to treatment.
In particular, standard care fails to address the needs of those who are actively using or have a history of injecting drug use. People who are injecting drugs, especially those who are without stable accommodation, are a hard to reach group. They are thus less likely to access healthcare due to fear of discrimination and stigma. Furthermore, they have frequently low health literacy, leading to miscommunication with health professionals.
The study also shows that community-based primary-care services and infrastructures are ideally placed to support hepatitis C screening and facilitate vulnerable individuals in accessing treatment and care, since they are equipped for the special needs of this risk group. As a result of this easier entry into care, 42% of the participants saw a general practitioner once a week.
The study was partially supported with unrestricted grants to Dr. John Lambert and the Mater Hospital Infectious Diseases Research Fund from AbbVie and Bristol-Myers Squibb Ireland. The funding bodies had no role in study design, collection, analysis, and interpretation of data or in writing the manuscript.
John S Lambert MD PhD, Consultant in Infectious Diseases, Medicine and Sexual Health (GUM) Mater, Rotunda and UCD