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Homeless shelter client and provider barriers and facilitators to implementing HCV testing, access, and linkage to care in the homeless population
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Jesse Powell, J. Konadu Fokuo, August Anderson, Dylan Bush, Barry Zevin, Margaret Ricco, Claudia Ayala, Carmen L. Masson, Mandana Khalili
Reported by Jules Levin
2019 AASLD/EASL HCV
Special Conference 01-02
February 2019, Miami, FL
AASLD/EASL Special Conf: Homeless Shelter Client and Provider Barriers and Facilitators To Implementing HCV Testing, Access, and Linkage To Care In The Homeless Population - (02/06/19)
Background: Limited data suggests hepatitis C (HCV) prevalence in the homeless population is very high. Although HCV therapy is successful among those experiencing homelessness, barriers to scaling up HCV testing and treatment in this population persist. We aimed to assess the facilitators and barriers to onsite HCV screening for individuals accessing homeless shelters prior to implementation of universal testing and HCV therapy within the shelters.
Methods: Four focus groups were conducted with homeless shelter clients (N=20) and health care providers (N=16) in San Francisco and Minneapolis. Focus groups followed a semi-structured interview format, and assessed key individual, program, and system level facilitators and barriers to universal HCV testing and linkage to HCV care. Shelter client focus groups were conducted separately by gender. Provider focus groups included nurses, nurse practitioners, physicians, pharmacists, and health workers. Transcribed focus groups were analyzed using qualitative thematic analysis.
Results: The overarching theme of "limited knowledge of HCV" was identified as the key indicator for client uptake of HCV testing and treatment. All groups believed that homeless clients are concerned about their health. In comparing individual-level barriers, providers were concerned about clients' alcohol and substance use disorders, limited English proficiency impacting physician-patient interactions, competing priorities, and medication side effects. Clients' concerns centered on perceived susceptibility to HCV, medication side effects, medical mistrust, and the negative impact of substance use disorders on health seeking behaviors. System-level barriers from providers included limited infrastructure and HCV treatment capacity, medication access, and treatment adherence. Clients focused on shelter policies and lack of advocacy for HCV therapy, and the impact of social stigma of homelessness on health seeking behavior. The main facilitators for HCV testing and treatment from providers and clients was that shelter residents are motivated for treatment and providers in both locations indicated buy in from shelter leadership. Lastly, clients identified eliminating HCV transmission as a powerful motivator for testing and treatment. Based on these findings, a universal HCV screening and linkage to care was implemented and being evaluated in four large shelters in both cities.
Conclusions: While barriers and facilitators to HCV testing and therapy spanned client, program, and system levels, the key emerging theme among both shelter clients and providers was the importance of enhanced knowledge of HCV and harm reduction. Scaling up HCV screening and treatment within homeless shelters therefore requires enhanced multi-level integrated infrastructure that also includes patient-centered approaches beginning with client and provider education.
Funding support: Gilead Sciences Inc.(IN-US-342-4531) and NIH (T32DA007250, K24AA022523).
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