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HIV and Hepatitis C Linkage-to-Care Initiative for New Orleans Residents Experiencing Homelessness During the COVID-19 Pandemic
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Katherine A. Cironi, BS , Austin T. Jones, MPHTM , Elizabeth M. Hauser, BS, BA ,
32 Joseph W. Olsen, MPH , Patricia J. Kissinger, PhD
1Tulane University School of Medicine, New Orleans, LA, USA
2Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
3CrescentCare clinic, New Orleans, LA, USA
Short Summary
A study evaluating a linkage-to-care initiative for those experiencing homelessness in New Orleans, LA during the COVD-19 Pandemic found effective strategies in connecting HIV and HCV patients with follow-up care.
Abstract
Background
People experiencing homelessness are disproportionately infected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). In response to COVID-19, cities nationwide temporarily housed people experiencing homelessness in unused hotels. One such initiative in New Orleans also enacted a screening, counseling, and linkage-to-care model for HIV and HCV treatment for this temporarily housed population between May and July 2020.
Methods
A non-concurrent cohort study was performed assessing follow up in the treatment of HIV and HCV for this population. Outcome data was collected on seropositive patients' electronic medical record to assess patient progression through the treatment cascade.
Results
Of 102 unhoused residents, 25 (24.5%) tested HCV seropositive. Of the HCV positive 21/25 (84%) were connected to the associated clinic for follow up care and 10 (40%) obtained HCV treatment medication. Furthermore, all three patients who tested seropositive for HIV either started or re-initiated anti-viral treatment. The greatest barrier to providing medication for the HCV seropositive patients, once care was initiated, was loss-to-follow-up.
Conclusion
Targeting homeless persons living in temporary residences for HCV and HIV screening can be effective at promoting access to care for those infected due to this population's high HCV seropositivity especially significant if the patient has a history of intravenous drug use or is over the age of 40. However, continued outreach strategies are needed to assist patients in retention of care.
Burden of HCV and HIV in Louisiana homeless population
This burden of HCV and HIV is especially profound in Louisiana. Among the 4.7 million people living in Louisiana, it is estimated that 60,000 and 20,907 are infected with HCV and HIV, respectively [4, 5]. During the 2013-2016 time frame, Louisiana was ranked fourth highest in the United States with an estimated Hepatitis C prevalence of 1,420 infected per 100,000 persons [6]. The city of New Orleans has the highest overall prevalence of HCV in Louisiana and it is estimated that 52% of people who inject drugs in New Orleans are HCV seropositive [7]. This can be further substantiated by analyzing the overlap between the opioid and HIV/HCV epidemics with the homeless at the epicenter of both. While difficult to measure the true rate of homelessness, the city estimates that 302 per 100,000 persons are homeless in New Orleans [8]. Overall, the homeless community is three and fourteen times more likely to be HIV and HCV seropositive, respectively compared to housed persons [9-11], thus HIV/HCV services are greatly needed for this vulnerable population.
The objective of this study was to analyze the effectiveness of a pilot program conducting rapid HIV and HCV testing among homeless persons residing in COVID-19 temporary housing, along with connecting seropositives to follow-up care at a comprehensive community clinic in New Orleans, LA. The unique format of utilizing hotels allowed for recruitment and testing at the patients' place of residence, aiding access to this notoriously difficult-to-reach population and improving retention in the treatment cascade.
RESULTS
Demographic Data
During the study period, 108 patients were tested for HIV and/or HCV and six patients were excluded because they were a non-homeless employee of the temporary housing site who received testing or completed treatment prior to the study. In total, 102 patients were included (Table 1). Participants were predominantly male (61.8%) and between the ages of 18 and 50 (55.9%) at the time of testing. Additionally, the majority were African American (56.9%) and heterosexual (68.6%). Furthermore, 24.5% reported a previous history of IV drug use, of whom 32% reported a history of sharing injecting equipment.
Antibody Testing
All participants stayed to receive their results. In total, 25/102 (24.5%) tested seropositive for HCV and 3/98 (3.1%) tested seropositive for HIV (Table 1). One participant was found to be HCV-HIV coinfected.
HCV Risk Factors
HCV seropositivity was significantly associated with a reported history of IV drug use, history of sharing injecting equipment, and those older than 40 (Table 2). Those reporting a history of IV drug use had an HCV seropositivity rate of 60% and were significantly more likely to be HCV seropositive than participants without a reported history of IV drug use (OR 10.05, 95% CI 3.55-28.44). Similarly, 75% of those who reported a history of sharing injecting equipment were HCV seropositive and significantly more likely to be HCV seropositive than those who have not shared injecting equipment (OR 11.84, 95% CI 2.21-63.39). Age less than 40 years old was found to be significantly protective of HCV seropositivity (6.9% vs 32.4%). (OR 0.16, 95% CI 0.03-0.71). Similarly, of those in the baby boomer generation (born 1946-1964), 42.4% were HCV seropositive and were more likely to be HCV seropositive than those not in this generation (OR 3.75, 95% CI 1.48-9.66). There was no significant association between HCV infection and assigned sex (p = 0.092) or being exclusively heterosexual (p =0.760).
HCV Treatment Cascade
Over half (60%) of the patients testing HCV seropositive were unaware of their HCV infection prior to testing. The HCV treatment cascade (Table 4, Figure 1) depicts the treatment of care for the 25 patients with a seropositive HCV test result that had not completed treatment prior to this study; 100% were communicated their antibody positive result, 21/25 (84%) were linked with follow-up care from CrescentCare clinic, 15/25 (60%) attended a telehealth appointment with a provider, 13/25 (52%) utilized transportation to have confirmatory start of care labs, 10/25 (40%) picked up their medication to start treatment, and 2/24 (8.3%) were cured throughout this process, defined by SVR12. The denominator was held at 25 for steps 1-5 to show the progression along the treatment cascade for all patients, this was adjusted to 24 for step 6 as those not chronically infected would not continue medication to achieve SVR12. The clinic did not establish chronicity for treatment to begin, thus the treatment cascade is evaluated for all HCV seropositive patients (n=25). Only those found to be chronically infected 12/13 (92.3%) with HCV were eligible to proceed on medication, 1/13 (7.7%) was not chronically infected (Table 4). However, this leads to a conservative estimate of SVR12, 2/24 (8.3%) since 12 of the 24 patients included in the denominator of step 6 were not evaluated for chronicity due to not completing step 4 (pre-treatment labs) (Table 4).
Of the 25 that tested seropositive for HCV without history of prior cure, 7/25 (28%)
relied on the in-house temporary housing case manager to connect with the clinic for treatment
and of those, 6/7 (85.7%) of patients did not make it passed the initial contact by the CrescentCare treatment manager (step 2) in the treatment cascade (Table 3). Additionally, pre-treatment labs (step 4) were the first step where transportation was necessary to continue along the treatment cascade. Of those that completed step four, 5/13 (38%) relied on a rideshare provided by the clinic to do so. Lastly, 20/25 (80%) of HCV seropositive patients in this study had active insurance confirmed and only 1/10 (10%) of those on treatment did not have insurance on file with the clinic.
Of the HCV seropositive patients, 0/25 (0%) were currently on PrEP and 7/25 (28%) of patients had never heard of the prophylaxis medication.
HIV Treatment Cascade
Of the three that tested seropositive for HIV, one patient (33.3%) had never been on HIV treatment prior to this program and one patient tested seropositive for both HIV and HCV. All three (100%) of the HIV seropositive patients received their test result, had their initial PCP appointment at CrescentCare, viral load assessed, and either started treatment or had assistance with re-starting their treatment regimen. All HIV seropositive patients were contacted by CrescentCare clinic the same day as the initial antibody test at the temporary housing site and all were given adherence counseling.
Discussion
This initiative identified a high seropositivity of 24.5% for HCV antibodies in the 102 patients experiencing homelessness that were tested while living in free housing during the COVID-19 pandemic. Due to the accessibility of testers and clinic personnel to the homeless residents in this structure of care, 21/25 (84.0%) of these seropositive patients were connected to follow up care from a local clinic. In order to reduce HCV transmission, it is imperative to frequently test at-risk populations, such as current or previous IV drug users and those 40 years of age and older. Providing routine testing specifically in the homeless population of an urban city can allow for early HCV diagnosis and prevention of chronic HCV infection. Due to the high seropositivity in this homeless population, it is imperative to also consider the effect this has on urban public health and spread amongst our communities. The temporary housing shelters created a unique opportunity to screen for HIV and HCV among a notoriously difficult to reach population that does not seek regular health care screenings.
This transient population typically has difficulty moving through the HCV treatment cascade and completing treatment [14]. As evident by the 10/25 (40%) of patients with a reported history of HCV seropositivity prior to this project (Table 3), these patients often cited lack of previous treatment completion due to loss-to-follow-up by medical providers and not fully understanding the disease and treatment available. A variety of barriers exist for people experiencing homelessness, including accessing testing, returning for test results, communicating with health care providers, and transportation to clinic for care and pharmacy for medications [13]. Our model aimed to eliminate some of these barriers by offering testing at the patient's current place of residence and providing results within 20 minutes of test initiation, allowing for day-of notification of results to 100% of patients screened for HCV and HIV. Telehealth services allowed for easy and convenient linkage to care, thus eliminating transportation as a barrier to accessing a primary care provider. In instances where in-person contact with the clinic was required, free means of transportation via a rideshare service was made available, thereby improving the patient's ability to access pre-treatment labs and procure necessary medications. Furthermore, an in-house case manager employed by the state resided at each hotel to assist patients with insurance enrollment and coordinating care with the clinic.
Additionally, due to the safe therapeutic index of the HCV treatment medications, CrescentCare clinic enacted a similar approach to the treatment of HCV as HIV. In this case, patients came in for pre-treatment labs to confirm their HCV RNA seropositivity and were able to pick up HCV treatment medication the same day. If the patient's labs came back depicting no chronic infection (n=1), they were communicated to discontinue medication. Those that did not pick up their medication the same day as the labs (n=3) did so due to patient choice or lost to follow-up. This method eliminated the barrier of additional communication and transportation needed for medication distribution.
Notably, this study had a relatively small sample size (n=102) from a single city; thus, findings may not be generalized to other areas of the country. An additional challenge was our ability to contact the patients that tested seropositive and connect them to follow up care. Of the HCV seropositive patients, 7/25 (28%) did not have their own cell phone, in such that the clinic relied on the hotel's in-house case manager to coordinate healthcare appointments. These homeless residents did not have their own transportation and the start of care lab site was inaccessible by way of most public transport. Furthermore, in order for the rideshare system to be effective, the patient needed to have a cell phone to accept the ride and communicate with the driver for pickup. In all, the greatest barrier to follow up care and treatment initiation for these patients was the difficulty for the clinic to establish consistent, direct patient contact. This is evident by the large drop-off in adherence between HCV medication pickup and confirming SVR12 (Table 4) where patients became lost to follow-up largely due to the closing of the temporary housing hotels causing greater difficulty in confirming treatment completion.
Future projects should continue to assist patients with obtaining a cellular device or reliable method of communication. Additionally, bringing health care providers to the patient for pre-treatment labs and providing a medication delivery service can be used to circumvent the transportation barrier seen in this project. Even though this population can be notoriously difficult to reach, subsequent studies should consider expanding to more temporary housing shelters in order to increase sample size. Additionally, having both enrollment and the testing service at the same location can allow for ease of patient recruitment and follow up for additional care if needed. Future approaches must aim to combat these barriers to reliably contact the urban homeless population and provide them with tools to successfully navigate the treatment cascade.
Moving Forward
It is well understood that those of high-risk behaviors (current or previous IV drug use) have increased risk for blood-born infectious diseases, such as HCV and HIV. This study's increased prevalence of infection compared to the general population underscores the importance of providing critical intervention and treatment of care services to this high-risk population. In addition to increasing funding for these groups to aid in mending the barrier of communication, further screening for HCV seropositivity must be expanded in all emergency departments to assist in early detection and treatment initiation.
Additionally, if the patient was born in the Baby Boomer generation (1946-1964), they have a higher likelihood of having HCV antibodies when compared to those who were not (42.4% vs 16.4%). Researching these high-risk populations provides the key to designing and implementing effective screening and follow-up care interventions in order to control the prevalence of HCV and HIV in the United States.
With the hardship of adjusting to the COVID-19 pandemic, state officials have taken valiant strides to help mitigate the spread of the virus, specifically in susceptible patients such as the urban homeless population. With the housing initiatives in New Orleans brought on by the pandemic, it allowed health care personnel to identify a notoriously hard to access population by localizing them all in one place – free housing hotels. This unconventional delivery of care would have been nearly unattainable without this housing configuration. Having this population centralized in one location assisted the health care team with both delivering the tests and results thereafter as well as connecting patients to follow up care. The high HCV seropositivity percent found in this population further substantiates the alarming prevalence of the virus in this difficult to access cohort and underscores the prioritization of future initiatives to assist this group in determining their serostatus and accessing treatment.
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