CASCADE OF CARE FOR CHRONIC HCV INFECTION IN A LARGE HOMELESS METROPOLITAN POPULATION
AASLD 2022 Nov 4-
Background: Persons experiencing homelessness (PEH) have a high risk of chronic hepatitis C infection (HCV), and liver disease is the 3rd most common cause of death in this population. The borough of Westminster has the largest homeless population in London. The WHO has called for elimination of HCV as a public health threat by 2030, whilst London has targeted 2025 to end all new HCV infections. Micro- elimination targets sub- populations for eradication. The aim of this study was 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 a GP practice dedicated to providing primary care ser-vices to PEH in Westminster borough were identified. A cascade of care was identified for all those with a positive HCV antibody 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 and secondary care, the Public Health England look- back exercise and the NHS England treatment register for London.
Results: The number registered with the GP practice is approximately 2300. Of these, 517 were identified as having a positive HCV Ab (estimated prevalence 22.4%). RNA testing had been performed in 448 patients with 370 positives for HCV RNA (82.5%). Treatment had been initiated in 288 individuals. Thirty-f ive had received treatment prior to the direct- acting antiviral era and 7 had been previously treated outside of London. Fibrosis assessment was performed in 199 treated patients, of whom 39 had cirrhosis (19.6%). The predominant genotypes were G1 (124/288) and genotype 3 (92/288). The genotype was unknown in 54. The anti- viral ther-apy was sofosbuvir/velpatasvir in 109/288; sofosbuvir/ledipasvir in 85/288; glecaprevir/pibrentasvir in 22/288; elbasvir/grazoprevir in 19/288; paritaprevir/ombitasvir/ritonavir plus dasabuvir in 10/288 and sofosbuvir/velpa-tasvir/ voxilaprevir in 1. The location of treatment was in primary care in 132; secondary care in 38; drug ser-vices 21; prison in 19 and other community services in 13. The SVR12 was measured in 202/288 (70.1%). The SVR12 rate was 93.1%.
Conclusion: Eradicating HCV infection within the homeless population remains a challenge. Significant improvements in testing and treating in sites where PEH access healthcare has improved the linkage to care, such that the outcomes in this population are equivalent to other populations. Flexibility in treating strategies and maximising opportunities for engagement are key to successful out-comes. To achieve micro- elimination in this population however, individualized strategies at a patient level may be required. The close liaison between different testing and treating services is essential if this goal is to be achieved.