Hepatitis C treatment program improves access to housing, income and healthcare

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1 CATIE-News CATIE s bite-sized HIV and hepatitis C news bulletins. Hepatitis C treatment program improves access to housing, income and healthcare 13 July 2015 Despite high rates of hepatitis C virus (HCV) infection among people who use street drugs, access to treatment for HCV is very low for this population. Studies in Canada and the U.S. have shown that less than 1% of people with HCV who inject drugs access treatment. A number of barriers to HCV treatment have been documented for people who use drugs, including a lack of knowledge about HCV infection and its impact on health, past negative experiences with healthcare providers, competing issues such as unstable housing or other health problems, and specialists who are not willing to treat people who use drugs. In order to address barriers to HCV treatment for people who use drugs, the Toronto Community Hepatitis C Program (TCHCP) has developed a low-barrier community-based multidisciplinary team model for providing HCV care. Previous research on this program demonstrated cure rates for HCV treatment among the program s clients that were similar to those seen in people in clinical trials. The current study goes beyond HCV cure rates to examine the impact of TCHCP on clients physical and mental health, substance use, housing, income supports and access to healthcare. It found that access to housing, income supports and healthcare improved over the course of the study. There was no change in participants perception of their overall health. The TCHCP TCHCP consists of multidisciplinary teams based in three primary healthcare settings that receive support from hospital-based medical specialists who offer appointments onsite. The program provides low-barrier HCV treatment and support to people who use drugs or have mental health issues, or both. The anchor of the program is a two-hour weekly support group meeting. Each support group cycle lasts 16 to 18 weeks and people can participate in multiple cycles. This support group is designed to be a low-barrier way for people who may avoid healthcare due to stigma and discrimination to be linked to HCV care and treatment. This group is the base through which they are connected to HCV nurses, doctors and specialists. To encourage access to the group, participants receive a meal during the meeting as well as transit fare and an honorarium. During the support group, people receive and share information about HCV and how to take care of their health. Appointments with HCV nurses, doctors and specialists take place while the group meets, allowing for easier access to these healthcare providers. Outside of the group, participants can also receive case management, counselling and further peer support. Abstinence from drugs and alcohol or participation in an opiate substitution program or addiction treatment program is not a requirement for joining the program.

2 About the study The goal of the study was to evaluate the health and psychosocial outcomes of TCHCP participants over time. Starting in 2011, all new participants in the program were invited to join the study. Participants were interviewed at three time points: upon joining the program, at the end of the first support group cycle they attended, and one year after they finished their first support group cycle. This study is ongoing and will end in 2016, when the last group finishes its one-year anniversary interviews. Interviews consist of standardized questionnaires that measure overall health status, physical and mental health, drug and/or alcohol use and healthcare utilization. Questions are also asked about housing, income and history of incarceration. Results A highly marginalized population There were 78 participants in the study. Three participants died during the study (for reasons unrelated to the study), 13 participants did not complete the study and four participants withdrew. Participants in the study were a highly marginalized group: 85% reported a history of incarceration, with an average of six years spent in prison 82% relied on social assistance as their primary income 49% were living in unstable housing, such as a shelter, motel, rooming house or public place 49% had an elementary school education or less 71% reported a history of physical abuse 46% reported a history of sexual abuse Many participants also had medical issues other than HCV infection, including the following: 78% reported at least one additional chronic health problem 58% reported anxiety in the past month 45% reported depression in the past month 41% reported having been in the hospital for a mental health issue 4% reported having HIV The majority of participants (nearly 90%) had a history of injecting street drugs; 11 had injected drugs in the past month. Half of the participants also used crack cocaine (non-injection) in the past six months and 68% used alcohol in the same time period. Access to HCV care improved Prior to starting the program, the majority of participants (85%) had a primary care doctor, however, only 15% had seen an HCV specialist. After one year of follow up, access to an HCV specialist had significantly increased, with 54% of participants seeing a specialist. Additionally, almost all participants (93%) also had a visit with the program s HCV primary care doctor and all participants had seen an HCV treatment nurse. By the end of the study period, participants had also received HCV assessments and related care, including: 95% had lab tests of their blood samples 77% received an ultrasound of the liver 58% had an assessment of liver injury 86% received vaccinations against hepatitis A and B viruses Prior to the study, only 4% of participants had previously started HCV treatment. After one year of monitoring, 19% (15 people) had started treatment and 12% (nine people) had completed treatment. Thirteen participants wished to start treatment but did not meet the criteria for government funding for treatment, and 10 participants reported the need to address other health issues as the main reason for not starting HCV treatment.

3 Access to housing and income improved Access to housing and income supports improved significantly for participants during the study. At the beginning of the study, 54% of participants reported stable housing, and this increased to 76% by the end of the study period. Similarly, the number of participants receiving provincial government disability benefits increased from 55% at the beginning of the study to 75% at the end. Accessing disability supports was considered the marker of income improvement because these benefits are higher than other social benefit programs in Ontario. Several medical assessments are necessary to be approved for benefits and the team supports people to get these assessments done. Housing and income have been shown to be linked to better health outcomes and improved use of healthcare. No changes in overall health Just over half of the participants reported their overall health as poor or fair at the beginning of the study, and this did not change over the study period. The researchers theorized that this might be because the majority of participants were dealing with major health challenges and a high degree of marginalization in their lives. Therefore, a positive shift in self-perceived health may not occur until a longer period has elapsed. Limitations One limitation of this study was its small sample size; however, it represents the largest sample in a prospective study (a study that follows people over time) of highly marginalized people with HCV who use drugs and receive support in a primary healthcare setting. As well, the program used a holistic approach, and participants could have been impacted by a number of interventions. The study wasn t designed to determine which interventions were responsible for which outcomes, making interpretation of results more difficult. Finally, participants may have received healthcare services or support from outside of the program and it was not possible to control for the effect of this support. Conclusions TCHCP was able to improve access to housing, income supports and HCV-related healthcare for people who are highly marginalized and offer support in these and other areas prior to starting HCV treatment. Furthermore, these improvements in care, treatment and support lay the groundwork for improvements in health beyond HCV. The results of the TCHCP study provide evidence for organizations that serve highly marginalized people with HCV who use drugs that this type of program can improve key factors that affect health for this population. Resources Toronto Community Hep C Program Guide Book East Toronto program successfully helps some marginalized people recover from hepatitis C virus CATIE News References Scott Anderson 1. Braveman PA, Cubbin C, Egerter S, et al. Socio-economic disparities in health in the United States: What the patterns tell us. American Journal of Public Health, 2010; 100(S1), S186 S196.

4 2. Charlebois A, Lee L, Cooper E, et al. Factors associated with HCV antiviral treatment uptake among participants of a community-based HCV programme for marginalized patients. Journal of Viral Hepatitis. 2012; 19(12), Grebely J, Raffa JD, Lai C, et al. (2009). Low uptake of treatment for hepatitis C virus infection in a large community-based study of inner city residents. Journal of Viral Hepatitis, 2009; 16, Krieger J, Higgins L, Housing and health: Time again for public health action. American Journal of Public Health, 2002; 92(5), Mason K, Dodd Z, Sockalingam S, et al. Beyond viral response: A prospective evaluation of a community-based, multi-disciplinary, peer model of HCV treatment and support. International Journal of Drug Policy. 2015; in press. 6. McIntosh CN, Finès P, Wilkins R, et al. Income disparities in health-adjusted life expectancy for Canadian adults, 1991 to Health Reports, 2009; 20(4), (Erratum in: Health Reports, 21(4), 101). 7. Mehta, SH Genberg BL, Astemborski J, et al. Limited uptake of hepatitis C treatment among injection drug users. Journal of Community Health, 2008; 33, World Health Organization. Commission on social determinants of health. Closing the gap in a generation: Health equity through action on the social determinants of health. 2008; Geneva: Final Report of the Commission on Social Determinants of Health.

5 Produced By: 555 Richmond Street West, Suite 505, Box 1104 Toronto, Ontario M5V 3B1 Canada Phone: Toll-free: Fax: Charitable registration number: RR Disclaimer Decisions about particular medical treatments should always be made in consultation with a qualified medical practitioner knowledgeable about HIV- and hepatitis C-related illness and the treatments in question. CATIE provides information resources to help people living with HIV and/or hepatitis C who wish to manage their own health care in partnership with their care providers. Information accessed through or published or provided by CATIE, however, is not to be considered medical advice. We do not recommend or advocate particular treatments and we urge users to consult as broad a range of sources as possible. We strongly urge users to consult with a qualified medical practitioner prior to undertaking any decision, use or action of a medical nature. CATIE endeavours to provide the most up-to-date and accurate information at the time of publication. However, information changes and users are encouraged to ensure they have the most current information. Users relying solely on this information do so entirely at their own risk. Neither CATIE nor any of its partners or funders, nor any of their employees, directors, officers or volunteers may be held liable for damages of any kind that may result from the use or misuse of any such information. Any opinions expressed herein or in any article or publication accessed or published or provided by CATIE may not reflect the policies or opinions of CATIE or any partners or funders. Information on safer drug use is presented as a public health service to help people make healthier choices to reduce the spread of HIV, viral hepatitis and other infections. It is not intended to encourage or promote the use or possession of illegal drugs. Permission to Reproduce This document is copyrighted. It may be reprinted and distributed in its entirety for non-commercial purposes without prior permission, but permission must be obtained to edit its content. The following credit must appear on any reprint: This information was provided by CATIE (the Canadian AIDS Treatment Information Exchange). For more information, contact CATIE at CATIE Production of this content has been made possible through a financial contribution from the Public Health Agency of Canada. Available online at: