HepCare: The Effectiveness of Community Based Interventions With Peer Support to Improve Case Detection, Carry Out Pre-treatment Assessments and Assist Underserved Populations Through HCV Treatment

1. Introduction

Hepatitis C infection is a major cause of chronic liver disease and death throughout the world1. Approximately 3% of the world's population is infected with hepatitis C virus (HCV)2.

HCV is transmitted by blood and in the UK occurs primarily through injecting drug use. Chronically infected people are at risk of progressive liver disease characterised by hepatocellular inflammation, hepatic fibrosis, cirrhosis and hepatocellular carcinoma (HCC). These complications develop only in a proportion of patients and only after many years or decades of infection3. It has been estimated that up to 20% of chronically infected individuals will develop cirrhosis of the liver over a 20 to 25 year period. Approximately 3% to 4% of patients with cirrhosis will develop HCC per year3.

New drug therapies such as protease and polymerase inhibitors called direct-acting antivirals (DAAs) have been developed in the last ten years and have recently been licensed for use worldwide. These DAAs have proven to be very well tolerated with minimal, and sometimes no, side effects. The current costs of these agents are extremely high, limiting their use to select populations of infected patients. However, they provide an opportunity to cure most patients with HCV if they can access and adhere to treatment. A bigger challenge is to engage and cure those who are not accessing medical care, or who have other complex problems, including homelessness, incarceration, and substance misuse. These underserved populations are disproportionately affected by infectious diseases such as HCV and face many challenges to access testing and adherence to treatment.

There has been previously demonstrated a high prevalence (13% RNA detectable HCV4) of chronic HCV infection among homeless people opportunistically screened at residential hostels and day centres across London. Data from the HALT Hepatitis Study5 showed that 41% of HCV Ab positive recruits were homeless at enrolment and that over 60% of HCV infected patients knew of their status but had disengaged from treatment services. This population therefore includes a high number of undiagnosed cases and previously known HCV positive cases who are not accessing treatment services.