Study Examines Engagement in Hepatitis C Virus Care among Homeless and non-Homeless VA Patients

BACKGROUND:
VA – the largest provider of care for persons with hepatitis C virus (HCV) – also provides healthcare to more than 200,000 homeless Veterans each year. Although chronic HCV infection is presumed to be highly prevalent among homeless Veterans, large comprehensive analyses are lacking. Thus, this study sought to describe engagement in HCV care among homeless and non-homeless Veterans in the new era of HCV treatment, which includes direct-acting agents (DAAs) with shorter treatment durations, fewer side effects, and higher sustained virologic response (SVR) rates than the older treatment regimens. Using VA data, investigators estimated the total number of VA patients who had chronic HCV infection in 2015, in addition to estimating the number of VA patients who had received HCV antiviral therapy in VA during 2015, as well as estimating the number of patients in VA healthcare in that same year with SVR. Veterans who had at least one outpatient visit in 2015 to any of the clinics designated by VA's National Center on Homelessness among Veterans (i.e., HUD, Veterans Justice Outreach), and who had received homeless services were included in the homeless cohort. Among 242,740 homeless Veterans in care and 5,424,712 non-homeless Veterans in care, 144,964 (13%) and 188,156 (4%), respectively, had chronic HCV infection.

FINDINGS:

• VA providers do a better job of testing for and diagnosing chronic HCV infection among homeless Veterans than they do among non-homeless Veterans: 90% of homeless Veterans who were estimated to have chronic HCV were diagnosed by laboratory testing compared with 77% of non-homeless Veterans.
• The percentage of the total homeless population with chronic HCV infection who had ever received HCV antiviral therapy (23%) was lower than the percentage of the total non-homeless population who had ever received HCV antiviral therapy (31%). However, the cumulative SVR rates achieved among homeless Veterans who had ever received HCV antiviral therapy (68%) and non-homeless Veterans who had ever received HCV antiviral therapy (74%) were comparable.

IMPLICATIONS:

• Efforts are needed to identify appropriate interventions to ensure that more homeless Veterans are candidates for HCV antiviral therapy. Homelessness should not necessarily preclude receipt of HCV antiviral therapy as the direction of future HCV care and treatment eligibility criteria with all-oral DAA regimens is considered.
• Additional research is needed to better describe the characteristics of homeless patients who were deemed eligible for therapy and any services supporting successful antiviral therapy.

LIMITATIONS:

• This study did not include information on the timing of Veteran homelessness in relation to the receipt of HCV care.

AUTHOR/FUNDING INFORMATION:
Dr. Backus is part of HSR&D's Center for Innovation to Implementation (Ci2i) in Palo Alto, CA.

Noska A, Belperio P, Loomis T, O’Toole T, and Backus L. Engagement in the Hepatitis C Care Cascade among Homeless Veterans, 2015. Public Health Reports. March/April 2017;132(2):136-139.