1. HEPCARE EUROPE Lessons learned on HCV testing and treatment through outreach to the community and linkage-to-care Dr. Jack Lambert
Dublin │ London │ Bristol │ Seville │ Bucharest

2. HEPCARE: A new Hepatitis C Care service model
OBJECTIVE: Improve access to HCV testing/treatment among risk groups, through outreach and integration of primary / secondary care
HEPCARE EUROPE: €1.8M 3-year EU-supported project at 4 member state sites
Consortium members: UCD (Ireland); SAS (Spain); SVB (Romania); University of Bristol (UK); University College London (UK)
Primary Care
Secondary care
WP4: HepCheck (screening)
WP5: HepLink (linkage to care)
WP 7: HepFriend
(peer advocacy support)
WP 6: HepED
(inter-professional education)
WP8: HepCost WP 1 Coordination; WP 2 Dissemination; WP3 Evaluation

3. Hepcheck: screening
The HepCheck component of the project offered screening for HCV across the four clinical sites: Dublin, London, Seville and Bucharest.
Point of care testing was offered to ‘at- risk’ groups who are frequently marginalized with respect to health service engagement.
Screening was conducted in prisons, opioid substitution treatment clinics and in homeless services.

4. Hepcheck
Active case finding at services used by ‘at risk’ groups (nurse liaison)
Identify HCV patients
Fibroscan testing
Providing harm reduction advice on preventing reinfection
Work in partnership with NGO / Primary care / Secondary care / Prison health services / Addiction treatment services
Ultimately linkage to care/cure (90:90:90)

5. WP - HEPCHECK- OVERVIEW
DUBLIN
Mounjoy prison
712/581
Cork 220/181
Mountjoy
129/581
23.3%
Cork 34/181
18.8%
Bloods : 576
Ab: 5
Cork (pending) 67
LONDON
BUCHAREST
SEVILLE
TOTAL
1. No. of individuals offered/screened
697/431
-/501
692/435
2822/2129
2. Proportion of individuals with positive HCV antibody on screening
HCV Ab Test: 34/131
(26%)
Known HCV chronic: 155/431 (36%)
Total HCV Ab +ve:
189/431 (43.9%)
 208/501
41.5%
HCV Ab Test: 151/435
Known HCV +: 13/98
Total HCV Ab +ve: 168/435
(38.6%)
728/2129
(34.2%)
3. No. of individuals screened (Ab only, bloods only, both Ab and bloods)
Screened Ab only: 97
Screened Ab + Venous: 12
Screened Ab + DBS: 22
DBS only: 41
No bloods (i.e. existing result): 104
Ab 365
Ab + bloods 106
Ab: 286
Bloods:127
Ab + bloods: 22 -
4. No. of HCV Ab+ individuals (either new or previously diagnosed) attending specialist appointment for HCV assessment.
179 referred
83* attending appointments
30* approved for treatment 66 62
278

6. Homeless Hepcheck Results Dublin
619 OFFERED SCREENING
547 SCREENED
72 NOT SCREENED
Previous HCV Ab test?
Yes +ve: 12
Yes -ve: 11
Yes, unsure of result: 3
No/missing: 46
38% Ab positive (206)
Of which:
112 "new positives"
94 "known positives
57% Ab negative (310)
31 no result/awaiting result (5%)
51 referrals
33 attendances
2 completed treatment

7. HepCheck- Homelessness study
Found that in this cohort, even the most stable population has difficulty accessing treatment
Active past 30-day drug use was common, along with attendance for drug treatment.
Unstable accommodation was the most common barrier to attending specialist appointments and accessing treatment.
Depression and anxiety, dental problems and respiratory conditions were common reported health problems.
'HepCheck Dublin': An Intensified Hepatitis C Screening Programme in a Homeless Population Demonstrates the Need for Alternative Models of Care

8. HepCheck- Homelessness study
This study demonstrates that the current hospital-based model of care is inadequate in addressing the specific needs of a homeless population and emphasises the need for a community-based treatment approach
The transient nature of this cohort results in difficulties in contacting and sending reminders for appointments
Bringing treatment to the community is key
Mobile health units, currently used in Ireland ‘SafetyNet’ programme for homeless and asylum
seekers , is being successfully implemented
'HepCheck Dublin': An Intensified Hepatitis C Screening Programme in a Homeless Population Demonstrates the Need for Alternative Models of Care

9. HepCheck Learnings
Community based screening intervention can enhance HCV diagnosis for at risk populations.
Referrals to/attendance to secondary care remains a challenge for this cohort.
Psychosocial factors at the core of why patients do not attend secondary care for HCV management.
Addiction, mental health and homelessness were especially problematic
New models to provide care in the community in partnership with secondary care are a critical priority (vertical linkage, horizontal linkage gaps are apparent)
Even with ‘free curative DAA treatment’ for all in Ireland, vulnerable groups are not getting the ‘cure’.

10. HepLink: Linkage to Care
The HepLink component aims to improve linkage to specialist care of HCV-infected patients across the four sites: Dublin, London, Seville and Bucharest
A model of HCV care (‘HepLink’) which integrates primary and specialist care was developed and implemented at each site, tailored to the population need and local primary care infrastructure
The feasibility, acceptability and likely efficacy of the ‘HepLink’ model of care is being evaluated

11. HepLink: Methods
Primary and community care sites in Dublin, London, Bucharest and Seville were recruited from the professional networks of consortium members
Patients were eligible to participate if:
≥ 18 years of age
on OST or at risk of HCV
attend the practice/service during the recruitment period
Data on patient demographics and current HCV management were collected on participating patients at baseline

12. Process of care 100 Nurse assessments
The integrated model of HCV care has been piloted in all 14 practices
100 Nurse assessments
45 HCV Ab+ patients had fibroscan
21/45 (46.7%) scored ≥8.5 kPa
13/45 (28.9%) were cirrhotic, i.e. scored > 12.5 kPa 12

13. HepLink Learnings
High HCV prevalence, but access to assessment/treatment a challenge (47% attended appointments, /15% received treatment and cure)
GPs need more training and education on HCV
Interpreting results
Manage patient cohort
HCV treatments
Patient rely on integrated nurse education to:
Reduce fears and stigma
Understand transmission and treatments
Manage treatment and lifestyle
Community outreach and service integration is key
Gaps in linking services vertically and horizontally need to be bridged/fixed
Multiple morbidities, multiple co-infections

14. WP 7 - HEPFRIEND DUBLIN LONDON BUCHAREST SEVILLE TOTAL Other
DUBLIN
LONDON
BUCHAREST
SEVILLE
TOTAL
Numbers of peers trained:
HCV awareness
Testing
Fibroscan 12
n/a 4 8 7 5 3 2 6 - 29 15 11
Numbers patients
contacted
Tested
Engaged with services
Treatment 57 27 9*
279
160 83 30 37 22
395
197
132 43
Data collected on peer intervention
Yes: Time, intervention& outcome
Yes: Specific cost and outcome data
Patient related data
Peers trained in other diseases
BBVs / TB TB
Linkage with influenza / pneumococcal / HBV vaccinations
HIV
?E-DETECT
Peers incorporated into treatment pathway or commissioned
Yes: allocated across 4 OST sites supporting referrals
Yes: Peers used by local referral teams
Possibly commissioning structure
Yes: Local treatment network of Romania university hospitals
Other
VOT
Traveller pilot study
E-DETECT collaboration?

15. Conclusions
Partnership with drug treatment centres that administer opiate substitution therapy is a well established strategy for treatment of HIV; it works for HCV as well
Partnership with homeless services in locations that dispense medications to their patients will work
Mobile health units can reach hard to engage populations
An integrated care nurse has been vital for linkage to care in this cohort
Peer support, to assist vulnerable clients through the complex journey HCV patient must travel, is promising.
HCV elimination in the EU by 2026/2030?

16. Acknowledgements
Co-funded by the European Commission through its EU Third Health Programme and Ireland’s Health Services Executive
Participating GPs, Addiction and Homeless Services, and patients
Our partners: UCL, Bucharest, U Bristol, SAS Seville
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