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Research Article
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Journal of Hepatitis
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Community-Based Infectious Disease
Clinics: A Tool of Engagement for Vulnerable
Populations
Vancouver Infectious Diseases Centre,
201-1200 Burrard St., Vancouver, BC,
Canada
Background: Hepatitis C virus (HCV) infection is a major international public health
concern, particularly among people who inject drugs (PWID). The Downtown
East Side of Vancouver (DTES) is known for a high prevalence of HCV infection.
Despite available services, significant numbers of patients remain undiagnosed or
lack access to potentially curative therapy. As such, there is a need to develop
innovative means of recruitment into care and to assess the interest to seek care.
Corresponding author:
Brian Conway
Methods: Community pop-up clinics (CPCs) were held at several DTES sites
(including InSite, the first supervised injection facility in North America). HCV
point-of-care testing was offered. Participants were also offered the opportunity
to complete a survey to collect demographic information as well as data related to
their knowledge about HCV treatment and readiness to receive it. A $10 incentive
was offered for participation.
 [email protected]
Results: Since the inception of the program in March 2013, 1743 individuals
have been tested, of which 1125 individuals completed the survey (implemented
in January 2014), with 568 (33%) infected with HCV. About 45% were unaware
of a cure for this infection, but a vast majority (over 80%) would consider HCV
treatment for it, if it was offered.
Vol. 2 No. 1: 7
Brian Conway
Syune Hakobyan,
Sahand Vafadary,
Tyler Raycraft,
Shawn Sharma
Abstract
2015
Vancouver Infectious Diseases Centre, 2011200 Burrard St., Vancouver, BC, Canada.
Tel: 6046426429
Conclusions: Despite the existence of a cure for HCV infection, several barriers to
HCV treatment have been identified, particularly in vulnerable populations. These
barriers can exist on the levels of the patient, healthcare provider, and the health
care system as a whole. There is a significant gap in HCV treatment knowledge, but
a general willingness to receive care. Innovative low-threshold programs must be
developed to engage those individuals in care.
Keywords: Chronic hepatitis C; People who inject drugs; Treatment barriers
Received: September 28, 2015; Accepted: December 08, 2015; Published: December
16, 2015
Introduction
Hepatitis C virus (HCV) infection is a major international
public health concern, particularly among people who inject
drugs (PWID). HCV is a blood-borne viral infection of the liver
affecting more than 170 million worldwide and over 300,000 in
Canada, including approximately 60,000 British Columbians [1].
Approximately 20% of these individuals are co-infected with
human immunodeficiency virus (HIV), adding to the burden of
disease. HCV can be transmitted through unprotected sex, razors,
toothbrushes, and, rarely, through vertical transmission. However,
© Copyright iMedPub | the major mode of transmission is through blood via sharing of
injection paraphernalia [2,3]. At a population level, injection drug
use is the single most important risk factor for acquiring new
HCV infections in developed countries [4]. According to the 2010
Canadian Hepatitis C Surveillance Report, 61% of HCV infection is
associated with injection drug use [5]. A recent study has shown
that in marginally housed adults in Vancouver, hepatic fibrosis
associated with HCV infection was most commonly associated
with death (hazard ratio 13.02) with none of 371 individuals who
were evaluated having ever accessed potentially curative therapy
for it [6].
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1
Journal of Hepatitis
The goal of treatment of HCV-infected persons is to reduce allcause mortality and liver-related health adverse consequences,
including end-stage liver disease and hepatocellular carcinoma,
by the achievement of virologic cure as evidenced by a sustained
virologic response. Historically, older HCV treatment regimens
had several limitations. Older regimens included interferon
injections, which were contraindicated for some individuals.
Similarly, PWID were offered HCV treatment only after some
period of abstinence according to old guidelines [7]. These older
medications also had lower cure rates. Newer HCV medications
are in some cases all-oral and offer the promise of cure in over
95% of most types of infection. Such regimens have become the
mainstays of treatment guidelines in most Western countries.
According to the recent evidence, treatment is recommended for
all patients with chronic HCV infection, except those with short
life expectancies that cannot be remediated by treating HCV, by
transplantation, or by other directed therapy. Patients with short
life expectancies owing to liver disease should be managed in
consultation with an expert. These same guidelines recommend
that even active injection drug users be considered for treatment
[8,9]. Many healthcare providers are still considering re-infection
as a potential issue and do not initiate HCV treatment in PWID.
As we seek to implement more effective treatment modalities
for HCV infection in all target populations, novel approaches
to engage patients in care must be considered to ensure
maximisation of the success of the intervention. This study
examines the effectiveness of community pop-up clinics as a
tool for engagement of such vulnerable populations. Further, we
sought to assess the knowledge of available HCV treatments and
the willingness to enter care amongst pop-up clinic participants.
Methods
We have evaluated a novel community-based approach to
identify inner city residents infected with HCV and have designed
a model of engagement in care as a prelude to the initiation
of HCV therapy. We have termed this model the “Community
Pop-Up Clinic” (CPC). These clinics are held at specific sites in
Vancouver’s Downtown East Side (including InSite, the first North
American supervised injection site) and are designed to evaluate
up to 30 adults over a 3-hour period. Sites were selected on the
basis of their location and the delivery of specific services (food,
temporary shelter, etc.) for the target population. For HCV testing,
we used the OraQuick® HCV Rapid Antibody Test. This is a singleuse oral swab immunoassay method that qualitatively assays the
presence of HCV antibodies. The participants were instructed to
refrain from eating or drinking thirty minutes before the test was
administered. The result took approximately fifteen minutes to
display. HCV test results were disclosed in a confidential setting.
All HCV-positive individuals were offered an immediate on-site
consultation with a nurse and/or a physician (Infectious Diseases
specialist) to discuss opportunities for engagement in care at
our multidisciplinary clinic. As an incentive for participation,
a $5 gift card was given at the end of testing. This clinic would
offer comprehensive medical care as well as access to trained
personnel to address social needs, such as completion of forms
to obtain government support or to access low cost housing.
Participants were also offered the opportunity to complete a
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2015
Vol. 2 No. 1: 7
survey to collect demographic information as well as data related
to their knowledge about HCV treatment and readiness to receive
it. An additional $5 gift card was provided upon completion of
the survey. All procedures were reviewed and approved by a local
research ethics board. All participants provided written informed
consent prior to participation in the CPC.
Results
Since the inception of the program in March 2013, 1743 individuals
have been tested, of which 1125 individuals completed the survey
(implemented in January 2014). Of these, 568 individuals (33%)
were found to be infected with HCV, 381 of whom agreed to
complete the questionnaire. Key demographic characteristics of
the surveyed population are shown in Table 1. The mean age was
52 and the population was principally men (74%). Almost 30%
identified themselves as First Nations/Aboriginal. Over 55% were
homeless or had unstable housing. A small minority (14%) were
gainfully employed and over 50% had been incarcerated in the
past. Over 40% had never injected drugs, while significant alcohol
use was present in about a fifth of the population. In terms of
knowledge about HCV infection, about 45% were unaware of
a cure for this infection, but a vast majority (over 80%) would
consider HCV treatment for it, if it was offered.
Discussion
Despite the existence of a cure for HCV infection, several barriers
to HCV treatment have been identified, particularly in vulnerable
populations [10]. These barriers can exist on the levels of the
patient, healthcare provider, and the health care system as a
whole.
We designed the CPC model with a few objectives in mind.
The first was to lower barriers to access to HCV testing. The
second was to provide education about HCV infection and
access to comprehensive health care in a context where all
the patients’ needs would be addressed and HCV treatment
could be provided. Our data suggest that the CPC program is
successful and its design has allowed us to access the target
population, with a prevalence rate of HCV infection of over 30%.
The demographic characteristics of the study population are
consistent with that of the DTES of Vancouver, suggesting that we
have evaluated a representative cross-section of the population
of the neighborhood as a whole [11]. Social needs with respect to
housing and income assistance are considerable and will need to
be addressed as part of a comprehensive plan to engage inner city
populations in HCV treatment. It is interesting that a significant
minority of the HCV-infected individuals we have studied claim
not to have ever injected recreational drugs. The role of crack
pipes in the transmission of HCV infection has been identified and
merits particular attention in our group [12]. Almost half of those
we interviewed were unaware of a cure for HCV infection. It will
be interesting to see if specific community-based educational
programs aimed at this specific point (i.e. “get tested, get cured”)
will favour engagement in care going forward. In this regard, it is
particularly encouraging that over 80.0% of participants would
consider HCV treatment if it was offered.
In conclusion, a comprehensive plan to address the HCV
This article is available in: http://hepatitis.imedpub.com/archive.php
2015
Journal of Hepatitis
Vol. 1 No. 1:7
Table 1 Demographics and Behavioural Characteristics of HCV Infected Participants (n=381) Evaluated at Community Pop-up Clinics.
1. Age
2. Ethnicity
3. Gender
4.Current Living Condition
5. Currently
6. Previously Incarcerated
7. Tested For HIV
8. Drinking Alcohol
9. Previous Or Current
10. Is There Cure For HCV
11. Consider HCV Treatment
Average Age
First Nations
White
Other
Male
Female
Transgender
Stable Housing
Unstable Housing
Homeless
Working
Not Working/Other
Yes
No
Yes
No
Never
Less Than Once A Day
≥1 Time Per Day
Injected Drugs
Never Injected Or Shared
Yes
No
I Do Not Know
Yes
No
I Do Not Know
pandemic must include a systematic approach aimed at HCVinfected PWID. Our CPC program in Vancouver has been quite
successful in identifying a target population that seems willing
to receive treatment. Going forward, we will use the information
© Under License of Creative Commons Attribution 3.0 License
52.0 y.o
114
228
43
289
90
4
181
109
105
48
307
269
97
327
52
141
167
69
311
51
290
38
54
295
40
37
29.9%
59.8%
11.3%
75.9%
23.6%
1.1%
47.5%
25.6%
27.6%
12.6%
80.6%
70.6%
25.5%
85.8%
13.6%
37.1%
43.8%
18.1%
81.6%
13.4%
76.1%
10.0%
14.2%
77.4%
10.5%
9.7%
gained in our preliminary CPC evaluations to optimize our
outreach programs, as well as the services we offer at our clinic to
encourage HCV-infected PWID, to engage in care, and to receive
curative HCV treatments in greater numbers.
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Journal of Hepatitis
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