Hepatology

Gastroenterologists back mission to bring HCV cures to the homeless


Dr Amany Zekry

Gastroenterologists are backing a model of clinical outreach clinics that aim to tackle high rates of hepatitis C in homeless men.

A team at St George Hospital in Sydney tracked the health problems of 257 of 561 men who resided at the Mission Australia Centre (formerly Sydney City Mission) homeless refuge in Surry Hills for six years to December last year.

Compared with the rate in the general population of up to 2%, 29% of the men who attended the clinic between November 2011 and December 2017 – the majority aged over 45 – had hepatitis C and other liver disease, their study found.

These were among key health issues for the men after mental health disorders (64%), metabolic disorders (44%), cardiovascular disease (38%) and respiratory disorders (21%).

Almost 70% were current smokers, 62% had a history of chronic alcohol abuse and 66% had abused other substances.

Writing in Internal Medicine Journal, co-author Dr Amany Zekry, associate professor of gastroenterology and hepatology at UNSW, said the need to embed HCV treatment of the homeless in a package of care was “essential” and “a national problem”.

As the disease is the “number one cause of liver cancer and liver transplants in Australia by eliminating it we are offloading a huge burden on the health system,” she said.

Since DAAs, with their 90-95% cure rate, were available on the PBS, every Australian, including the homeless, was entitled to the same treatment and standard of care, she stressed.

Lead author Professor Mark Brown, Professor of Renal Health at St George Hospital and UNSW and colleagues proposed that on-site clinics at all homeless residential centres in Australia could be established in a “co-ordinated permanent and funded fashion” by state health departments and Primary Health Networks.

The outreach service set up by St George Hospital was initially a specialist physician-led clinic with on-site blood collection and dispensing of antihypertensives, other drugs and vaccinations with occasional specialist referrals for dermatology and other interventions as well as programs for smoking and abuse of alcohol and crystal meth.

When new DAAs became available the service developed in 2015 to include monthly-on-site liver screening (including fibroscans) and treatment of Hepatitis C. Soon after weekly psychiatric care was introduced.

Caseworkers held medications for the men “which ensures 100% compliance, particularly for Hepatitis C treatment over a 12-week period”, the authors noted.

With 1 in 200 people homeless each night, more often men and most commonly through family breakdown, violence and assault, the study showed that this model – a whole person medical care program on-site at refuges – should be possible “if Health Departments recommend this be implemented”, the authors stated.

Professor Brown, told the limbic that the title of the paper – Medical Complications of Homelessness: A Neglected Side of Men’s Health “was deliberate”.

“Unfortunately it’s known that homeless people die younger than everyone else and the reasons that they die are largely for the reasons that other people die – it’s just decades younger. Part of that is access to healthcare.

“We got data from day one so we know what sort of problems we were facing.  So now we can adjust, including hepatitis C treatment, on-site.”

Both specialists agreed that a state-wide, if not nationally co-ordinated approach to an agreed model of healthcare for the homeless needed immediate attention.

Professor Brown said the hospital outreach model they used, which was scalable with relatively few costs but in other places largely voluntary, “is working”.

And while there may be “better systems” to evolve, a start would be to allocate every homeless shelter to a relevant health district as “part of their remit”.

“The point [of the paper] was just to get this message out and hopefully now – with data – have meaningful discussions with health planners in the future,” Professor Brown said.

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