Abstract
Background/Aims Approaching hepatitis C virus (HCV) elimination we are left with an increasing complex and marginalised cohort such as people who are homeless (PWAH). We aimed to assess not only clinical but patient reported outcomes (PRO) and health economic outcomes of a novel community-based care model for PWAH. Methods The END C study (2019–2023) based at multiple community homeless sites in southeast England provided point of care HCV testing, transient elastography (TE), onsite direct acting antiviral (DAA) treatment, peer mentor support, and contingency management (food vouchers). Generic (SF-12v2 and EQ-5D-5L) and liver-specific (SFLDQoL) health related quality of life (HRQoL) was assessed before and at end of HCV treatment. Costs/HCV case detected and cured were calculated. Primary outcome measure was sustained virological response (SVR12) (intention to treat ITT). Results A total of 418 individuals were recruited, mean age 44 ± 10.6, 78% male, 74% being homeless at initial assessment. Prevalence of current injecting drug use (IDU), alcohol use and positive HCV RNA were 25% (95% CI 21%-29%), 65% (95% CI 60%-69%) and 28% (95% CI 24%-33%) respectively. Forty-seven percent of the cohort had previously been incarcerated. Of the 344 individuals with a valid TE result, prevalence of cirrhosis (LSM≥12kpa) was 12%. Of the n=116 with a positive RNA, n=105 (91%) received DAAs of whom 91% were currently homeless, current IDU and current alcohol use being 88% and 93% respectively. ITT SVR12 rates were 81% (95% CI 72%-88%). The only predictor of non-SVR 12 was ≥80% adherence (OR 0.04, 95% CI 0.012–0.148, p<0.001). Reinfection data awaited. HRQoL improved significantly at end of treatment in those with SVR12: SFLDQoL: symptoms (p=0.0043), effect on daily life (p=0.0031), memory (p=0.2403), distress (p=0.0155), loneliness (p=0.0126), hopelessness (p=0.2476), sleep (p=0.0164) and stigma (p=0.0055); SF-12 v2 :physical (p=0.0023) and mental health domains (p=0.0374); and EQ-5D-5L composite profile score (p=0.0037) and visual analogue scale (p<0.001). Cost (British pounds 2022) per case detected was £279; mean cost per cure (excluding DAA costs) being £137. Mortality in the treated cohort was 9.5%, the most common cause being drug overdose. Conclusions With novel engagement strategies, excellent SVR12 rates can be achieved in PWAH at modest costs. In addition, SVR12 is associated with significant improvement in both generic and liver specific HRQoL.