Introduction

Hepatitis B and C viruses (HBV, HCV) are major causes of hepatocellular carcinoma (HCC). Risk factors for HBV/HCV frequently occur in conjunction with homelessness or individuals with experiences of homelessness (IEH) bearing a disproportionate risk (e.g., veterans). Although vaccination for HBV and treatment of HBV/HCV could reduce the prevalence of HCC among IEH, the transient nature of IEH makes treatment and vaccination challenging. The field of homeless services has moved towards a permanent supportive housing model which provides unlimited time housing without behavioral contingencies. The stability of this new housing model provides a unique opportunity to provide HBV/HCV education/screening, deliver HBV vaccination and treat HBV/HCV in IEH.

Methods

GRASSROOTS HEALTH is an innovative cross-sector model, using community health workers (CHW) and nursing staff to bring HBV/HCV education, screening, HBV vaccination, and treatment to the door of residents in permanent supportive housing in Houston, TX- HOU (Phase I). In Phase II of the program, services were expanded to veterans and additional counties starting with San Antonio, TX- SA. During outreach, clients receive HBV/HCV education tailored to responses on a knowledge-based screener. Consenting clients receive a venous blood draw at their residence to test for HBV/HCV and samples are tested for HBsAg and anti-HBs. HCV reflex testing is used to assess HCV status. Clients not undergoing a blood draw receive the OraQuick® HCV Rapid Antibody Test.

Community health workers deliver test results to the clients at their residence, offering immediate vaccination with Engerix-B or HEPLISAV-B for those who are non-immune. Individuals who test positive for HBV/HCV are navigated to a partnering clinic and contacted by CHW daily to encourage treatment adherence.

Results

In Phase I (2018-2022), we provided HBV/HCV education to 918 residents and addressed misperceptions of 62% of these residents. Nearly half of residents reported that they were unsure or had never been tested for HBV (48%) or HCV (44%) with >85% reporting no past year testing. In total, we tested 659 residents. Only 10% reported previous HBV vaccination with 410 clients lacking hepatitis B surface antibodies. We vaccinated 255 clients with 1+ HBV dose (561 vaccinations). In total, 17 clients tested positive for active infection with HBV and 40 for HCV, with 41% navigated into HBV and 90% into HCV treatment, with navigation into HCV treatment taking the CHW approximately 730 instances. 

Phase II has been active for a year and have provided education to 488 residents (219 HOU, 269 SA). We tested 165 HOU residents for HBV and 198 for HCV, of whom 27% reported no lifetime or past year (34%) testing. In SA, we tested 209 residents for HBV and 214 for HCV, of whom 29% reported no recent or lifetime (42%) testing. In addition, 23% of HOU clients and 21% of SA clients indicated no HBV vaccination history. Of those tested, 50% of HOU clients and 72% in SA did not have hepatitis B surface antibodies. A total of 40 residents in HOU and 85 in SA received 1+ vaccination. A total of 2 clients tested positive for HBV (1 HOU, 1 SA) and 13 for HCV (11 HOU, 2 SA).

Conclusion

GRASSROOTS HEALTH reduced barriers to the HBV/HCV continuum of care among permanent supportive housing residents. Despite elevated risks, a majority of clients had not been tested for HBV/HCV in the past year with over 1/3 reporting no lifetime testing. We have had relatively low HBV/HHCV positivity rates, which may be because we provided universal screening to residents, rather than targeting risk factors. A majority of the clients reported that they had not been vaccinated for HBV and did not have hepatitis B surface antibodies. Through the GRASSROOTS HEALTH model, we were able to provide one or more doses of the HBV vaccination to over half of those eligible and had high levels of medication adherence success. The GRASSROOTS HEALTH model represents an effective model to prevent HCC with potential to expand to additional health outcomes.