Hepatitis C Virus Reinfection in a Real-World Cohort of Homeless-Experienced Individuals in Boston.

BACKGROUND: People experiencing homelessness are disproportionately affected by hepatitis C virus (HCV) infection compared with housed populations. Surveillance for HCV reinfection after successful treatment is a critical step in the care cascade, but limited data on reinfection are available among this highly marginalized group. This study assessed posttreatment reinfection risk in a real-world cohort of homeless-experienced individuals in Boston. METHODS: Individuals receiving HCV direct-acting antiviral treatment through Boston Health Care for the Homeless Program during 2014-2020 with posttreatment follow-up assessment were included. Reinfection was identified based on recurrent HCV RNA at 12 weeks posttreatment with HCV genotype switch or any recurrent HCV RNA following sustain virologic response. RESULTS: A total of 535 individuals were included (81% male, median age 49 years, 70% unstably housed or homeless at treatment initiation). Seventy-four HCV reinfections were detected, including 5 second reinfections. HCV reinfection rate was 12.0/100 person-years (95% confidence interval [CI]: 9.5-15.1) overall, 18.9/100 person-years (95% CI: 13.3-26.7) among individuals with unstable housing and 14.6/100 person-years (95% CI: 10.0-21.3) among those experiencing homelessness. In adjusted analysis, experiencing homelessness (vs stable housing, adjusted hazard ratio, 2.14; 95% CI: 1.09-4.20; P = .026) and drug use within 6 months before treatment (adjusted hazard ratio, 5.23; 95% CI: 2.25-12.13; P < .001) were associated with increased reinfection risk. CONCLUSIONS: We found high HCV reinfection rates in a homeless-experienced population, with increased risk among those homeless at treatment. Tailored strategies to address the individual and systems factors impacting marginalized populations are required to prevent HCV reinfection and to enhance engagement in posttreatment HCV care.

Factors Associated with Sustained Virologic Response to Hepatitis C Treatment in a Homeless-Experienced Cohort in Boston, 2014-2020.

BACKGROUND: Engaging people experiencing homelessness or unstable housing in hepatitis C virus (HCV) treatment is critical to achieving HCV elimination. OBJECTIVE: To describe HCV treatment outcomes, including factors associated with retention through the treatment cascade, for a cohort of individuals treated in a homeless health center in Boston. DESIGN: Retrospective cohort study. PARTICIPANTS: All individuals who initiated HCV treatment with Boston Health Care for the Homeless Program's HCV treatment program between January 2014 and March 2020 (N = 867). OUTCOME MEASURES: The primary outcome was sustained virologic response (SVR), defined as an HCV ribonucleic acid (RNA) level ≤ 15 IU/mL at least 12 weeks after treatment completion. We used multivariable logistic regression to examine the association between baseline variables and SVR. Process-oriented outcomes included treatment completion, assessment for SVR, and achievement of SVR. RESULTS: Of 867 individuals who started HCV treatment, 796 (91.8%) completed treatment, 678 (78.2%) were assessed for SVR, and 607 (70.0%) achieved SVR. In adjusted analysis, residing in stable housing (OR 3.83, 95% CI 1.85-7.90) and age > 45 years old (OR 1.53, 95% CI 1.04-2.26) were associated with a greater likelihood of achieving SVR. Recent drug use (OR 0.63, 95% CI 0.41-0.95) was associated with a lower likelihood of SVR. Age, housing status, and drug use status impacted retention at every step in the treatment cascade. CONCLUSION: A large proportion of homeless-experienced individuals engaging in HCV treatment in a homeless health center achieved SVR, but enhanced approaches are needed to engage and retain younger individuals, those with recent or ongoing substance use, or those experiencing homelessness or unstable housing. Efforts to achieve HCV elimination in this population should consider the complex and overlapping challenges experienced by this population and aim to address the fundamental harm of homelessness itself.

Estimating the Prevalence of Advanced Fibrosis in Homeless Adults with Hepatitis C in Boston.

BACKGROUND AND AIMS: Hepatitis C virus (HCV) infection is highly prevalent among homeless individuals, but the scope of HCV-associated liver fibrosis in this population is poorly understood. METHODS: Using the FIB-4 Index, we describe the prevalence and correlates of advanced fibrosis among a retrospective cohort of all homeless-experienced adults with HCV seen at Boston Health Care for the Homeless Program (BHCHP) over a one-year period. RESULTS: Of 832 BHCHP patients with HCV, 15.8% had advanced fibrosis. In multivariable regression analysis, alcohol use disorder (adjusted odds ratio [aOR] 2.50, 95% confidence interval [CI] 1.65-3.81) and having unknown or poorly characterized housing circumstances (aOR 2.88, 95% CI 1.02-8.14, relative to housed patients) were independently associated with advanced fibrosis. CONCLUSIONS: The prevalence of advanced fibrosis in this cohort of homeless adults with HCV appears similar to national estimates among housed individuals, but their psychosocial complexity is greater, especially among those who are older.

What do surviving children wish for from a dying parent? A qualitative exploration.

Legacy may play an important role in how children integrate the loss of a parent. Sixteen adults (19-40 years old, 69% women) who experienced the death of a parent from an illness before age 12 were interviewed, exploring legacies from their deceased parent. Transcribed interviews were iteratively analyzed by three independent coders. Extracted themes described their experiences and wish for remembrances and specific communication left for them, information about the parent's values and feelings about them, and personal possessions. This study provides novel data about legacies that bereaved children wish for in adulthood.

Hepatitis C treatment outcomes among homeless-experienced individuals at a community health centre in Boston.

BACKGROUND: Hepatitis C virus (HCV) infection prevalence is high among adults who experience homelessness but data on HCV treatment outcomes are limited in this population. We examined HCV treatment engagement and outcomes in a cohort of homeless-experienced adults treated through an innovative community-based primary care program in Boston, Massachusetts, USA. METHODS: We conducted a retrospective chart review of individuals referred for HCV treatment at Boston Health Care for the Homeless Program (BHCHP) from January 2014 to March 2017. We assessed HCV treatment initiation, treatment completion, sustained virologic response (SVR), and reinfection rates. We conducted univariate and multivariable logistic regression analyses to examine the predictors of these outcomes. RESULTS: Of 510 referred for HCV treatment, 210 (41.1%) did not initiate treatment, principally because of being lost to follow-up (N = 93) or having superseding social issues (N = 49). Of 300 who initiated treatment, 80% were male, 52.3% were non-white, and 29% were homeless. Over half (58.6%) had a history of opioid use disorder (OUD). Twenty percent had cirrhosis. Treatment was completed by 285 (95.0%) individuals, and 255 (85.0%) achieved SVR. In multivariable analyses, individuals with bipolar disorder (OR 0.38, 95% CI 0.15-0.99), treated (OR 0.36, 95% CI 0.14-0.96) or untreated (OR 0.18, 95% CI 0.05-0.57) OUD, or on-treatment insurance change (OR 0.16, 95% CI 0.04-0.67) were less likely to achieve SVR, while individuals living with HIV (OR 10.43, 95% CI 1.33-81.96) were more likely to achieve SVR. Among 126 individuals with post-SVR follow-up data, 27 reinfections were identified during 206 person-years of follow up (rate 13.1 per 100 person-years). CONCLUSION: Homeless-experienced individuals initiating HCV treatment in a community-based program achieved high rates of treatment completion and SVR, but a large proportion did not initiate treatment. Individuals with OUD experienced lower but still substantial rates of cure. Treatment strategies targeting homeless-experienced people should focus on improving initial engagement and minimizing reinfection risk following treatment.

Needs Assessment of HCV-Infected Individuals Experiencing Homelessness and Implications.

The advent of tolerable, efficacious therapies for hepatitis C virus (HCV) creates an opportunity to provide HCV treatment for individuals experiencing homelessness. A federally-qualified community health center serving individuals experiencing homelessness in Boston conducted an anonymous needs assessment survey of a sample of HCV-infected patients in order to inform development of an HCV treatment program (N = 240). Primary care providers (PCPs) were identified as the chief source of HCV education. Main motivators to consider HCV treatment were identified as "taking care of your health" (73.5%) and "your provider says you should get treated" (53.6%). Interest and confidence to complete HCV treatment were high. The majority of respondents (51.4%) preferred to receive HCV treatment in the primary care setting. Preference for PCP-based treatment was significant compared to liver specialty-based treatment (30.8%, p < .0001). This is the first assessment of its kind describing the preferences of homeless individuals concerning hepatitis C treatment.

Recognition and treatment of depression and anxiety in patients with acute myocardial infarction.

The objective of this study was to determine the ability of providers (medical residents and nurse practitioners) on inpatient cardiac units to recognize and appropriately treat patients with clinically significant depression and anxiety among a cohort admitted with acute myocardial infarction. Patients within 72 hours of acute myocardial infarction underwent screening with the Standardized Clinical Instrument for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition module for major depressive disorder (MDD), the Beck Depression Inventory (BDI-II), and the Beck Anxiety Inventory (BAI). In addition, the study psychiatrist and a treatment team clinician independently assessed whether they believed that patients had clinically significant depression or anxiety. Prescription of antidepressants and benzodiazepines during hospitalization was recorded by chart review. Assessments were completed for 74 patients. Providers identified < 15% of patients with current MDD or with a BDI score > or = 10; 11% of patients with current MDD had appropriate treatment with antidepressants. There was no significant correlation of providers' assessment of depression with current MDD, BDI scores, or psychiatrists' clinical assessment of depression. In contrast, providers identified 31% of patients with a BAI score > or = 10 and 50% of patients who were assessed by psychiatrists as anxious; > 80% of patients with high anxiety received benzodiazepines. Providers' assessments of anxiety were significantly correlated with BAI scores and with psychiatrists' clinical assessments. In conclusion, medical residents and nurse practitioners routinely under-recognize and undertreat depression among patients with acute myocardial infarction on inpatient cardiac units. Recognition and treatment of anxiety is substantially better, up to 50% of patients who are found to be anxious by psychiatrists after acute myocardial infarction remain unrecognized.