Street-Based Hepatitis C Treatment and Patient Experiences Among Adults Experiencing Unsheltered Homelessness.

Abstract

IMPORTANCE: Despite high rates of hepatitis C virus (HCV) infection among people experiencing unsheltered homelessness and the availability of highly effective treatments, this population remains underserved by traditional treatment models. OBJECTIVE: To explore the perspectives of patients experiencing unsheltered homelessness who are engaged in street-based HCV treatment. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study conducted one-time, in-person, semistructured interviews from June to August 2023 of adults (aged ≥18 years) who initiated HCV treatment through a street medicine program providing comprehensive primary care to people experiencing unsheltered homelessness in Los Angeles County, California. Data were analyzed using a modified grounded theory approach with thematic analysis from November to December 2023. EXPOSURE: Engagement in street-based HCV treatment as part of patient care via a street medicine program. MAIN OUTCOMES AND MEASURES: Primary outcomes were participant-reported experiences with HCV treatment. Secondary measures included treatment completion, sustained virologic response (SVR), and clinician confidence ratings, obtained through medical record review and clinician survey. RESULTS: A total of 15 participants (mean [SD] age, 48.8 [7.6] years; 12 [80%] male) were interviewed, 13 (87%) of whom were unsheltered at treatment initiation. Of the 15 participants, 12 (80%) completed treatment and 10 (67%) achieved SVR. Two participants who completed treatment were lost to follow-up before confirmatory SVR laboratory samples could be drawn. Four major themes emerged: things that changed, including participants' housing status, optimism, sense of agency, commitment to their health, and HCV-related knowledge; barriers to treatment, including challenges related to unsheltered homelessness, concerns about medication adverse effects, and prior denial of treatment; facilitators to treatment, including support networks, trusted relationships with clinicians, close follow-up, and tolerability of newer medications; and communication, reflecting participants' desire to share treatment successes and encourage peers to seek treatment. Clinician confidence in treatment completion varied and did not consistently align with patient outcomes. CONCLUSIONS AND RELEVANCE: In this qualitative study of street-based HCV treatment among adults experiencing unsheltered homelessness, participants described care as accessible, supportive, and transformative, reporting wide-ranging psychosocial benefits achieved through engaging in care. Findings highlight street-based, patient-centered models as a promising approach to HCV treatment for unsheltered homeless populations and the importance of policy environments that enable low-barrier care delivery.