Provider assessment of eligibility for hepatitis C treatment in HIV-infected homeless and marginally housed persons

Purpose: To characterize the group of providers delivering medical care to HIV and hepatitis C (HCV) co-infected homeless and marginally housed individuals in San Francisco and to assess factors affecting provider decisions to initiate HCV treatment in this population. Subjects and methods: The Research in Access to Care for the Homeless (REACH) cohort is a representative sample of HIV-infected homeless and marginally housed individuals identified from single room occupancy hotels, homeless shelters and free lunch programs in San Francisco. Primary care providers (PCP) for active, HIV/HCV co-infected REACH cohort participants were administered face-to-face, semi-structured interviews. REACH participants were administered quarterly face-to-face structured interviews. Results: 52/62 (83.9%) providers were interviewed regarding 133/155 (85.8%) active, HIV/HCV co-infected patients. Providers classified 94/133 (70.7%) patients as ineligible for HCV treatment. The mean number of reasons for ineligibility was 3.2. Most frequent reasons for provider determination of ineligibility included likelihood of poor medication adherence, depression, active injection drug use and patient disinterest in treatment. In addition, structural barriers to treatment included poor access to testing, delays in evaluation by a gastroenterologist and exclusion from treatment of patients with comorbidities. Conclusions: While HCV infection is common, HCV treatment is rare in the HIV/HCV coinfected urban poor. On average, the PCP in this study are experienced and are familiar with this patient population. There are many reasons for providers classifying patients as ineligible for HCV treatment. While these reasons indicate that treatment is difficult given chaotic lifestyle and concurrent medical conditions of this population, they are not insurmountable barriers. New treatments and strategies are necessary to treat this population with high rates of hepatitis C infection.