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HEPATITIS C TREATMENT OF A MARGINALIZED POPULATION: A MULTI-DISCIPLINARY PRIMARY PRACTITIONER-LED TREATMENT MODEL IN PRACTICE
A Newman, S Beckstead, S Finch, T Knorr, C Lynch, M MacKenzie, R Robertson, R Shore
Street Health Centre, Kingston, Ontario
Aims: Kingston’s Street Health Centre provides accessible and responsive health care to communities that are marginalized from mainstream health services. The client population includes people who use illicit drugs, people involved in the sex trade, people who are homeless, high-risk youth, and people recently released from incarceration. Street Health serves approximately 750 clients, the majority of whom are Hepatitis C Virus (HCV) positive.
In June 2006, Street Health began a HCV Treatment Clinic. Street Health’s HCV clients are traditionally excluded from standard gastroenterology clinics due to ongoing drug use, psychiatric comorbidities, or social instability. Street Health’s approach aims to show that by using a multi-disciplinary and collaborative treatment model, a marginalized HCV population can be successfully treated.
Methods: Street Health’s HCV Clinic accepts internal referrals of HCV RNA-positive patients. Patients undergo an extensive assessment by a multi-disciplinary team: the Nurse Practitioner completes a general physical assessment; the Family Physician (who has completed a Canadian College of Family Physicians Hepatitis C Fellowship) determines if a liver biopsy is warranted; the Counsellor administers the Addiction Severity Index and provides practical assistance; and the Psychiatrist assesses all patients. The clinical team evaluates likelihood of success against client motivation, medical safety, social stability, and severity of disease before selecting suitable patients for treatment.
Patients who elect to initiate treatment receive standard doses of pegylated interferon and ribavirin. Treatment protocol requires weekly Clinic visits with the Hepatitis C Nurse, who administers the interferon injection and monitors compliance, side effects, quality of life and treatment success. Patients meet with the Counsellor bi-weekly and with the Family Physician and Psychiatrist as required. The clinical team meets weekly to evaluate treatment progress.
Results: To date 12 patients have initiated or completed treatment. All are former or current illicit drug users. Fifty percent completed treatment, 25% are still in treatment, and 25% stopped early. Of those who completed treatment, four achieved sustained virological response (SVR). The remaining two achieved early virological response and have yet to be tested for SVR. Treatment was stopped because of non-response in two patients and side effects in one patient. The majority of treatment patients (8) were genotype 1 and the remainder (4) were genotype 3.
Conclusions: Treatment of high-risk, marginalized and traditionally underserved HCV patients is possible in a community-based clinic using a multidisciplinary collaborative model of care.