Introduction

Hepatitis C virus (HCV), the most common bloodborne illness in the U.S., is a leading cause of death, and it costs the U.S. healthcare system billions each year [1,2]. Over 2 million people in the U.S. (about 1% of the U.S. adult population) are living with HCV, and more than 40% of people with chronic HCV are unaware of their status [3,4]. More than 50% of the HCV cases in the U.S. are concentrated in 9 states, including Texas [5,6]. Historically, the highest prevalence rates of chronic HCV in the U.S. were reported among “baby boomers” (individuals born between 1945–1965), but in 2018, the largest proportion of reported chronic HCV cases were among individuals aged 20–39 and 50–69 (the latter group are baby boomers) [7]. Furthermore, studies indicate that HCV prevalence among adults with experiences of homelessness ranges from 9.8% to 52.5% [8].

Screening and knowing one’s HCV status is the first step in the HCV care continuum, but only 56% of individuals with HCV are aware of their status [5,8,9]. For example, a study among 246 women experiencing homelessness in San Francisco found that approximately one-third of the women who were positive for HCV were unaware of their status [10]. Though previous screening guidelines focused on screening baby boomers, new Centers for Disease Control and Prevention (CDC) screening guidelines recommend screening all individuals 18 years and older at least once in their lifetime, all pregnant women during each pregnancy, and all individuals with risk factors for HCV (with repeat testing while risk behaviors continue) [5]. Being unaware of one’s HCV status not only increases the risk of infecting others, but it may also lead to serious health complications [7].

A lack of health insurance, disjointed medical care, and low health literacy have been cited as challenges to implementing HIV and HCV prevention programs among individuals engaged in substance use and individuals experiencing homelessness [8,11,12]. Researchers have found that individuals engaged in substance use receive less referrals to HCV specialists due to a lack of knowledge and skill-building around HCV among providers [8]. Researchers have also found that participants referred to another site for HCV-related care seldom show up [8,13]. However, strategies such as reflex testing (e.g., HCV antibody test first, then confirmatory HCV test, if antibody test is positive) may reduce the number of individuals who do not receive confirmatory testing following their initial screening [8,14]. Also, point-of-care testing such as rapid HCV tests, along with other same-day services (e.g., for medication), are effective ways to eliminate barriers for individuals experiencing homelessness, who often lack access to transportation [15].

Ending the HCV epidemic requires expanding the type of providers who screen for, diagnose, and treat HCV to include those in non-traditional, community settings [16,17]. Community organizations can effectively screen, diagnose, navigate high-risk individuals into care, and retain them in HCV care [18]. Screening for HCV in community settings can also help reach individuals who are disengaged from medical care in a way that is relevant to their circumstances [16,19]. Alternative settings for HCV screening have helped improve community awareness and identify individuals who were unaware of their HCV infection or aware of their HCV infection but not connected to treatment [17].

HCV screening is not a main priority for many individuals experiencing homelessness [15], who are at disproportionately high-risk for HCV because they are more likely to engage in known risk behaviors for HCV [20,21]. HCV is transmitted through contact with infected blood, most commonly through injection drug use [7,13,22,23]. Organizations providing homeless services may benefit from integrating healthcare for HCV and providing integrated services [20]. Integration of services for high-risk groups, such as individuals experiencing homelessness and those engaged in substance use, increase uptake of both screening and treatment for HCV [13]. However, it is critical to understand participant needs and characteristics to effectively integrate HCV care with other services for high-risk groups [13].

Multidisciplinary program models are essential to the prevention of HCV and HIV among high-risk groups [11]. Integrated HIV/HCV testing at a methadone clinic resulted in a testing rate of 79%, and HIV/HCV screening programs integrated to medication assisted treatment (MAT) programs found screening rates between 95–99% [13]. Providing screening, education, counseling, and case management at methadone clinics was shown to be an effective method of treating HCV and ensuring adherence to care [24]. Screening utilizing both rapid HCV and HIV tests at substance abuse treatment programs was also shown to be cost effective [25]. Rapid HCV tests offered in an MAT facility significantly increased HCV screening rates from 76% to 94% [13]. Integrated STI and HCV testing also led to an HCV testing rate of 92% among people who inject drugs [13]. A nurse-led HCV care model found that integrated programs promoted both testing and treatment initiation, with a 78% screening rate and a 100% cure rate for those who were positive for HCV [15].

Despite their great promise for improving HCV screening, integrated programs face challenges such as staff opposition to workload and training, as well as limited organizational capacity and resources [13]. Providing referrals to additional care is another challenge in less integrated programs (such as those that only provide screening) [13].

There are multiple gaps in the current literature related to integrated program models. First, studies on integrated models with HCV provide a quality of evidence that is low to moderate, with very few rigorous designs [13]. Second, HCV integration approaches varied across studies, making a comparison between studies and replication of program models difficult [13]. Third, studies on integrated models with HCV utilized small samples, and were implemented in settings that may not be generalizable to other locations and populations [15]. Fourth, there is scant information about strategies to improve teamwork and communication among teams implementing integrated HCV programs, although these strategies may be critical to the expansion of these programs and also increase retention [11]. Lastly, there is a limited understanding of budgetary concerns and considerations, which are critical to the implementation of integrated HCV program models [11].

In the present study, we investigated organizational challenges and facilitators associated with screening individuals experiencing homelessness for HCV. This study aimed to identify challenges and facilitators in screening individuals experiencing homelessness for HCV as reported by homeless service providers.

Methods

Results

Participant characteristics

A total of 21 employees of two community-based organizations that provide social and health services to individuals experiencing homelessness in Houston, Texas, participated in this study. Mean participant age was 41 years old (median: 38; SD: 12.83), with a range from 24 to 67 years old. Most participants were female (71%; n = 15) and identified as Black or African American (57%; n = 12) (Table 1). Participants had various levels of educational attainment: some college, Associate’s Degree, or technical degree (38%; n = 8); a Bachelor’s degree (24%; n = 5); and postgraduate studies (29%; n = 6).

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Table 1. Demographic characteristics of study sample.

https://doi.org/10.1371/journal.pone.0273302.t001

Most participants had been employed at their respective organization between one year, but less than three years (33%; n = 7), and some had been employed for more than 10 years (24%; n = 5). Almost half of participants were employed in social services (42%; n = 9) as case managers, navigators, social workers, and community health workers (CHWs). The remaining participants were employed in management/administration (29%; n = 6) and in clinical roles (29%; n = 6).

Discussion

The present study investigated the organizational challenges and facilitators to providing HCV screening to individuals experiencing homelessness from the perspective of homeless services providers. Participants identified (a) funding, logistics, and resource-related challenges, as well as (b) limited information and collaboration around HCV screening as the primary barriers to providing HCV screening to individuals experiencing homelessness. Screening facilitations included (a) providing HCV education and training to all staff and (b) the need to incentivize, formalize, and fund HCV screening.

Other studies on HCV have noted that there is a limited understanding of budgetary concerns and considerations, which are important to the adequate implementation of integrated program models [11]. In the case of HCV screening at the two participating organizations, established grant-funded priorities set the agenda for which screenings are prioritized. Policymakers and funders can move the needle on HCV screening by increasing funding opportunities available to community-based organizations and by making HCV screening as much of a funding priority as other infectious diseases known to disproportionately impact individuals experiencing homelessness. Organizations can use these resources to provide staff training and education, increase staffing, and eliminate existing procedural and structural barriers hindering access to screening.

In addition to grant-funded priorities, several logistical and resource-related limitations were identified as barriers to screening individuals experiencing homelessness for HCV, including not providing on-site screening and rapid testing. Previous studies have reported that high-risk individuals who are referred out for HCV-related care seldom show up for appointments at another location due to challenges related to transportation [8,13]. Having integrated HCV screening would allow individuals to have convenient access to a one-stop shop of services, which has been shown to increase uptake in HCV screening [13]. Researchers have concluded that point-of-care testing strategies (such as rapid testing) and same-day services eliminate barriers including long wait times and ongoing transportation needs [8,13,15]. Understanding the needs and priorities of high-risk groups can support the effective implementation of integrated HCV care with other social and health services [13].

Another substantial challenge around HCV screening is limited information and collaboration, as well as limited knowledge HCV and discomfort discussing HCV. In fact, HCV screening and HCV-related care coordination is not mentioned in either of the participating organization’s websites, though one organization’s website mentions HIV and TB testing. Previous studies have found that individuals engaged in substance use receive less HCV care referrals, a challenge that can be alleviated through provider education about HCV care, stigma, and bias against people engaged in substance use [8]. This gap in knowledge presents organizations with an opportunity to provide staff with training about HCV, HCV screening recommendations, and HCV screening process. Posting easily visible and accessible materials around the facility can also help increase HCV education among staff.

Issues around collaboration and information sharing were also identified as challenges to screening individuals experiencing homelessness for HCV. Previous studies have reported challenges in providing referrals, and this breakdown in collaboration and information sharing is a significant challenge to providing information, education, and access to HCV screening to individuals experiencing homelessness [13]. Because clients at both the social services organizations and their neighboring clinic partners overlap, a commitment to innovative, full integration can prove highly effective in increasing HCV screening and treatment, as researchers have shown in past studies [16,17]. Future studies should consider exploring the wide spectrum and variability of integration approaches within community-based organizations.

The incentivization, formalization, and funding of HCV screening were mentioned by participants as additional ways to facilitate HCV screening. Establishing standard and formalized protocols for HCV screening (e.g., frequency and eligibility of screening) can help mobilize staff to screen more individuals and elevate HCV as an organizational priority. Clinical staff would benefit from education about the most recent HCV screening guidelines set forth by the CDC and other health agencies. Social service and administrative staff would benefit from knowledge around their clinic partner’s procedures for HCV screening in order to inform clients of what to expect and how to prepare for HCV screening. Another strategy that can help prioritize HCV screening is having screening tied to grant funding, which will require staff to meet reporting metrics and other grant-related goals.

The present study had several limitations. As is common with qualitative studies, the transferability of this study may be limited and its findings may not be applicable to other organizations, geographic locations, and populations. The self-reported and cross-sectional data only have the potential to provide a point-in-time, snapshot estimate of the individuals interviewed. This study was conducted during the COVID-19 pandemic, during which programs were operating at minimized capacity to adhere with social distancing and other safety precautions. Because of the COVID-19 pandemic, the participants of this study were not representative of all the positions/roles within the organizations, as many employees at the organizations were working remotely. As a formative study, analyses were exploratory and intended to inform hypothesis generation. Further research is needed to confirm findings and to further understand the challenges and facilitators facing integrated health/social service organizations providing services to individuals experiencing homelessness.

In spite of the aforementioned limitations, the present study makes a unique contribution to the literature about HCV screening among individuals experiencing homelessness. This study provides insight into the budgetary concerns and considerations critical to implementing integrated program models, a known gap in the literature [11]. This study also provides some insight into specific teamwork and communication challenges. The lack of knowledge of strategies for improving these challenges has also been identified as a gap in the current body of literature and is critical to the expansion of integrated programs [11]. To the best of our knowledge, universal HCV screening among those with experiences of homelessness is not standard practice, and no known studies have examined why this is so and the challenges and facilitators associated with screening people experiencing homelessness for HCV. Future studies should consider piloting and evaluating the impact of universal HCV screening within integrated programs serving people experiencing homelessness.

Qualitative research concerning the organizational challenges and facilitators to screening individuals who are homeless for HCV is scarce. Much of the literature concerning HCV is focused on quantifying the burden of disease and rates of infection, treatment, adherence, and screening rates (e.g., Cole et al., 2019; Weick, Watson, & Salgia, 2019; Fuster & Gelberg, 2019) [21,34,35]. The day-to-day context and experiences of individuals employed at community-based organizations who are on the frontlines providing homeless services is missing from the scientific literature, and may provide meaningful insight that can improve how HCV education and screening is provided to high-risk individuals.

Supporting information

Acknowledgments

We are thankful to the organizations that participated in the present study for trusting us with this information. We would also like to thank Lionel Santibáñez for his editorial assistance.