1. Hep C clinic Jessie Anderson, Cathy Scott, Kim Macbeth, Dave Findlay and John Budd Edinburgh Access Practice

2. Hep C clinic Jessie Anderson, Cathy Scott, Kim Macbeth, Dave Findlay and John Budd Edinburgh Access Practice

4. Remit of EAP “To provide primary care services to patients who are homeless, at risk of homelessness or who have a severe and established difficulty in engaging with mainstream services”

5. What TAP can provide A range of services for vulnerable homeless people where we can help with: Finding a home Getting care and support Emergency Accommodation Seeing a GP or nurse, or CPN Accessing specialist health and other services

6. Scottish Consensus Conference 2004 1 Public health crisis 2 Failing/inadequate service response 3 Need for a new integrated approach to engage with at risk population 4 Community-based model of care needed 5 Nurse led outreach clinics

7. Clinic Background 1 High Hep C prevalence amongst homeless injecting drug users 2 High levels of on-going risk behaviour 3 Gap between testing, diagnosis, assessment and treatment 4 Difficulties engaging with hospital services 5 Recognition of need to extend treatment to marginalised groups

8. Clinic Aims 1 Provide accessible + integrated service 2 Partnership between TAP, RIE liver unit and the Homeless Outreach Project (HOP) 3 Awareness raising, education + enhancing BBV activity in primary care and front line statutory + non-stat services

9. Objectives 1 Assessment + support into and through treatment + follow up of patients 2 Remove need to attend hospital clinic 3 Evaluate effectiveness

10. CASE STUDY 1 Mr T, 50 yrs old, joined our practice in May 2010. Homeless due to relationship breakdown. 20 yr Hx of alcohol misuse Hx of traumatic childhood, poor relationship with his father, who was a heavy drinker. One son from a failed relationship; No contact with his son. When he was nineteen he joined the British Army to escape from an abusive home life. He was in the army for several years and was medically discharged due to back problems. He returned to Edinburgh hoping to rebuild relationships with his family. First IDU 2010 after family bereavement. Started methadone treatment. Diagnosed Hep C +ve in 2011. Started on anti-depressant and referred by EAP assessment clinic for treatment with RIE. Poor engagement. Heavy alcohol use continued. Mr T did not respond to treatment. Mr T re-engaged with the EAP HCV treatment clinic. The second 12 week course of treatment was given in August 2014: Peginterferon, Sofosbuvir and Ribavirin. Still drinking. Attended all appointments with support from Dave Findlay(HOP). Good response to treatment. PCR –ve at 6months post treatment His accommodation was in temporary B&B’s and hostels, where the temptation to use drugs and alcohol were always present. Now allocated a tenancy in Edinburgh with support from The Cyrenians.

11. CASE STUDY 2 Mr S joined our practice in September 2013. He has been continually homeless and registered with us since then. Mr S previously lived in north England with his wife and children. The relationship broke up due to excessive alcohol and drug use, with their children being taken into care. Before coming to Edinburgh he had been treated for Hep C. Poor concordance and was probably a non-responder. Mr S came to Edinburgh in 2013 to start a new life on his own. On methadone treatment. Re-diagnosed Hep C 2013, linked in with EAP Hep C clinic. The Hep C team worked closely with his CPN and GP to address his alcohol and drug use before starting treatment. Started on an antidepressant. The12 week course of treatment was given in August 2014: Peginterferon and Sofosbuvir and Ribavirin. PCR negative at 6 months post treatment. His accommodation was always temporary living in B&B’s and hostels for a year, where the temptation to use drugs and alcohol were always present and he continued to live a chaotic lifestyle. Mr S was allocated supported accommodation in Edinburgh whilst going through treatment; he is now living in his own tenancy. He now has contact with his children in England.

12. Lessons Learned 1, All under roof – whole team approach 2, Familiar and non-judgemental enviroment and relationships 3, Practical help + Assertive outreach – crucial role of HOP 4, Clear communication with patients 5, Good links with CPNs/substance misuse team 6, Flexible approach eg appointments 7, Relationships with hostel staff + housing