Need: Mortality due to liver cancer is increasing at a rate that is faster than any other cancer with an incidence rate that is the second fastest growing of all cancers. Incidence rates in South Texas range from 9.9 to 28.9 and are continuing to rise in some high need counties (e.g., Bexar, Frio). Among individuals with liver cancer, hepatitis is a contributing factor in 65-78% of cases, making prevention and treatment of Hepatitis B (HBV) and Hepatitis C (HCV) one of the most effective ways to reduce liver cancer. Prevalence of HCV among persons experiencing homelessness (PEH) range from 22-69% and 23-40% for HBV. Although vaccination for HBV and treatment of HCV could reduce the prevalenc...

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Need: Mortality due to liver cancer is increasing at a rate that is faster than any other cancer with an incidence rate that is the second fastest growing of all cancers. Incidence rates in South Texas range from 9.9 to 28.9 and are continuing to rise in some high need counties (e.g., Bexar, Frio). Among individuals with liver cancer, hepatitis is a contributing factor in 65-78% of cases, making prevention and treatment of Hepatitis B (HBV) and Hepatitis C (HCV) one of the most effective ways to reduce liver cancer. Prevalence of HCV among persons experiencing homelessness (PEH) range from 22-69% and 23-40% for HBV. Although vaccination for HBV and treatment of HCV could reduce the prevalence of HBV/HCV among PEH, both treatment and vaccination require multiple doses administered over several months. The transient nature of PEH coupled with behavioral health issues can make treatment engagement challenging. However, there has been an evidence-based shift in approaching homelessness with a "Housing First" model to provide permanent supported housing (PSH) followed by supportive healthcare services. Unlike earlier housing models designed to provide temporary shelter to those who met behavioral contingencies (e.g., sobriety), individuals in PSH are able to stay as long as needed. The stability of this new housing model provides a unique opportunity to deliver HBV vaccination and HCV treatment to PEH, a medically underserved population.

Overall Project Strategy: In our current program, GRASSROOTS HEALTH, we provide low-barrier HBV/HCV education, testing, vaccination (HBV) and treatment (HCV) to PEH with one of the largest PSH providers in Texas, New Hope Housing. We propose to expand GRASSROOTS HEALTH to include new partners and provide HBV/HCV services to more high-need Texans. We propose to expand services to veteran-based housing in Houston and low-income housing units in Public Health Region 8 (PHR 8 – including Bexar, Comal, Guadalupe and Frio County). Veterans with experiences of homelessness are at increased risk for viral hepatitis and we will partner with the local Veterans Affairs medical center and local providers to provide HBV/HCV services to this important subpopulation. Additionally, there is a need for HBV/HCV services in low-income communities in medically underserved and rural areas in PHR 8. We will partner with Prospera Housing Community Services, one of the largest low-income housing providers in Texas to serve these communities. We will provide education to clients, test for HBV/HCV onsite, and deliver HBV/HCV results direct to clients. If medically indicated, clients will be offered HCV treatment using a method based on directly-observed therapy. HBV negative individuals will be offered HBV vaccination directly at the housing sites. HBsAg positive individuals will be navigated to our clinical partners for evaluation. We will also distribute HBV/HCV education at organizations serving PEH. We will partner with three organizations to provide clinical care: 1) Healthcare for the Homeless Houston (HHH), a federally qualified health center focused on delivering healthcare to PEH; 2) Michael E. DeBakey Veterans Affairs medical center that has homeless program staff and community partners that serve high risk veterans; 3.) UT Health San Antonio School of Nursing that operates mobile healthcare units and can provide HBV/HCV services on-site where PEH are. With our clinical partners and an evaluator, we will monitor and evaluate the program to meet objectives.

Specific Goals: The specific goals of this project are to reduce the risk of hepatocellular carcinoma in homeless and at-risk populations by providing education for viral hepatitis, screening for HBV and HCV, immunizing those who are HBV naive, and treating those who are HCV positive. We will expand on our current project and success by: 1) Scaling to veteran-based housing to address HBV/HCV in this high risk population; 2) Expanding to low-income housing in medically underserved Bexar, Comal, Guadalupe and Frio counties to reach high need, low resource communities.

Significance and Impact: There are several programs that integrate primary care with homeless services, but no known programs specifically address HCC in PSH. Our in-house program increases engagement and adherence by "meeting people where they are" and eliminating often insurmountable barriers to care for HBV/HCV. In our expansion, we will demonstrate our ability to replicate our innovative model in two high need populations and locations. This proposal addresses a high priority area for CPRIT, reducing HCC risk, in a high risk, medically underserved population, expanding to areas of the state of highest priority for CPRIT with the some of the lowest resources. Vaccination against HBV and achieving sustained HCV viral suppression improves the health of homeless adults and also improves population health by reducing transmission of viral hepatitis to others.

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