Homeless at Risk

HCV funding and support for vulnerable populations lag far behind HIV
by Larry Buhl

A study published in the July/August 2012 issue of Public Health Reports shows that more than a quarter of homeless adults in the Skid Row area of downtown Los Angeles may be infected with the hepatitis C virus (HCV).

It is just the latest of several studies that demonstrate that urban homeless adults in the U.S. are at high risk for HCV infection, says study co-leader Dr. Lillian Gelberg, a professor of family medicine at UCLA’s Geffen School of Medicine. The report concluded that almost half who tested positive for hepatitis C didn’t know they carried the disease.

“Homeless adults need interventions that include hepatitis C virus education, counseling, voluntary testing and treatment services,” Gelberg wrote. “Hepatitis C virus prevention and treatment programs could be modeled after relevant successful interventions developed for U.S. homeless persons with HIV/AIDS.”

Unfortunately, while a few homeless intervention programs for HCV do follow the successful HIV/AIDS model, there isn’t enough support, both political and financial, to handle the epidemic of hepatitis C in homeless populations nationwide.

Although hepatitis doesn’t just afflict the homeless, several issues make the homeless a much more difficult population to reach and treat. The prevalence of IV drug use among the homeless is very high, and IV drug users are at a very high risk of spreading blood-borne diseases like hepatitis C. Add to this the issues that create homelessness—drug abuse and mental illness among the top reasons—and you have a perfect storm, according to Angelica Skouras-Castanon, director of the Center for Harm Reduction at Homeless Healthcare Los Angeles (HHCLA).

HHCLA operates on a harm reduction model, a somewhat controversial plan that eschews abstinence (unlike the traditional “disease model” of addiction) and promotes changes in behavior that will decrease harm to the person who chooses high-risk behavior.

HHCLA reduces harm by advocating clean needles, safe living spaces, counseling, and other services. It runs one of only two freestanding needle exchange facilities in Los Angeles County. In surrounding counties, needle exchange programs are illegal, so the Center gets the bulk of those users, too.

But as the harm reduction model presumes that the users must understand that they need help, and must seek it, HHCLA relies on word-of-mouth among those populations, Skouras-Castanon tells A&U.

“Services have to be easy,” she says. “If someone shows up at the county hospital, they will have to first ditch their needles. We don’t make them do that. We do require them to give us information on their habits and where they’ve been, before they can see the doctor. We need that information to compile for demographic studies [of them].”

Skouras-Castanon, who has a background in HIV prevention and treatment, says the harm reduction model works, but what’s missing is enough funding to treat and prevent HCV as effectively as HIV/AIDS.

“The key is linkage to care, and for hepatitis there isn’t the infrastructure for that kind of support” she says.

“When I was at AIDS Healthcare Foundation, the second I had a client who tested positive for HIV, I would call someone from the linkage team. Then someone in a demographic group who would make the client feel comfortable—gay, Latino, female, whoever—and take them to the clinic where they would be counseled, given thirty days of meds, whatever they needed. But there’s just no money for the same kind of support for hepatitis.”

She points to several barriers to the kind of comprehensive treatment that homeless (and non-homeless) IV drug users need in order to stop the spread of hepatitis C.

• The Federal ban on purchasing syringes, which was reinstated last year after it had been lifted for twenty-one-years.

• Lack of community education. Skouras-Castanon points to the clash brought on by gentrification in downtown L.A. that has led residents and police to take a “clean up the streets” attitude over what she says is a more helpful approach of outreach and harm reduction. “LAPD’s ‘Operation Clean Sweep’ is removing homeless people from the streets and throwing bleach on the sidewalks, but the fact is, if the city offered more services they wouldn’t have so many people on the sidewalks.”

• Political pressure. At the local, state, and national level, harm reduction strategies are hot potatoes for politicians. “[Politicians] say drug users are being enabled when you give them access to clean needles and safe places to use them. It isn’t true but it’s a winning political issue.”

The solutions, as she sees it, require money and a change in perspective about how to reach out to IV drug users.

Larry Buhl is a freelance journalist and screenwriter living in Los Angeles.

August 2012