Highlights
- Nontargeted hepatitis C virus (HCV) screening in emergency departments (EDs) increases test acceptance and detection among persons experiencing homelessness compared to targeted strategies.
- Persons experiencing homelessness have significantly higher prevalence of HCV seropositivity and viremia independent of screening approach and recognized risk factors.
- Linkage to care after ED-based HCV diagnosis remains suboptimal, especially among marginalized populations, highlighting the need for enhanced care coordination.
- Comprehensive ED-based screening incorporating point-of-care testing and risk assessment can identify high-risk individuals often underserved in traditional healthcare settings.
Background
Hepatitis C virus (HCV) infection remains a critical public health issue with substantial morbidity and mortality worldwide. Persons experiencing homelessness form a particularly vulnerable group due to higher exposure to risk factors such as injection drug use, coexisting psychiatric illness, and limited access to consistent healthcare. Emergency departments (EDs), by virtue of their accessibility and high utilization by marginalized populations, are strategic sites for HCV screening initiatives.
Despite national recommendations advocating HCV screening, concerns persist regarding optimal approaches—targeted based on risk factors or nontargeted universal screening—and their effectiveness in reaching underserved groups such as the homeless population. The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C Screening Trial offers rigorous, pragmatic evidence addressing these challenges.
Key Content
DETECT Hep C Screening Trial: Study Design and Population
The DETECT trial conducted a multicenter, randomized pragmatic clinical trial comparing nontargeted versus targeted HCV screening approaches in ED settings. A secondary analysis from Denver Health Medical Center included 67,223 ED visits, stratified roughly equally into nontargeted and targeted groups. Approximately 13.5% of patients in each group were persons experiencing homelessness.
Screening Offer, Acceptance, and Seroprevalence Among Persons Experiencing Homelessness
Contrary to initial concerns, homelessness was not associated with differential test offering in either screening arm. Notably, in the nontargeted screening group, persons experiencing homelessness exhibited significantly higher test acceptance (21.7%) compared with housed counterparts (15.7%), with an adjusted risk ratio (aRR) of 1.31 (95% CI 1.22–1.41). In targeted screening, acceptance was numerically higher among homeless individuals (30.2%) versus housed (23.2%) but did not reach statistical significance (aRR 1.05, 95% CI 0.97–1.14).
Persons experiencing homelessness demonstrated markedly increased HCV seropositivity: 14.2% versus 2.6% in nontargeted screening and 17.6% versus 6.0% in targeted screening cohorts. Similarly, rates of viremia were approximately threefold higher among homeless patients regardless of screening strategy. These associations persisted after adjusting for demographics, clinical severity, arrival method, payor status, and known HCV risk factors, underscoring homelessness as an independent marker for elevated HCV burden.
Comparative Analysis: Targeted Versus Nontargeted Screening in EDs
The DETECT data provide compelling evidence favoring nontargeted screening among persons experiencing homelessness, with greater test acceptance and detection rates. Targeted screening, relying on documented risk factors, may miss individuals due to underreporting or unrecognized exposures. This is consonant with findings from prior ED screening studies demonstrating that risk-based strategies, while useful, underdetect HCV cases in marginalized populations.
Linkage to Care Challenges after ED-Based Diagnosis
Screening and diagnosis represent only initial steps toward HCV elimination. Prior studies evaluating linkage to care (LTC) post-ED diagnosis indicate substantial drop-offs—amicable to logistic regression analyses identifying homelessness, younger age, substance use, white race, and psychiatric comorbidities as predictors of LTC failure. Linkage rates remain low (approximately 20%) despite ED identification, highlighting gaps that persist beyond detection.
Substantial barriers include unstable housing, competing social needs, and fragmented healthcare systems. Innovative care coordination models integrated within ED workflows and community outreach are critical for improving LTC outcomes.
Point-of-Care Testing and Risk Assessment Strategies
Complementing the DETECT findings, Australian studies implementing point-of-care rapid anti-HCV antibody testing in inner-city EDs have demonstrated feasibility and identified high seropositivity rates among persons with a history of injecting drug use—a population in which homelessness is disproportionately represented. However, linkage to treatment after ED discharge remains insufficient, underscoring the need for enhanced pathways and integrated clinical support.
Health Status and Screening Participation in Homeless Populations
Broader descriptive studies reveal that persons experiencing homelessness have poorer overall health status, higher prevalence of chronic conditions including HCV, and elevated use of emergency services. Their engagement with preventive screening programs is limited, likely due to barriers including lack of stable primary care access and competing psychosocial challenges.
Expert Commentary
The DETECT trial’s secondary analysis advances our understanding of HCV screening efficacy among persons experiencing homelessness in the ED setting. The findings highlight that nontargeted screening may overcome some limitations of risk-based approaches, as it minimizes reliance on prior risk disclosure and clinician judgment, thereby fostering greater test acceptance and case identification.
The significantly elevated HCV seroprevalence and viremia in homeless individuals, independent of other risk factors, reinforce the need for routine, nonjudgmental screening policies in acute care settings. This is crucial to reduce HCV transmission and address health disparities.
However, identification alone is insufficient. The challenge of linking marginalized populations to curative antiviral therapy necessitates innovative interventions: embedded navigation, prompt confirmatory testing, patient-centered engagement, and addressing social determinants such as housing instability are paramount.
Limitations include potential residual confounding in observational analyses and variability in linkage interventions across sites. Nonetheless, these real-world data are transferable to similar urban EDs with high homeless patient volumes.
Furthermore, point-of-care rapid testing technologies and streamlined confirmatory diagnostics can accelerate diagnosis-to-treatment timelines. Collaboration with community services and integration of harm reduction strategies remain essential components.
Conclusion
Emergency departments are critical access points for hepatitis C virus screening, especially for persons experiencing homelessness who bear disproportionate disease burden and face healthcare access barriers. Evidence from the DETECT Hep C Screening Trial demonstrates that nontargeted screening enhances test acceptance and detection in this population compared with targeted approaches.
Despite detection advances, linkage to curative treatment post-ED diagnosis remains suboptimal, underscoring the need for comprehensive care coordination and social support interventions tailored to marginalized groups.
Future research should focus on optimizing post-screening care pathways, integrating rapid diagnostics, and evaluating innovative models addressing social determinants to maximize HCV elimination efforts among homeless populations.
References
- Joseph KM et al. Hepatitis C Screening Among Persons Experiencing Homelessness in the Emergency Department: A Secondary Analysis of the DETECT Hep C Screening Trial. Ann Emerg Med. 2026 Jul 6. PMID: 42405913. https://pubmed.ncbi.nlm.nih.gov/42405913/
- Barocas JA et al. Predictors of linkage to care for a nontargeted emergency department hepatitis C screening program. Am J Emerg Med. 2020 Jul;38(7):1396-1401. PMID: 31836342. https://pubmed.ncbi.nlm.nih.gov/31836342/
- White B et al. Point-of-care Hepatitis C virus testing and linkage to treatment in an Australian inner-city emergency department. Int J Drug Policy. 2019 Oct;72:84-90. PMID: 31351752. https://pubmed.ncbi.nlm.nih.gov/31351752/
- Joseph SS et al. Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department. Ann Emerg Med. 2016 Jan;67(1):119-28. PMID: 26253712. https://pubmed.ncbi.nlm.nih.gov/26253712/
- Dalla Villa P et al. Health status of homeless persons: a pilot study in the Padua municipal dorm. Ann Ig. 2017 Jan-Feb;29(1):54-62. PMID: 28067938. https://pubmed.ncbi.nlm.nih.gov/28067938/