'Hep C's like the common cold': understanding barriers along the HCV care continuum among young people who inject drugs

The role of stigma and trauma in hepatitis C virus treatment in veterans: Applying the common-sense model

Hepatitis C Virus (HCV), a blood borne pathogen capable of causing severe liver disease, disproportionately affects veterans in the United States. While there are antiviral medications to treat HCV, stigma and trauma in this population may lead to avoidance of care. Those veterans who do undergo treatment have certain illness representations about HCV and its treatment. They undergo treatment even while facing stigma and trauma. The Common-Sense Model may be useful in elucidating how such representations, when matched to an appropriate illness prototype, may inform an action plan of how to respond to HCV. An exploration of the illness representations among veterans with HCV, and the effects of stigma and trauma on these representations, may help to explain how they exercise the choice to undergo treatment and may inform interventions to encourage treatment in veterans who have yet to do so.

Determinants of Hepatitis C Treatment Adherence and Treatment Completion Among Veterans in the Direct Acting Antiviral Era

BACKGROUND

Despite the availability of direct acting antiviral medications (DAAs), there are ongoing concerns about adherence to hepatitis C virus (HCV) treatment. We sought to understand the barriers to and facilitators of DAA adherence in the Veteran population.

METHODS

Patients completed semi-structured interviews focused on barriers to and facilitators of HCV treatment adherence both pre- and post-DAA treatment. Adherence was assessed via provider pill count and self-report. Thematic analyses were conducted in the qualitative software program Atlas.ti in order to understand anticipated barriers to and facilitators of treatment adherence and completion. Charts were reviewed for clinical data and sustained virologic response (SVR12).

RESULTS

Of 40 patients, 15 had cirrhosis and 10 had prior interferon-based treatment. Pre-treatment interviews revealed anticipated barriers to adherence such as side effects (n = 21) and forgetting pills (n = 11). Most patients (n = 27) reported following provider advice, and others had unique reasons not to (e.g., feeling like a "guinea pig"). Post-treatment interviews uncovered facilitators of treatment including wanting to cure HCV (n = 17), positive results (n = 18), and minimal side effects (n = 15). Three patients (8%) did not complete therapy (whom we further elaborate on) and 6 (15%) missed doses but completed treatment. SVR12 was achieved by all participants who completed therapy (93%). Patients who did not complete therapy or missed doses were all treatment naïve, mostly non-cirrhotic (8 of 9), and often anticipated concerns with forgetting their medications.

CONCLUSIONS

This qualitative study uncovered several unanticipated determinants of HCV treatment completion and provides rationale for several targeted interventions such as incorporating structured positive reinforcement.

HCV treatment access among Latinxs who inject drugs: qualitative findings from Boston, Massachusetts, 2016

BACKGROUND

Compared with Caucasians, Latinxs with the hepatitis C virus (HCV) tend to initiate treatment less often, discontinue treatment, become infected younger, and have higher reinfection rates post-treatment. Little is known about HCV treatment experiences among Latinxs who inject drugs in the Northeastern USA. We assessed knowledge, attitudes, and perceptions tied to HCV, as well as HCV treatment readiness, and explored the overall HCV treatment experience of Latinx people who inject drugs (PWID) in Boston.

METHODS

We conducted qualitative interviews with monolingual and bilingual Spanish-speaking Latinx PWID (n = 15) in Boston, Massachusetts, between 2015 and 2016. We used a thematic content analysis approach to code and analyze data to identify knowledge, attitudes, and experiences related to HCV treatment.

RESULTS

We identified barriers and facilitators to HCV treatment. Six salient themes emerged from the data. For participants who had not initiated HCV treatment, lack of referral, fear of quitting drugs, and fear of relapse were perceived barriers. Trust in medical providers and a willingness to quit drugs were primary facilitators. Most participants had positive HCV treatment experiences, and several emphasized the need for outreach to Latinxs about the advantages of newer treatment options. Concerns about HCV reinfection were also notable.

CONCLUSIONS

We identified a range of experiences tied to HCV treatment among Latinx PWID. HCV care providers play a key role in determining treatment uptake, and more treatment information should be disseminated to Latinx PWID. Healthcare providers should capitalize on treatment facilitators by ensuring referrals to treatment and should continue to address perceived barriers.

Strategies used by people who inject drugs to avoid stigma in healthcare settings

BACKGROUND

People who inject drugs (PWID) have limited engagement in healthcare services and report frequent experiences of stigma and mistreatment when accessing services. This paper explores the impact of stigma against injection drug use on healthcare utilization among PWID in the U.S. Northeast.

METHODS

We recruited PWID through community-based organizations (CBOs; e.g., syringe service programs). Participants completed brief surveys and semi-structured interviews lasting approximately 45 min exploring HIV risk behaviors and prevention needs. Thematic analysis examined the emergent topic of stigma experiences in relation to healthcare utilization.

RESULTS

Among 33 PWID (55% male; age range 24-62 years; 67% White; 24% Latino), most used heroin (94%) and injected at least daily (60%). Experiences of dehumanization in healthcare settings were common, with many participants perceiving that they had been treated unfairly or discriminated against due to their injection drug use. As participants anticipated this type of stigma from healthcare providers, they developed strategies to avoid it, including delaying presenting for healthcare, not disclosing drug use, downplaying pain, and seeking care elsewhere. In contrast to large institutional healthcare settings, participants described non-stigmatizing environments within CBOs, where they experienced greater acceptance, mutual respect, and stronger connections with staff.

CONCLUSIONS

Stigma against injection drug use carries important implications for PWID health. Increased provider training on addiction as a medical disorder could improve PWID healthcare experiences, and integrating health services into organizations frequented by PWID could increase utilization of health services by this population.

Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.

Evidence-based and guideline-concurrent responses to narratives deferring HCV treatment among people who inject drugs

BACKGROUND

Hepatitis C virus (HCV) infection is increasingly prevalent among people who inject drugs (PWID) in the context of the current US opioid crisis. Although curative therapy is available and recommended as a public health strategy, few PWID have been treated. We explore PWID narratives that explain why they have not sought HCV treatment or decided against starting it. We then compare these narratives to evidence-based and guideline-concordant information to better enable health, social service, harm reduction providers, PWID, and other stakeholders to dispel misconceptions and improve HCV treatment uptake in this vulnerable population.

METHODS

We recruited HIV-uninfected PWID (n = 33) through community-based organizations (CBOs) to participate in semi-structured, in-depth qualitative interviews on topics related to overall health, access to care, and knowledge and interest in specific HIV prevention methods.

RESULTS

In interviews, HCV transmission and delaying or forgoing HCV treatment emerged as important themes. We identified three predominant narratives relating to delaying or deferring HCV treatment among PWID: (1) lacking concern about HCV being serious or urgent enough to require treatment, (2) recognizing the importance of treatment but nevertheless deciding to delay treatment, and (3) perceiving that clinicians and insurance companies recommend that patients who currently use or inject drugs should delay treatment.

CONCLUSIONS

Our findings highlight persistent beliefs among PWID that hinder HCV treatment utilization. Given the strong evidence that treatment improves individual health regardless of substance use status while also decreasing HCV transmission in the population, efforts are urgently needed to counter the predominant narratives identified in our study. We provide evidence-based, guideline-adherent information that counters the identified narratives in order to help individuals working with PWID to motivate and facilitate treatment access and uptake. An important strategy to improve HCV treatment initiation among PWID could involve disseminating guideline-concordant counternarratives to PWID and the providers who work with and are trusted by this population.

Barriers and facilitators of hepatitis C treatment uptake among people who inject drugs enrolled in opioid treatment programs in Baltimore

BACKGROUND

Hepatitis C virus (HCV) infection is a major public health issue among people who inject drugs (PWID) with prevalence of 50-80% in the United States. Effective, simple, oral direct acting agents (DAA) of short duration with minimal side effects have been associated with cure rates > 95%. However, HCV treatment uptake among PWID remains low. We characterized the HCV care continuum, HCV treatment knowledge, as well as barriers and facilitators to HCV treatment uptake among PWID enrolled in two opioid treatment programs (OTPs) in Baltimore, Maryland, USA.

METHODS

Between July and November 2016, 124 HCV infected PWID were recruited from two opioid treatment programs in Baltimore through convenience sampling. Participants completed a 50-item questionnaire to assess HCV treatment knowledge, attitudes, and practices. Progress through the HCV care continuum was assessed based on a series of questions assessing evaluation for HCV treatment, recommendation for HCV treatment by a provider, and HCV treatment initiation. HCV status was assessed based on participant self-report.

RESULTS

The median age was 52 years (IQR 44-58), 56% were male, the majority were African American (69%), and 19% reported HIV coinfection. Participants had been tested for HCV at their primary care provider's (PCP's) office (34%), drug treatment center (20%), emergency room (11%), or prison (9%), and most (60%) had been diagnosed with HCV over 5 years prior. The majority reported that HCV was a major health concern for them (91%), were aware there were new treatments for HCV (89%), and that the new treatments cure most people (69%). More than half (60%) had seen a health professional who could treat HCV, 40% had HCV therapy recommended by their HCV specialist, and 20% had started or completed treatment. In univariable analysis, PWID were significantly more likely to have been treated if they were HIV co-infected (OR 3.4 (95% CI 1.3-9.2)) or had a partner or friend concerned about their HCV (OR 3.4 (95% CI 1.2-9.7)), and were significantly less likely to have been treated if they had used any illicit drugs in the preceding 6 months (OR 0.4 (95% CI 0.2-0.99). In multivariable analysis, having a friend or partner concerned about their HCV remained significantly associated with HCV treatment (OR 5.0 (95% CI 1.4-17.7)). When questioned about what would facilitate HCV treatment, the majority (85%) reported that a friend telling them that HCV treatment had helped them and having HCV treatment provided at their opioid treatment program would make them more likely to engage in HCV treatment.

CONCLUSION

Despite a high prevalence of HCV among opioid treatment program patients and the availability of effective treatments, uptake remains low. We identified several key barriers and facilitators that can affect HCV treatment uptake.