Barriers to Assessing and Treating HCV Infection
Barriers to Assessing and Treating HCV Infection
Provision of hepatitis C virus (HCV) assessment and treatment via opioid substitution treatment (OST) clinics has been posed as an effective means of engaging populations with high HCV prevalence. This study explores OST client and health professional reports concerning barriers and facilitators affecting the delivery and uptake of HCV care and treatment within OST settings. In-depth interviews were conducted with 57 clients, 16 staff from four NSW clinics participating in the Australian ETHOS study and three peer workers. Client participants included those who had not had HCV assessment; those who had HCV assessment only; and those who were awaiting or undertaking HCV treatment. A clear difference in decisions about HCV treatment emerged between participant groups. For those who have not been assessed, barriers to engaging with HCV care included the perception that they were physically well, were not experiencing HCV symptoms, had other life priorities and were concerned about the side effects and tolerability of treatment. Those who had engaged with care expressed motivations stemming from seeing friends becoming unwell, wanting to live longer and hearing positive stories of treatment. For those interested in HCV treatment, issues related to both provider and setting were important, such as presence of an engaged clinician, an accessible treatment pathway and availability of support. In this integrated care model, some barriers to HCV care and treatment (particularly those relating to health provider and the system) are minimized. In this setting, HCV treatment remained an unattractive option for a significant number of clients. Providing ways for those without HCV symptoms to be assessed for liver damage may be important to open up alternative conversations about HCV care. Further, the importance of a changing discourse of treatment is apparent from these data and could be enhanced by peer communication that provides information about successful treatment experiences.
Treatment for hepatitis C virus (HCV) infection has improved considerably over the previous decade, but HCV-related disease burden continues to increase. Although HCV treatment can lead to reductions in HCV-related morbidity and mortality, uptake of HCV treatment remains low in the overall population and among people who inject drugs (PWID). Given that the majority of new and existing cases of HCV infection occur among PWID, strategies to enhance HCV assessment and treatment in this population are required.
Barriers to uptake of HCV treatment have been described previously at patient, provider and systems levels. At the patient level, limited awareness about HCV and its treatment, the asymptomatic nature of HCV infection, treatment fears, poor adherence to physician recommendations (including attendance at pretreatment appointments), economic or social pressures, psychiatric disease and injection drug use have been cited as barriers to HCV care. At the provider level, a lack of knowledge and awareness by practitioners, limited specialist availability and/or lack of referral and communication issues may impair HCV assessment. Lastly, at the systems level, a lack of treatment promotion, insufficient funding, limited accessibility of testing, results and treatment, long waiting lists for treatment, lack of insurance coverage, high out-of-pocket expenses, excessive paperwork, poorly developed surveillance systems, inadequate educational initiatives and fragmented viral hepatitis services may impair HCV assessment and treatment uptake. Further, traditional models referring patients to tertiary hospital-based specialist HCV clinics may not be suitable to engage PWID in HCV assessment and treatment, and additional models of care are needed.
Models incorporating 'one-stop shop' multidisciplinary care may present opportunities for addressing barriers to HCV assessment and treatment. Although one size may not fit all, the provision of HCV services at clinics with existing drug and alcohol services may be useful for engaging large numbers of people with HCV. For example, programs integrating opiate substitution treatment (OST) and HCV treatment have demonstrated favourable treatment outcomes. However, the provision of HCV treatment in the OST setting may raise additional barriers or indeed, facilitators of treatment assessment and uptake that require careful examination.
The Enhancing Treatment for Hepatitis C in the Opioid Substitution Setting (ETHOS) study was established to evaluate an innovative model of assessment and treatment for chronic HCV infection among current and former PWID through a collaborative network of OST clinics and community health centres in NSW, Australia. The aim of this study was to explore barriers and facilitators to HCV assessment and treatment in the OST setting among clients and practitioners at sites involved in the ETHOS study employing qualitative research methods. In particular, this study focused on the barriers to HCV treatment remaining after factors related to provider and systems were minimized via the provision of colocated HCV and OST services.
Abstract and Introduction
Abstract
Provision of hepatitis C virus (HCV) assessment and treatment via opioid substitution treatment (OST) clinics has been posed as an effective means of engaging populations with high HCV prevalence. This study explores OST client and health professional reports concerning barriers and facilitators affecting the delivery and uptake of HCV care and treatment within OST settings. In-depth interviews were conducted with 57 clients, 16 staff from four NSW clinics participating in the Australian ETHOS study and three peer workers. Client participants included those who had not had HCV assessment; those who had HCV assessment only; and those who were awaiting or undertaking HCV treatment. A clear difference in decisions about HCV treatment emerged between participant groups. For those who have not been assessed, barriers to engaging with HCV care included the perception that they were physically well, were not experiencing HCV symptoms, had other life priorities and were concerned about the side effects and tolerability of treatment. Those who had engaged with care expressed motivations stemming from seeing friends becoming unwell, wanting to live longer and hearing positive stories of treatment. For those interested in HCV treatment, issues related to both provider and setting were important, such as presence of an engaged clinician, an accessible treatment pathway and availability of support. In this integrated care model, some barriers to HCV care and treatment (particularly those relating to health provider and the system) are minimized. In this setting, HCV treatment remained an unattractive option for a significant number of clients. Providing ways for those without HCV symptoms to be assessed for liver damage may be important to open up alternative conversations about HCV care. Further, the importance of a changing discourse of treatment is apparent from these data and could be enhanced by peer communication that provides information about successful treatment experiences.
Introduction
Treatment for hepatitis C virus (HCV) infection has improved considerably over the previous decade, but HCV-related disease burden continues to increase. Although HCV treatment can lead to reductions in HCV-related morbidity and mortality, uptake of HCV treatment remains low in the overall population and among people who inject drugs (PWID). Given that the majority of new and existing cases of HCV infection occur among PWID, strategies to enhance HCV assessment and treatment in this population are required.
Barriers to uptake of HCV treatment have been described previously at patient, provider and systems levels. At the patient level, limited awareness about HCV and its treatment, the asymptomatic nature of HCV infection, treatment fears, poor adherence to physician recommendations (including attendance at pretreatment appointments), economic or social pressures, psychiatric disease and injection drug use have been cited as barriers to HCV care. At the provider level, a lack of knowledge and awareness by practitioners, limited specialist availability and/or lack of referral and communication issues may impair HCV assessment. Lastly, at the systems level, a lack of treatment promotion, insufficient funding, limited accessibility of testing, results and treatment, long waiting lists for treatment, lack of insurance coverage, high out-of-pocket expenses, excessive paperwork, poorly developed surveillance systems, inadequate educational initiatives and fragmented viral hepatitis services may impair HCV assessment and treatment uptake. Further, traditional models referring patients to tertiary hospital-based specialist HCV clinics may not be suitable to engage PWID in HCV assessment and treatment, and additional models of care are needed.
Models incorporating 'one-stop shop' multidisciplinary care may present opportunities for addressing barriers to HCV assessment and treatment. Although one size may not fit all, the provision of HCV services at clinics with existing drug and alcohol services may be useful for engaging large numbers of people with HCV. For example, programs integrating opiate substitution treatment (OST) and HCV treatment have demonstrated favourable treatment outcomes. However, the provision of HCV treatment in the OST setting may raise additional barriers or indeed, facilitators of treatment assessment and uptake that require careful examination.
The Enhancing Treatment for Hepatitis C in the Opioid Substitution Setting (ETHOS) study was established to evaluate an innovative model of assessment and treatment for chronic HCV infection among current and former PWID through a collaborative network of OST clinics and community health centres in NSW, Australia. The aim of this study was to explore barriers and facilitators to HCV assessment and treatment in the OST setting among clients and practitioners at sites involved in the ETHOS study employing qualitative research methods. In particular, this study focused on the barriers to HCV treatment remaining after factors related to provider and systems were minimized via the provision of colocated HCV and OST services.