A community based model for non-invasive detection, stratification and treatment of hepatitis C-related chronic liver disease in substance misusers: Exploring barriers to and attitudes towards testing and treatment

Abstract

Background: Despite discovery of direct acting antiviral agents (DAA), a two–three fold increase in hepatitis C virus (HCV) detection and treatment is necessary to reduce the national HCV burden. Ninety percent of HCV positive individuals in England are people who inject drugs (PWID), a population with a history of poor engagement with health services. This study forms part of a wider evaluation of an integrated ‘one stop’ community-based hepatitis and addiction service in Brighton. Our primary aim was to assess feasibility of non-invasive detection, stratification and treatment of HCV-related chronic liver disease (CLD) in the community. Our secondary aim was to evaluate the service via qualitative interviews with patients and clinical staff, with a particular focus on exploring barriers and motivators to hepatitis C testing and treatment. Methods: A total of nine participants were recruited for the qualitative sub-study. Participants were either currently receiving, waiting to start or had completed HCV treatment. Semi-structured interviews were conducted, covering topics such as history of injecting drug use, motivations for starting treatment and perceptions of the community-based service. Interviews were audio-taped, transcribed verbatim and analysed using thematic content analysis. Results: This is a vulnerable group of patients with complex health, emotional and social needs. The interviews identified multiple interrelated barriers to HCV care at the individual-, provider and system-level. At the individual-level fear of treatment side effects, reluctance to confront the diagnosis and competing health and social issues emerged as key barriers. Overall, hospital services appeared ill-adapted to meet the needs of this vulnerable population; the bureaucratic, inflexible and impersonal hospital environment coalesced to create a mistrust of secondary care. Many of these constraints were minimised in the community-based setting. However, the interviews revealed distinct and contrasting attitudes among participants towards the community-based treatment service: although a number of participants preferred an integrated ‘one stop’ service, for some the stigma attached to the SMS acted as an important system-level barrier. Despite multiple barriers a number of facilitators to engaging in HCV care emerged from the interviews. Most notably, an awareness of the impact of untreated HCV on the liver, a trusting client-provider relationship and the desire to regain one’s health following addiction recovery. Conclusion: Preliminary findings from this qualitative study have important implications for interventions aimed at engaging this complex population in hepatitisCtesting and treatment. Future research should explore the impact of newer treatments on existing barriers to treatment uptake.