Full length article‘Hep C’s like the common cold’: understanding barriers along the HCV care continuum among young people who inject drugs
Introduction
HCV infections in the United States have increased significantly among young people during the past decade (Suryaprasad et al., 2014). Between 2002 and 2013, HCV infections in Massachusetts (MA) increased by 137% among those aged 15–29, with more than 2000 newly reported infections each year (MDPH, 2014). This increase has largely been attributable to injection drug use (MDPH, 2014). In recent years, new treatments have been developed for the hepatitis C virus (HCV) that could potentially be life saving for people who inject drugs (PWID); however, uptake has been less than optimal.
Beginning in 2013, new oral direct acting antivirals (DAAs) were introduced for treatment of HCV. Unlike their interferon predecessors, these new medications have demonstrated high rates of treatment success in clinical trials (>95%) with short treatment durations (≤12 weeks) and minimal side effects (Jacobson et al., 2013). While access to DAAs is still limited in many areas, some restrictions to health insurance coverage for HCV treatment (e.g., sobriety, fibrosis criteria) were recently removed in Massachusetts, paving the way for better access to HCV treatment (NVHR and The Center for Health Law and Policy Innovation, 2016). Further, the state has worked with pharmaceutical companies to significantly lower the cost of DAAs for consumers (Bartlett, 2016). Despite these policy changes, few young PWID who are living with HCV receive DAA treatment. Some barriers impeding widespread treatment of HCV among young PWID include: the high price of the DAAs, psychosocial factors that can contribute to missed doses of medication, emergence of viral resistance, and risk for re-infection (Harris and Rhodes, 2013).
Treatment as prevention is a major component of strategies to combat HIV (identification, linkage, and treatment), but has yet to be widely implemented or evaluated for HCV (Kay et al., 2016). Increasing HCV treatment among young PWID can decrease virus circulation in the community, translating to a decreased infection rate (Cousien et al., 2016). Previous qualitative studies have examined how social factors have influenced HCV prevention and treatment among people who inject drugs, and found that risk perception, uncertain knowledge, and stigma are important determinants (Davis and Rhodes, 2004aa; 2004b; Davis et al., 2004; Clark and Gifford, 2015). These studies have been critical for understanding prevention and treatment in the lives of PWID during the interferon era, prior to the advent of DAAs. Many of the determinants remain highly relevant; however, little is known about HCV treatment knowledge and treatment readiness among young PWID in the current era of DAAs, or factors that may contribute to treatment uptake and adherence, as few studies have examined the willingness to pursue new DAA treatments for HCV among young PWID, and how their experiences with the health care system contribute to – or impede – their preferences for care. The shorter treatment time, higher success rates, and reduced side effects associated with DAA treatment may impact many of the previously documented attitudes and behaviors among young PWID, as prior research on this issue may have a strong tie to side effects of interferon (Batchelder et al., 2015), thus limiting applications to the new treatments.
Qualitative research can help to elucidate issues that are relevant for practice decisions around the HCV care continuum, particularly with respect to testing, treatment availability and access, and aspects of willingness and readiness to initiate treatment. Understanding the barriers and facilitators to care among PWID in Boston, an urban area with gold-standard health care, insurance coverage, and access to HCV treatment experts, can shed light on important barriers impeding access or hindering uptake among this population in the current treatment environment. Using qualitative in-depth interviews, we aimed to provide a greater understanding of the perspectives and experiences of young PWID navigating the HCV care continuum, and in turn, to inform future treatment as prevention strategies.
Section snippets
Conceptual framework and interview guide development
Our study was informed by a model originally developed by Andersen (1968), along with a more recent framing by Andersen and Newman (2005), which provides a framework for understanding health care utilization among PWID. This framework holds that social determinants influence individual-level determinants, which guide decisions around individuals’ healthcare needs and ultimately their ability to engage in related services (Anderson and Newman, 2005). The framework is rooted in three domains:
Results
Between February and August 2016, we conducted 24 in-depth interviews with participants aged 22–30 who self-identified as having HCV and tested positive for HCV antibodies via the Oraquick ® HCV Rapid Antibody test. The average age of participants was 27 years. At the time of the interviews, no participants had been prescribed or had taken DAAs to treat their HCV. The majority of participants came from street recruitment, chain referral, and local syringe exchange programs (Table 1).
While the
Discussion
As the HCV epidemic surges among young PWID in the United States, our findings from Boston provide a first glimpse into young PWID perspectives and experiences surrounding the HCV care continuum in the new era of DAAs. Young PWID represent a growing fraction of the opioid epidemic in the United States and are likely to live with HCV for long periods without significant symptoms, increasing their likelihood of spreading the virus. Building upon findings from prior qualitative research with this
Conclusions
Through qualitative interviews informed by a model for understanding healthcare utilization, we were able to gain important insights into the perceptions of young PWID with respect to social determinants of engagement in care, as well as illness levels, related to the HCV care continuum. Evidence suggests that PWID can successfully complete DAA treatment and can be cleared of HCV (Grebely et al., 2013; Grebely and Dore, 2014). Our study highlights that young PWID may have the determinants of
Role of the funding source
The study team was supported by a grant from the Tufts Institute for Innovation Pilot Study program (PI: Stopka) through Tufts University for data collection, analysis, and manuscript preparation. Additional support for Dr. Stopka’s time during manuscript preparation came from the National Institutes of Health, Clinical and Translational Science Award (UL1TR001064) (Stopka), and the Lifespan/Tufts/Brown Center for AIDS Research (P30 AI042853). Additional support for Dr. Ladin’s time during
Contributors
MR Skeer, L Wilkins, DM Landy, and TJ Stopka conducted the qualitative interviews, and, along with K Ladin, developed the codebook, analyzed the data and drafted the manuscript. All authors approved of the final manuscript before submission.
Conflict of interest
No conflict declared.
Acknowledgements
The authors acknowledge our funding sources for this work: The Tufts Institute for Innovation, the National Institutes of Health (Awards UL1TR001064 and KL2TR001063), and the Lifespan/Tufts/Brown Center for AIDS Research (P30 AI042853). The authors also acknowledge the full Tufts REACTs team for their collaboration and support during the data collection and manuscript preparation phases of this project. We also acknowledge Harsha Amaravadi and Margaret Levene for their help with editing the
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