The State of Hepatitis C Elimination from the Front Lines: A Qualitative Study of Provider-Perceived Gaps to Treatment Initiation

Abstract

Background

Hepatitis C (HCV) is a curable chronic infection, but lack of treatment uptake contributes to ongoing morbidity and mortality. State and national strategies for HCV elimination emphasize the pressing need for people with HCV to receive treatment.

Objective

To identify provider-perceived barriers that hinder the initiation of curative HCV treatment and elimination of HCV in the USA.

Approach

Qualitative semi-structured interviews with 36 healthcare providers who have evaluated patients with HCV in New York City, Western/Central New York, and Alabama. Interviews, conducted between 9/2021 and 9/2022, explored providers’ experiences, perceptions, and approaches to HCV treatment initiation. Transcripts were analyzed using hybrid inductive and deductive thematic analysis informed by established health services and implementation frameworks.

Key Results

We revealed four major themes: (1) Providers encounter professional challenges with treatment provision, including limited experience with treatment and perceptions that it is beyond their scope, but are also motivated to learn to provide treatment; (2) providers work toward building streamlined and inclusive practice settings—leveraging partnerships with experts, optimizing efficiency through increased access, adopting inclusive cultures, and advocating for integrated care; (3) although at times overwhelmed by patients facing socioeconomic adversity, increases in public awareness and improvements in treatment policies create a favorable context for providers to treat; and (4) providers are familiar with the relative advantages of improved HCV treatments, but the reputation of past treatments continues to deter elimination.

Conclusions

To address the remaining barriers and facilitators providers experience in initiating HCV treatment, strategies will need to expand educational initiatives for primary care providers, further support local infrastructures and integrated care systems, promote public awareness campaigns, remove prior authorization requirements and treatment limitations, and address the negative reputation of outdated HCV treatments. Addressing these issues should be considered priorities for HCV elimination approaches at the state and national levels.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-024-08807-6.

INTRODUCTION

The incidence of hepatitis C (HCV), a curable infection, has tripled in the United States (US) over the past decade [1–3]. Lack of treatment contributes to cirrhosis, liver failure, and hepatocellular carcinoma, and to the continued transmission of HCV [4]. The US Department of Health and Human Services has called for HCV elimination by 2030 [5, 6]; however, a recent study revealed that only 34% of treatment-eligible individuals received direct acting antiviral medications (DAAs) from 2013 to 2022 [7–9]. Beyond screening for and diagnosing HCV, initiating timely DAA-based treatment is vital to achieving elimination, yet treatment initiation challenges contribute to a large gap in the HCV treatment cascade [8, 10].

Healthcare providers, and primary care physicians (PCPs) in particular, play a major role in determining whether patients receive treatment, and are critical to implementing the national strategic plan to eliminate HCV [11]. Stigma towards people who use drugs, lack of clinical experience, requirements from third-party payers, the asymptomatic nature of HCV, and the slow progression of its complications all limit whether providers treat HCV for individual patients [12–15]. Providers may therefore have unique insights into strategies that effectively engage those that are not treated. However, past research eliciting perspectives of US providers on managing HCV have largely explored barriers limiting screening or adherence to treatment, rather than barriers impeding treatment initiation, and have also assessed these barriers within single healthcare systems or among specific patient populations, limiting the transferability of findings [16–18]. Moreover, these studies have not identified provider-recommended strategies that could potentially overcome these barriers. While several states have proposed or begun implementing HCV elimination plans [19], there remains a need to understand the provider-perceived barriers that continue to hinder the initiation of DAAs across diverse settings in the US, and their recommendations for strategies to overcome those barriers.

To fill this gap, we conducted a qualitative study of healthcare providers across clinically and geographically diverse settings. We sampled PCPs, HCV specialists, and substance use treatment providers, including both clinical and non-clinical staff, from three geographic regions. Guided by Andersen’s model of health services utilization and the Consolidated Framework for Implementation Research (CFIR) [20, 21], we identify provider-perceived barriers and strategies recommended by those providers to improve HCV treatment initiation. Addressing these barriers while considering these preferred strategies is a prerequisite for implementation of a successful HCV elimination plan in the US.

METHODS

Study Sample and Setting

We recruited healthcare providers between 9/2021 and 9/2022 in three regions with differing sociodemographic and policy environments: New York City (a large, urban area in the northeastern US), Western/Central New York (including smaller urban and rural areas in the northeastern US), and Alabama (including urban and rural areas in the southern US). We invited healthcare providers, including physicians and advanced practice providers, who treated HCV with DAAs or who regularly screened for HCV and referred patients for treatment elsewhere. We recruited providers from investigators’ contacts and internet searches, and purposively sampled for diversity in provider specialty, clinical setting (e.g., academic or non-academic), region, as well as experience managing and treating HCV. Accounting for this diversity, we estimated 30–40 providers would be sufficient for thematic saturation. We contacted providers by email using a standardized script, completed a verbal consent process, and offered gift card incentives for participation. We invited 43 providers, 36 of whom were recruited and individually interviewed. The study was approved by the Biomedical Research Alliance of New York Institutional Review Board.

Data Collection

Four researchers (SL, EW, CG, SK) trained in qualitative methods conducted one-time individual interviews using a semi-structured interview guide (Supplementary File 1) through Zoom video conference software. The interview guide was informed by prior studies of health services utilization [22]; literature pertaining to implementation of HCV treatment initiation; and expert experience related to HCV treatment access. Interview questions focused on (1) experience with managing HCV and related conditions; (2) perceived barriers and facilitators to providing and initiating treatment; and (3) approaches to treating patients with HCV. We also collected self-reported provider demographic characteristics (age, sex, race/ethnicity) and practice-specific information (credentialed specialty, clinical practice setting, and duration of practice). Interviews ranged from 25 to 35 min in length, were audio recorded, deidentified, and professionally transcribed. Audio recordings and transcripts were stored on a HIPAA-compliant secure server accessed by two-factor authentication.

Data Analysis

Interview transcripts were analyzed using NVivo14. To facilitate consolidation of an initial codebook, three investigators (EW, CG, SK) independently performed line-by-line coding of 3 transcripts, identifying concepts using a hybrid inductive-deductive thematic approach [23–25]. Deductive coding was guided by Andersen’s model of health services utilization [20]. Codes were compiled into a preliminary codebook using a summative approach. To increase coding validity, 2 coders (CG and SK) independently coded the remaining transcripts using this codebook, meeting with the investigative team (led by EW) weekly to reconcile differences, revise the codebook, and combine codes into categories. Ultimately, 98 codes emerged (Supplementary File 2). Coding structures were then refined to capture emerging themes, reconciling discrepancies through consensus [26, 27]. The resulting thematic structure closely aligned with well-established implementation frameworks [21].

Consistent with the study objective of identifying provider-perceived barriers and strategies recommended by those providers to improve HCV treatment initiation, thereby informing implementation of HCV elimination plans in the US, themes were then further refined and organized based on the major domains of CFIR [28]. CFIR is a practical theory-based framework that categorizes potential barriers and facilitators to implementation into five major domains: the individual (e.g., treating physicians), the inner setting (e.g., organizational context), the outer setting (e.g., extra-organizational context), the intervention (i.e., treatment), and the implementation process. The major domains of CFIR guided the thematic structure, but given the scope of the research question and interview guide, subthemes were developed inductively based on emerging codes [23–25]. Final themes and subthemes were refined through discussions with the remainder of the investigative team.

RESULTS

The characteristics of the 36 providers interviewed are presented in Table 1. The analysis resulted in 4 major themes and 14 subthemes presented in Table 2 with representative quotations. Figure 1 presents these themes and subthemes as they align with the major domains of CFIR. We describe the themes with additional quotations:

Table 1.

Characteristics of Providers: The State of Hepatitis C Elimination from the Front Lines

Characteristics		New York City [n = 12] (%)	Alabama [n = 12] (%)	Western/central NY [n = 12] (%)	Total [n = 36] (%)
Sex	Female	6 (50)	5 (41.7)	6 (50)	17 (47.2)
Race	White	3 (25)	7 (58.3)	9 (75)	19 (52.8)
	Black	4 (33.3)	1 (8.3)	1 (8.3)	6 (16.7)
	Asian	4 (33.3)	1 (8.3)	2 (16.7)	7 (19.4)
	Unknown*	1 (8.3)	3 (25)	0 (0)	4 (11.1)
Ethnicity	Non-Hispanic	8 (66.7)	9 (75)	10 (83.3)	27 (75)
	Hispanic	3 (25)	3 (25)	2 (16.7)	8 (22.2)
	Declined	1 (8.3)	0 (0)	0 (0)	1 (2.8)
Age	< 30	0 (0)	0 (0)	2 (16.67)	2 (5.6)
	30–40	3 (25)	4 (33.3)	4 (33.3)	11 (30.5)
	40–50	6 (50)	3 (25)	0 (0)	9 (25)
	50–60	1 (8.3)	2 (16.7)	4(33.3)	7 (19.4)
	60–70	0 (0)	2 (16.7)	2 (16.7)	4 (11.1)
	70–80	1 (8.3)	1 (8.3)	0 (0)	2 (5.6)
	Declined	1 (8.3)	0 (0)	0 (0)	1 (2.8)
Specialty†	Infectious Dis	4 (33.3)	3 (25)	2 (16.7)	9 (25)
	Hep./Gastro	2 (16.7)	3 (25)	1 (8.3)	6 (16.7)
	Primary Care	2 (16.7)	6 (50)	1 (8.3)	9 (25)
	Addiction	4 (33.3)	0 (0)	8 (66.7)	12 (33.3)
Degree	MD	8 (66.7)	8 (66.7)	4 (33.3)	20 (55.5)
	NP	1 (8.3)	1 (8.3)	2 (16.7)	4 (11.1)
	PA	2 (16.7)	1 (8.3)	2 (16.7)	5 (13.9)
	PharmD	0 (0)	0 (0)	3 (25)	3 (8.3)
	RN	0 (0)	1 (8.3)	1 (8.3)	2 (5.6)
	Other‡	1 (8.3)	1 (8.3)	0 (0)	2 (5.6)
Setting§	Academic	6 (50)	7 (58.3)	4 (33.3)	17 (47.2)
	Non-Academic	6 (50)	5 (41.7)	8 (66.7)	19 (52.8)
Practice treats HCV‖	Yes	10 (83.3)	11 (91.67)	12 (100)	33 (91.7)
	No; Refers	2 (16.7)	1 (8.3)	0 (0)	3 (8.3)
Practice treats SUD¶	Yes	10 (83.3)	8 (66.7)	10 (83.3)	28 (77.8)
	No; Refers	2 (16.7)	4 (33.3)	2 (16.7)	8 (22.2)

HCV hepatitis C virus, SUD substance use disorder, Hep/Gastro hepatology/gastroenterology

^* “Unknown” includes providers that declined to answer or did not answer

^†Specialty is based on provider self-identified primary area of clinical practice

^‡ “Other” includes associate degree and ED.S degree

^§Setting is based on if the providers’ primary clinical practice site is or is not directly affiliated with an academic institution

^‖Practice treats HCV refers to whether providers’ primary clinical practice site prescribes treatment for HCV or not

^¶Practice treats SUD refers to whether providers’ primary clinical practice site prescribes treatment for SUD or not

Table 2.

Themes and Subthemes: The State of Hepatitis C Elimination from the Front Lines. Providers are Characterized using Self-Identified Primary Area of Clinical Practice, Bolded for Clarity

Theme 1. Individual: Providers want to be able to treat HCV, but don’t always feel they can or must
Limited knowledge	“It’s not something all primary care physicians have seen. They may be afraid or feel ill-equipped to treat, so they’ll refer to a specialist.” [Primary Care]
	“I feel very uncomfortable treating HCV. I don’t know the pros and cons of different drugs. But I feel very comfortable referring patients with HCV.” [Primary Care]
Beyond scope of practice	“For 30-plus years, I’ve worked with a lot of patients who are positive for HCV. I haven’t treated a lot because we have direct access to specialists. Patients get referred to them.” [Addiction]
Gratification of cure	It’s very satisfying to be able to tell my patient, “We’re going to have this many visits, and then you’re going to be cured.” [Primary Care]
Educational resources	“Training to explain how simple it is would be helpful. Different treatment options, what to look out for, what are the baseline questions to ask.” [Primary Care]
	“A community partner took us through a slideshow of HCV treatment, and I’ve gone back and referenced that slideshow quite a bit. It’d be nice to have refreshers through continued medical education.” [Primary Care]
Theme 2. Inner Setting: Providers strive for streamlined and inclusive practice settings
Partnering with experts	“Some insurances require you to have an infectious disease or gastroenterology consult in order to get screens covered. We’ve been able to overcome that through partnerships with specialists.” [Primary Care]
	“Patients could not ever dream of affording HCV treatment without our collaboration: Medicaid would not let me write the prescription for the medication without an infectious disease consultation, and we’re 80 miles from the nearest infectious disease center.” [Primary Care]
Access improves efficiency	“If [patients] decide they want to be treated, they want it to happen almost immediately. For them to have to wait two-weeks to come back in the clinic, they won’t come to that day. We have to be more available.” [Addiction]
Institutionally building trust	“I work closely with a specialist in house. If the patient doesn’t know that specialist, I can introduce them. It makes all the difference” [Addiction]
	“We work very closely with a counselor, who has a good established relationship with the patient, to identify any barriers or hesitancy the patient might have.” [Infectious Diseases]
Advocating for integrated care	“They don’t wanna go elsewhere. They have transportation barriers. They need to be at work at a certain time. Having testing and treatment available at the place they’re already being seen is optimal.” [Primary Care]
	“In primary care, you are already seeing the patients. It’s easier to just get everything taken care of under one roof. They’ve been coming to the same clinic for years; patients feel more comfortable and will be more successfully treated if it can be done in primary care.” [Primary Care]
Theme 3. Outer Setting: Public awareness and policies have improved, but structural barriers persist
Unfavorable social determinants discourage providers	“When we first talk to patients, they just have that denial because there is stigma behind it. Then they also try to hide from family, from friends.” [Addiction]
	“Economic factors play an important part. Patients can’t afford transportation or can’t afford to come to the doctor due to a copay. We try to find a FQHC that is able to provide treatment and work with them on a sliding scale basis.” [Infectious Diseases]
Awareness motivates providers	“Word of mouth is a lot better than it was it was ten years ago. Patients get to see other patients who are cured, so I think they’re more receptive to consider treatment.” [Addiction]
	“Baby boomers often had a risk or an exposure earlier in life and are really interested in their health and wellbeing. They’re coming to clinic with a desire to get cured of their Hep C.” [Infectious Diseases]
Evolving policies have reduced barriers	“We still need to get prior authorization for the majority of the patients we treat. But there haven’t been any people who have been denied recently.” [Infectious Diseases]
	“Treatment has generally been covered- although insurances each approve different ones. And most don’t cover the shorter treatment option.” [Primary Care]
Theme 4. Intervention: Improved treatments make it easier for providers to treat, though the reputation of past treatments lingers
Substantially better treatments	“Treatment is relatively straightforward, and it’s pretty well tolerated, so it feels simple.” [Primary Care]
Minimal complexity	“The only thing we have to consider is interactions with other medications. And potential coinfection with Hepatitis B.” [Gastroenterology]
Residual reputation	“That horrible treatment that made people feel like they were dying is no longer the way. I still have to explain that.” [Addiction]
	“There is a need for patient education. Telling patients that the medicines that we have now are not medications we’ve previously used in the past. They’re easy to take. There are very little side effects.” [Primary Care]

Figure 1.

The state of HCV elimination from the front lines: alignment of themes and subthemes with major domains of the Consolidated Framework for Implementation Research (CFIR).

Adapted from Damschroder et al. Fostering implementation health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Sci 4, 50 (2009).

Theme 1. Individual: Providers want to be able to treat HCV, but Don’t Always Feel They Can or Must

Providers referenced several barriers related to their own ability to treat HCV. PCPs acknowledged having limited knowledge related to treatment initiation, including a lack of familiarity with DAAs and of prior experience managing HCV. One specialist expressed that there was also limited knowledge about the need for timely treatment: “Providers don’t recognize that we should treat HCV early.” Several providers felt that treating HCV did not necessarily fall within their scope of practice, particularly because patients could simply be referred to specialists who were more familiar with treatment.

Conversely, many providers were motivated by a sense of pride that comes from being able to offer patients a cure and felt this facilitated treatment.

In reference to potential strategies to improve treatment provision, providers primarily mentioned the potential benefits of receiving “more education about the silent epidemic,” noting that educational resources, like lectures, can help improve knowledge and confidence in treating HCV. One said, “Training would help providers to feel more comfortable. They would understand it’s actually not that scary to do.”

Theme 2. Inner Setting: Providers Strive for Streamlined and Inclusive Practice Settings

Providers felt that the clinical practice setting strongly influenced whether practitioners treat HCV. In terms of barriers, participants reported that numerous structural challenges persist, including difficulties identifying lab results within a fragmented health system and identifying specialists for referral. The referral process can particularly delay and thwart treatment: “I refer them to infectious diseases. A lot of them don’t follow up. It’s not an ideal plan.” Providers referenced practice-level norms that also hindered treatment, such as not routinely testing for HCV, not asking about drug use, requiring abstinence from people who inject drugs (PWID) before initiating treatment, or requiring an undetectable HIV viral load.

In contrast, certain practice-level structures and cultures seemed to enable treatment provision. Structural facilitators included resources that providers perceived to improve workflow, such as antibody reflex testing, access to interpreters, and pharmacy services that offer medications efficiently. Inclusive practice cultures seemingly facilitated treatment, with providers referencing good bedside manner, building trust with patients, and organizational missions supporting HCV treatment. Providers noted that integrated care settings and in-house specialists often offered several of these features, making treatment convenient, accessible, and trustworthy. One explained, “PCPs are already seeing the patients; the patients are already there. If we just make it easier, patients will be more likely to get treated successfully, and we won’t lose them in the system.”

Providers suggested several strategies that could increase HCV treatment provision, including partnering with experts, to either assist with directly providing treatment (through consultants or pharmacist-run treatment infrastructures) or to streamline the referral process. Other solutions mentioned by providers included collaborations with specialists or others with more experience treating HCV, either within their own practices or through community-academic partnerships. One said, “We present patients to our academic partner, and they help us make a determination of what else we need to do: do we need to do any further testing and which antiviral medication we need to use.” Solutions also included allocating resources to increase HCV treatment access, such as implementing telemedicine, translation services, flexible hours, and patient navigation. Other strategies aimed to develop institutional cultures that encouraged HCV treatment, such as providing trauma-informed care and treating patients holistically: “We need to spend time breaking down barriers– trust is really important.” Finally, providers felt it was important to continue advocating for integrated care settings, particularly for treatment provision by PCPs, substance use disorder treatment sites, and syringe exchange programs.

Theme 3. Outer Setting: Public Awareness and Policies have Improved, but Structural Barriers Persist

Several providers felt that HCV often went unaddressed in clinical encounters because other seemingly more pressing demands superseded treating HCV: “a mix of not thinking it’s a high priority and it getting lost in the shuffle.” Providers primarily cited barriers outside of clinical encounters that they felt limited patients’ access to treatment, including transportation issues, language barriers, and lack of insurance. In Alabama, the lack of Medicaid expansion was felt to limit access to treatment. These perceived access barriers added to other perceived deterrents, including feelings that patients either did not want to discuss HCV because of stigma, had limited knowledge of HCV, or did not want to be treated (particularly those who were asymptomatic). Several said that PWID and younger patients often did not regard HCV as an immediate threat: “it’s just not a priority– they don’t feel sick.” Others noted that some older individuals felt it was not a threat at all: “They think ‘I’ve had it forever and I’m fine.’” Meanwhile, unnecessary insurance and prior authorization policies were considered ubiquitous (or pervasive) barriers to DAA provision. One provider said, “I know right off the bat that prior authorization is a hurdle I’m going to have to accomplish.” Providers, particularly in Alabama, noted that several policies did not support treatment: “Medicaid, if your drug screening is not cleared, and that includes cannabinoids, then they won’t pay for treatment. We have to wait six months.”

Nonetheless, providers felt that patients “know quite a bit” about HCV and curative treatment, and were more often the ones that motivated providers to discuss HCV at all. Providers often attributed this to television advertisements that highlight the benefits of cure, particularly among older people: “Now patients come in and say: I have seen the commercial, and I want that pill.” Most felt that PWID were generally familiar with HCV and treatment, having heard about it through contacts. One provider noted, “more of their friends have it.” Moreover, providers noted that insurance and prior authorizations policies had improved considerably over time.

Providers referenced several strategies to improve HCV treatment. They suggested leveraging direct discussions and community outreach to increase patient knowledge about HCV, and allocating resources to support patients through assistance programs and offer discounted care costs. They felt they could overcome the lack of urgency among some patients by either stressing “the consequences of untreated HCV” or the ease and benefits of treatment (“getting rid of one more thing on your plate is easy and short term”). While low-volume prescribers completed prior authorizations themselves, others sought assistance from care managers or HCV patient navigators: “The HCV coordinator helps a tremendous amount with the prior authorization in addition to making sure the patient doesn’t get lost in the system.” Others assigned additional specific personnel, including pharmacists, to overcome insurance-mediated barriers to treatment provision. One noted: “We have administrative staff keep me up to date on what’s on formulary and what’s not. And we just shift to whatever we can get.”

Theme 4: Intervention: Improved Treatments Make it Easier for Providers to Treat, Though the Reputation of Past Treatments Lingers

Providers felt that there was still some complexity associated with treating HCV, particularly for generalists, who may be less familiar with treatment. This included the complexity associated with treating patients who were pregnant, managing the duration of treatment, handling potential medication interactions, and ensuring appropriate post-treatment follow-up. Providers also perceived that patients’ experiences with the older, less well-tolerated treatments (i.e., interferon and ribavirin) at times made it challenging to offer new treatments. They felt some patients, particularly older ones and PWID, had pre-conceived notions limiting their openness to treatment: “The Baby Boomers are under the mindset that treatment is interferon-based. They have had experience themselves, or have heard how terrible that is, and they don't want to get treatment.”

Nonetheless, providers primarily highlighted the benefits of modern treatments and their significant advantages as simpler, shorter in duration, associated with fewer side effects, and more effective in comparison to previous treatment options.

Providers largely suggested increasing public-facing education regarding the new treatment options. One provider noted, “There needs to be a lot of re-education. If you have HCV, you can be treated and treatment is nothing like it was.”

DISCUSSION

This qualitative study of US healthcare providers used established implementation frameworks to identify several themes illustrating the current state of HCV elimination, including the barriers that hinder treatment initiation and the provider-recommended strategies to improve implementation of elimination plans. Providers identified several remaining barriers to eliminating HCV, including clinicians’ limited experience with providing treatment contributing to continued reliance on referrals, a fragmented health system serving patients who often have overwhelmingly limited resources, and the enduring reputation of prior poorly-tolerated treatments. Providers also identified several facilitators to increasing treatment initiation, including educational initiatives to increase provider comfort with and patient awareness of DAAs, which were broadly acknowledged to be simple, safe, and effective. Participants highlighted the critical importance of trusted relationships with patients, and the utility of infrastructures that support efficient and patient-centered treatment. Guided by health services and implementation frameworks, these findings align with the major domains of CFIR and thus offer several targeted opportunities to improve implementation of HCV elimination plans (Table 3).

Table 3.

Opportunities to Overcome Gaps to Treatment Initiation and Eliminating Hepatitis C Infection

Opportunities	Primary actors
Opportunity 1. Disseminate training materials that empower providers to treat HCV
• Increase clinical comfort among PCPs, focusing on the ease and efficacy of DAAs • Motivate early treatment of HCV, highlighting the benefits of cure • Illustrate common gaps in the treatment cascade; encourage direct treatment provision over referrals • Equip providers to use stigma-reducing communication strategies	Individual Physicians Physician Practices Credentialing Agencies Professional Organizations
Opportunity 2. Adopt clinical practices, guidelines, and infrastructures that facilitate treatment
• Establish partnerships with specialized providers and academic health centers • Enact guidelines that ensure equitable access to HCV treatment • Offer flexible hours and telemedicine options for visits • Leverage care managers, patient navigators, pharmacists, and specialty coordinators •Integrate care within substance use treatment centers and syringe exchange programs	Individual Physicians Physician Practices Credentialing Agencies Professional Organizations Public Health Departments Community Organizations
Opportunity 3. Expand public awareness campaigns to reach undertreated populations
• Utilize linguistically and culturally sensitive materials; leverage local media • Emphasize the consequences of untreated HCV and the ease of treatment • Reassure and prepare patients to initiate discussions about treatment with providers • Dispel misconceptions and promote the benefits of newer treatment regimens, including DAAs	Public Health Departments Community Organizations Policy Makers Insurers
Opportunity 4. Eliminate harmful policies and allocate resources appropriately
• Eliminate prior authorization and sobriety requirements • Eliminate discriminatory treatment limits based on substance use disorder • Support peer programs, partnerships, care coordination, and integrated care • Reimburse telemedicine consultations to improve patient access to care • Expand access to economic assistance programs	Individual Physicians Physician Practices Credentialing Agencies Professional Organizations Public Health Departments Community Organizations Policy Makers Insurers

PCP primary care physicians, DAA direct acting antivirals, HCV chronic hepatitis C

Despite over a decade since the introduction of DAAs, our study reveals that providers continue to cite previously recognized barriers. In a 2017 qualitative study including PCPs in the Veterans Affairs system, Rogal et al. found that PCPs often favored referring patients with HCV to specialists rather than providing treatment directly, and many did not provide treatment unless patients actively sought it [29]. Providers in our study voiced similar sentiments, and recent data suggest treatment provision by PCPs remains low [30]. Eliminating HCV may require broader dissemination of the strategies that encourage and empower PCPs to provide treatment. Specifically, they should consider leveraging providers’ understanding of and attribution to patient perceptions, which emerged across the themes in our study. This includes strategies that increase public awareness of treatment availability. HCV public health awareness campaigns have been incorporated into several state-wide elimination plans and have successfully increased awareness of HCV. They may achieve additional success by highlighting experiences of those previously treated, correcting misconceptions about transmission and treatment side effects, and illustrating how providers welcome requests for treatment [31]. Also echoing prior findings, providers alluded to several patient-level barriers, particularly transportation. This is consistent with prior reports that over 5.8 million persons in the US have delayed medical care due to transportation barriers [32].

While historically cited as predominantly system-based barriers to treatment initiation [29], providers in our study felt that policies related to medication cost and access have improved considerably. This is consistent with evidence that DAA costs have declined considerably since their initial approval [33, 34]. Over 20 state Medicaid programs have now removed prior authorization requirements for most patients [35, 36]. Nonetheless, the continued requirement for prior authorization remains an important problem in many settings, and obtaining such authorization is resource intensive [17, 37]. The states and insurers that have yet to remove prior authorization requirements should consider the overall costs of maintaining them and their detrimental impact on eliminating HCV. Our study sampled providers in Alabama and New York, states with substantially different policies regarding prior authorization for Medicaid beneficiaries. Although providers in Alabama alluded to more stringent restrictions, providers across both states often characterized prior authorizations as unavoidable, especially for retreatment. Many employed dedicated staff and established partnerships specifically to facilitate approval. The allocation of substantial time, personnel, and financial resources required to address prior authorization increases costs of treatment and can restrict access, particularly in less-resourced settings. It is also likely a deterrent to expanding treatment access to providers who diagnose and treat HCV less frequently, albeit those who are vital to eliminating HCV [17]. Moreover, providers noted that several policies continue to impede HCV treatment specifically among PWID, underscoring the need for educational initiatives that promote established guidelines and for continued advocacy for elimination of discriminatory policies [36, 38].

One key factor that emerged in our study was the importance of leveraging patient networks and professional connections. Providers believed that patients’ treatment readiness was influenced by peers’ experience living with HCV and their impressions of the success and tolerability of DAA regimens. Health systems may want to utilize successful peer-mediated interventions to facilitate treatment provision [39]. Providers also felt their own connections with other providers were crucial to providing treatment. They often advocated for integrating HCV care within settings already connected to patients, including primary care settings or substance use treatment centers. In a recent study, 90.2% of HCV-infected individuals achieved a sustained virological response when treated through a facilitated telemedicine model integrated into opioid treatment programs compared to 39.4% treated through offsite referral [40]. PCPs and substance use treatment providers may benefit from coordinated care models that facilitate treatment provision at trusted locations through expert assistance. As an example, Project ECHO (Extension for Community Healthcare Outcomes) builds primary care capacity to treat HCV by building collaborations with specialists facilitated by regular videoconferencing, and it has substantially increased the number of PCPs providing HCV treatment and the number of eligible individuals receiving DAAs [41]. Further research is needed to understand how to increase the reach of these programs.

Limitations

Though we aimed to recruit a sample representing a variety of clinical settings and experiences with HCV treatment, participants were recruited through academic partnerships and primarily captured experiences of providers that provide or have access to providing HCV treatment, limiting the transferability of findings. However, our sampling scheme captured the experiences of providers in diverse geographic and clinical settings, including rural areas distanced from academic partners. Concerns reported by our participants may be even more widespread among providers without established relationships with academic sites. Considering our aim of identifying common barriers and facilitators to HCV treatment initiation across clinically and geographically diverse settings, we did not perform a comparative analysis.

CONCLUSIONS

Relatively few patients with HCV are provided curative treatment, contributing to a rise in HCV incidence and hindering progress toward HCV elimination. Our findings provide valuable insights into the remaining barriers experienced by clinicians in initiating HCV treatment across diverse settings. Strategies to improve patient awareness, reduce stigma, streamline medication access, eliminate prior authorization requirements, and adopt patient-centered approaches should be implemented to enhance HCV treatment initiation and facilitate its elimination.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK123205), the National Institute on Drug Abuse (K01DA048172), the Patient-Centered Outcomes Research Institute (PCOORI IHS-1507–31640), and the National Institute of Aging-funded Cornell Edward R. Roybal Center (P30AG022845), and was partially supported by the Troup Fund of the Kaleida Health Foundation.

Declarations:

Conflict of Interest:

R.F. has received funds paid to his institution from Gilead Sciences, Inc., Abbvie, Merck & Co, Inc., and a consulting fee from Thera technologies. S.N.K. and A.R.L. have received funds paid to their institutions from Gilead Sciences, Inc. A.H.T. has received honoraria and funds to his institution from Gilead Sciences, and the latter from Merck and Co. and Abbott Laboratories. All other authors report no potential conflicts of interest.

Disclaimer:

The statements in this work are solely the responsibility of the authors and do not necessarily represent the views of the National Institutes of Health, or PCORI, its Board of Governors or its Methodology Committee.