Identifying Varying Influences on Eliminating Hepatitis C Across Medical Specialties

Abstract

Objective:

To identify specialty-specific influences in administering HCV treatment among primary care, gastroenterology/hepatology, infectious diseases, and addiction specialties, and strategies to potentially eliminate HCV.

Study Setting and Design:

Qualitative study using remote interviews with healthcare providers in New York and Alabama who treated or screened patients for HCV, purposefully sampling for specialty, clinical setting, and HCV treatment experience.

Data sources and Analytic Sample:

Interviews occurred 9/2021—8/2022. Transcripts were analyzed using a hybrid inductive-deductive approach; a content analysis identified codes arising uniquely within specialties.

Results:

Thirty-six providers were interviewed: primary care (n=9), addiction medicine (n=12), infectious diseases (n=9), and gastroenterology/hepatology (n=6). Distinct challenges and facilitators emerged across specialties. Primary care and addiction providers similarly emphasized the convenience and usual practice of referring patients to specialists for HCV treatment, while infectious disease and gastroenterology noted challenges with patients not completing the referrals. Primary care providers expressed wanting training and peer support related to treatment provision. Addiction providers described structural barriers, such as lacking on-site phlebotomy services and patients’ competing health concern prioritization, but highlighted strategies to improve treatment access, including trust-building. Infectious disease providers highlighted using patient navigators to overcome logistical barriers, while gastroenterologists emphasized collaborative relationships, particularly with addiction specialists. Specialty-specific opportunities emerged regarding training, collaboration, navigation, and infrastructure.

Conclusions:

Eliminating HCV requires addressing specialty-specific concerns for providers managing HCV. Potential opportunities include dissemination of specialty-tailored training, facilitating interdisciplinary care and desired cross-specialty collaborations, and overcoming unique infrastructural needs. Future research should evaluate implementation strategies addressing these specialty-specific needs.

INTRODUCTION

Over 2.4 million people are currently living with chronic hepatitis C virus (HCV) infection in the United States (US).^1,2 HCV can cause cirrhosis, cancer, and death.³ The introduction of direct-acting antivirals (DAAs) in 2011 made treating and curing HCV simpler, with very few side effects and exceptionally high efficacy.⁴ With highly curative DAAs now available, the World Health Organization (WHO) declared a goal of eliminating HCV by 2030. However, due to the opioid and stimulant epidemics, the incidence of HCV has continued to increase in the United States (US), and current progress suggests that the goal will become unachievable.³

While specialists, primarily gastroenterologists and hepatologists, historically oversaw HCV care,⁵ eliminating HCV necessitates that providers evaluating patients with HCV be ready to engage those patients in treatment, regardless of the provider’s specialty.^6,7 Several barriers create difficulties for providers to diagnose and treat patients with HCV,³ including treatment restrictions imposed by government health insurance programs,^8–10 stigma and discrimination,^9,11 and limited HCV testing and outreach in substance use disorder (SUD) treatment settings.^12,13 Recent publications,¹⁴ including our own,⁹ have identified barriers and facilitators affecting HCV elimination in the US as reported by providers across all specialties, including those in primary care. Common provider-reported barriers include limited experience with treatment, complex social issues for patients, and insurance-based restrictions to accessing treatment. Common facilitators include the use of interdisciplinary teams and the relative effectiveness and simplicity of DAAs. However, there is considerable variation in treatment initiation between providers, particularly from different specialties,¹⁵ and little information about what factors contribute to this variation. While additional evidence has explored barriers faced by specific specialties (particularly by primary care providers) or certain patient populations,^16,17 there remains a need to identify and understand the challenges and opportunities to providing HCV treatment across various specialties that commonly encounter patients with HCV.

Considering the lagging pace toward HCV elimination, identifying the challenges and opportunities unique to each specialty could inform the strategies used to better engage and support these specialties’ provision of HCV treatment and the elimination of HCV.

METHODS

Study Sample and Setting

For this qualitative study, we recruited providers practicing in the medical specialties that predominantly evaluate patients with HCV in the US: primary care, gastroenterology/hepatology, infectious diseases, and addiction medicine.¹⁵ Recruitment occurred between 9/2021 and 9/2022, and providers came from 3 regions with differing sociodemographic and policy environments: New York City (a large, urban area in the northeastern US), Western/Central New York (including smaller metropolitan and rural areas in the northeastern US), and Alabama (including urban and rural areas in the southern US state with historically restrictive treatment requirements). Participant inclusion criteria included providers, such as physicians and advanced practice providers, who treated or regularly screened for HCV and referred patients for treatment elsewhere in the past 5 years.

Investigator’s academic partnerships and networks were the primary mediums for recruitment. In Alabama, we recruited providers from community sites with a prior relationship to the University of Alabama at Birmingham network,^18,19 predominantly composed of primary care providers. The Western/Central New York sites recruited providers engaged previously in research leveraging telemedicine to offer HCV treatment and included several addiction care networks.^20,21 Finally, we recruited New York City providers through investigators’ academic partnerships, which included many specialists. The sampling of provider specialty was not even across these three locations.

The study team contacted providers by email using a standardized script, then completed a verbal consent process and offered $150 gift card incentives for participation. We invited 43 providers for interviews, of whom 36 were recruited and individually interviewed. We purposefully sampled for provider specialty, clinical setting, region, and experience managing and treating HCV. Accounting for this diversity, we estimated 30–40 providers would be sufficient for thematic saturation. The study received approval from the Biomedical Research Alliance of New York Institutional Review Board.

Data Collection

Trained in qualitative methods, researchers (EW, CG, SK), two male and one female, performed one-time individual interviews through Zoom video conference software with a semi-structured interview guide.⁹ Written notes were taken during interviews. Research on the implementation of HCV treatment initiation, expert experience, and prior studies of health services utilization informed the interview guide.²² Questions focused on providers’ experiences managing HCV and related conditions, perceived barriers and facilitators to providing and initiating treatment, and their approaches to treating patients with HCV. Researchers derived practice-specific information (credentialed specialty, clinical practice setting, and duration of practice) and demographic characteristics (age, sex, race/ethnicity) from clinician responses. Interviews were audio recorded, deidentified, and professionally transcribed. Interviews ranged from 21:02 – 48:16 minutes, with a median duration of 30:2 minutes. The study team stored audio recordings and transcripts on a HIPAA-compliant secure server accessed by 2-factor authentication.

Data Analysis

The study team analyzed interview transcripts using NVivo14, which participants did not receive. Investigators EW, CG, and SK independently conducted line-by-line coding of 3 transcripts, identifying concepts using a hybrid inductive-deductive thematic approach.^23–25 Deductive coding based on Andersen’s model of health services utilization and the Consolidated Framework for Implementation Research, which provided a determinant framework to delineate barriers and facilitators in existing health services surrounding HCV treatment.^22,26 Then, codes were compiled into a preliminary codebook using a summative approach. To increase coding validity, coders CG and SK independently coded the remaining transcripts using this codebook, meeting with the investigative team weekly to reconcile differences, revise the codebook, and combine codes into categories.^27,28 Findings from the initial analysis, including provider-perceived structural barriers for patients, were previously published.⁹ CPM and CG then analyzed facilitators and barriers to treatment provision that emerged uniquely across primary care, gastroenterology and hepatology, addiction, and infectious diseases providers. A content analysis identified concepts and codes that emerged exclusively among providers within a specialty or that emerged differently across specialties. Through discussion and consensus, findings were categorized into and presented as barriers and facilitators identified by each specialty. Participants did not provide feedback. From this analysis, 83 unique codes emerged (eTable 1).

RESULTS

The characteristics of the 36 providers interviewed, including provider practice setting, highest academic degree, and experience level, are in Table 1. Tables 2a and 2b detail barriers and facilitators by specialty.

Table 1.

Participant Characteristics Among Provider Specialties

Characteristics		Infectious Disease [n = 9]	Primary Care [n = 9]	Addiction [n = 12]	Gastro/Hepatology [n = 6]
Race	Asian	1	3	1	2
	Black	2	0	4	0
	White	5	5	6	3
Ethnicity	Hispanic	4	1	2	1
Experience Level	Less than 5	2	3	6	4
	5–10 years	6	3	2	2
	11–20 years	0	1	3	0
	20+	1	1	1	0
Academic vs Non-Academic †	Academic	6	2	2	6
Location ‡	AL	3	6	0	3
	NYC	4	2	4	2
	UB	2	1	8	1
Provider Practice Setting §	FQHC	4	3	1	0
	RHC	0	2	0	0
	Hospital Based	4	1	2	6
	OTP	1	1	9	0
	Independent Clinic	0	2	0	0
Offers SUD Rx ¶	Yes	9	7	12	4
HCV Dx and Tx on Site #	Yes	7	7	10	4
	No	2	1	0	2
	Dx Yes Tx No	0	0	2	0
Highest Academic Degree	Bachelors or Associates	1	0	0	0
	EdS	1	0	0	0
	MD	6	5	4	5
	NP	0	1	2	1
	PA	0	1	4	0
	PharmD	1	0	2	0
	PhD; RN	0	1	0	0
	RN	0	1	0	0

^†Academic status details participant’s clinical setting’s association to an academic institution.

^‡Location reflected participants clinical practice’s geographical site, with AL representing Alabama, NYC for New York City, and UB for Western/Central New York.

^§Provider practice setting described participants clinical practice’s type.

^¶Offers SUD Rx represents a clinics’ ability to provide medical prescription for substance use disorder.

^#HCV Dx and Tx on Site signifies a clinic’s ability to provide HCV diagnosis and treatment on site. Acronyms: FQHC, Federally Qualified Health Center; RHC, Rural Health Center

Table 2a.

Barriers Among Provider Specialties

Provider Specialty	Barriers	Example Quotes
Primary Care	1) Lack of experience managing HCV and unfamiliar with formal training opportunities (CME) for treating HCV.	“Another barrier is I'm not too knowledgeable in hepatitis C treatment. I don’t have as much experience.” – 2010
	2) Accustomed to referring to specialists for prior authorization and medication requirements.	“But the biggest... barriers toward getting people treated that is unique to Hep C is it always require a prior authorization... So, I think just knowing off the bat that that is a hurdle I'm going to have to accomplish...” – 1013
Addiction	1) Limited onsite phlebotomy services delay diagnosis and treatment of HCV.	“I think our clinic specifically... the biggest barrier that we have encountered is... once we identify patients that need treatment and that have Hep C, getting them the right baseline labs has been a challenge. So, a lot of these patients may not have transportation to an outside lab.” – 3009
	2) Accustomed to referring to specialists for treatment.	“I've worked with a lot of patients who are positive for hepatitis C. I haven’t treated a lot because in most of the practices I've been, we have a doctor who does infectious disease, so most of the hepatitis C patients get referred to this doc.” – 3008
	3) Lack of longitudinal and recurrent formal training opportunities to learn to treat HCV.	“I think training needs to be ongoing and admittedly, that probably is one of the events too because say no matter we get this changed, then they'll see patients, so when is that going to occur? We have to find a way in which to facilitate that, even though we're betting on that it’s not going to be easy.” – 1007
Infectious Diseases	1) HCV misclassification as a low priority disease can lead to poor referral rates.	“I think often it’s probably a mix of not thinking that it’s a high priority, especially in the inpatient setting, it just kind of gets lost in the shuffle and so the referral doesn’t get made. Or maybe some people aren’t familiar with who they can refer to.” – 1009
	2) Missed appointments incur a cost and hinder providers desire to follow up with patients.	“You know missed appointments are zero revenue for people, and so a lot providers don’t want zero revenue time slots and these individuals are more likely to be no shows.” – 1000T
Gastro/Hepatology	1) Substance use disorder can inhibit HCV treatment initiation for some providers.	“We have a lot of restrictions currently on active drug use or not treating a lot of people with active drug use. They had to have been sober for a period of time.” – 1002
	2) Missed appointments incur a cost.	“I feel like the patients who use are again, just high, there’s a high no-show ratio I guess in our clinic for patients who are actively using drugs.” – 2012

Table 2b.

Facilitators Among Provider Specialties

Provider Specialty	Facilitators	Example Quotes
Primary Care	1) Training helps PCPs become familiar with handling patient’s HCV concerns.	“I think just CME would just be helpful. That would be great. Or even... updates on HCV screenings, if it’s just--with cirrhotic but I guess if there's any updates about--any-follow-up with some of the cirrhotic patients I think that would be good.” – 1005
	2) Pharmacists, infectious disease colleagues, and HCV Navigators assist with the HCV treatment cascade.	“In my ideal world it would be somebody whose job is to do the prior authorizations or to do the drug assistance program who is familiar with the different forms and makes it very streamlined and easy, somebody who is calling the patients to remind them about their appointments, their blood work.” – 1013
Addiction	1) Having mental health services and travel assistance for patients.	“I find that when mental health issues are not addressed, then you can’t address anything else. So, we have a psychiatrist on site so that we could address the mental health issues early on.” – 1011
	2) Interdisciplinary HCV care that includes pharmacists, social workers, and counselors.	“One of the easiest things for me is that, as I said, I work closely with the HIV, Hep C doctors, so any issues, if the patients is not showing up, we talk to each other. We can prescribe for each other.” – 1010
	3) Formal training opportunities focused on providing team-based care for HCV.	“The reality is in my humble opinion the training and education needs to also include the social workers and counselors because questions are coming to them from the patients about, “what do you think?” So, we need to make sure they are knowledgeable enough and continue to be knowledgeable enough.” – 1007
Infectious Diseases	1) ID providers want inclusion in educational training initiatives for non-ID providers (e.g. Primary Care providers).	“At the health department where I go several doctors who do primary care approach me and ask about how to treat HCV. If I can help I always say yes, and the bottom line is that there is education and we need to offer more of it.” – 2004
	2) HCV navigators help overcome stigma and assist with patient appointments and follow ups.	“The job of a hep C navigator is to try to lure people away from stigma, not only patients, not only providers, but also my colleagues at work as well…We try to use different words and address people with dignity so that they know that there’s still a human being, even though they might not be dumb.” – 1006
	3) Pharmacy coordination for medication distribution.	“Sometimes we find transportation being a problem for them to get to the pharmacy to pick their medication up. So, it’s basically like linking with the pharmacy to see if we can schedule that they can mail the medication out, or if they mail it to our office, I'll take it to the post office and mail it to their home.” – 2007
	4) Traveling to a patient’s location and using patients’ social networks helps expand outreach potential.	“I think the other thing that we really focus on is making sure people understand transmission. So, we do a lot of trying to treat individuals while encouraging them to have their network be treated at the same time.” – 1000T
Gastro/Hepatology	1) Partnerships with pharmacies and care navigators alleviate prior authorization and medication distribution barriers.	“I think having a comprehensive system of the physician/pharmacist testing and treating. So, a combination of all those things. Having avenues for people to get tested and then linked to treatment. ” – 2011
	2) Additional care access options like open-door policies help patients connect with treatment.	“Sometimes I would have open office hours, and I would spend the day at the methadone clinic, and you know if a patient wants to come in and talk then I'm there for them, I can provide education regarding Hepatitis C or anything else that may be relevant.” – 3000T
	3) Collaborations with addiction treatment services.	“I think it would be great if someone could even give a patient who wanted to get treatment and appointment at a syringe exchange program with you a provider that could treat their hepatitis, that would be enough.” – 1003

Primary Care Providers (PCPs)

PCPs felt that patients diagnosed with HCV either came in requesting treatment or otherwise knew very little about HCV, its transmission, and its treatment. In discussing their own challenges, PCPs expressed a general lack of knowledge and experience with managing and treating HCV. This included a lack of familiarity with newer treatment options and their cost, but also uncertainty about the specific indications for referring individuals diagnosed with HCV to specialists. They explained that PCPs often refer patients to specialists for treatment, rather than directly providing treatment themselves, because (1) historically, all patients diagnosed with HCV had been referred to specialists, such as gastroenterology and hepatology, for further evaluation and treatment; (2) prior authorization for treatment sometimes required that patients with HCV be evaluated by a specialist, and (3) the referral process was convenient. Moreover, not all PCPs considered treating HCV to be within their scope of practice, feeling it was within the scope of the specialist’s practice.

Regarding facilitators for providing treatment, PCPs stated that they were open to treating HCV themselves with the appropriate training and with supervision from those with experience treating HCV. While they felt unaware of formal training opportunities (i.e., continued medical education) on HCV, they requested training on how to communicate with patients about HCV and its treatment options, particularly for those patients with limited knowledge of the condition. PCPs who provided HCV treatment themselves reported receiving assistance from peers, pharmacists, and infectious diseases colleagues, and leveraging HCV navigators to facilitate prior authorization processes and scheduling of patients with HCV.

Addiction Providers

Addiction providers felt that patients did not view HCV treatment initiation as an urgent concern. Particularly among older patient populations, they felt that patients prioritized managing multiple other medical conditions over seeking HCV care, which delayed treatment initiation. When discussing their own challenges in providing HCV treatment, addiction providers expressed that the lack of onsite phlebotomy services delayed the diagnosis process significantly, hindering the provision of HCV treatment. Similar to PCPs, they also explained that patients diagnosed with HCV had historically been referred to specialists, and so continued offsite referral was the usual practice.

Addiction providers shared that they frequently linked patients to mental health services. They also frequently provided direct resources, such as phones and transit fares, to patients in need. By addressing patients’ competing priorities, addiction providers perceived that they were building trust and engaging patients in HCV care. Additionally, they felt that interdisciplinary care that includes pharmacists, social workers, physician assistants, and counselors has been critical to treating HCV. Relatedly, addiction providers felt that formal training opportunities would streamline the clinical workflow for delivering HCV care by enhancing the team’s engagement in providing HCV care and strengthening teamwork. While they voiced awareness of specific training opportunities, addiction providers felt that there was an insufficient quantity of such opportunities and hoped these training opportunities would be offered through longitudinal and recurrent curricula.

Infectious Diseases (ID) Providers

ID providers noted that by treating HCV, providers sometimes incur the costs of missed appointments, which could disincentivize them from rescheduling those appointments. ID providers also noted that referrals to ID were needed for a given ID clinician to be able to provide treatment, however, other healthcare staff did not always view HCV as a high priority, particularly in inpatient settings, leading to referrals not being made.

ID providers discussed using several strategies to reach patients and to provide HCV treatment and follow up. For example, they described leveraging navigators to overcome stigma and logistical barriers and coordinating with pharmacies to approve and deliver medication to patients. One patient navigator detailed even traveling to patients’ homes to ensure they received HCV care. ID providers also explained that leveraging patient social networks could help increase their reach to other patients with HCV. ID providers endorsed educational training initiatives and expressed interest in participating, particularly as trainers, to share their expertise with other providers. Lastly, they discussed seeking and receiving in-depth trainings focusing on technical knowledge, such as guidance on medication interactions and treatment options in the case of reinfection.

Gastroenterology/Hepatology (GI) Providers

GI providers described barriers to HCV treatment shared by providers across all other specialties and, like ID providers, specifically highlighted the cost of patients missing their scheduled appointments. They also noted that some providers, across specialties, may not initiate treatment for people who use drugs, feeling that SUD could interfere with follow up.

GI providers explained that established partnerships with pharmacies facilitated the rapid dispersion of medications and the resolution of formulary or prior authorization issues. Additionally, GI providers felt that since people who use drugs are at high-risk for HCV, collaborating with addiction treatment services, such as addiction specialists, methadone programs and syringe services programs, could facilitate treatment provision of both conditions. Lastly, they felt that patients with HCV could benefit from additional assistance with scheduling and attending follow up appointments. They mentioned leveraging care navigators, as well as additional access opportunities, such as open-door policies, single-visit test and treat options (i.e. from screening to treatment), and transportation sponsored by medical institutions to help combat distance and travel issues.

DISCUSSION

Our findings reveal distinct challenges and opportunities across the four specialties that predominantly treat patients with HCV. Both PCPs and addiction providers emphasized the convenience of referring patients to specialists for treatment – even as those same specialists emphasized the challenges with patients not completing referrals. While PCPs felt that historical practices, inadequate familiarity with HCV management, and limitations in their perceived scope of practice contributed to their referral practice, they were willing to treat HCV with appropriate training and peer support. Comparatively, addiction providers described insufficient onsite diagnostic services and patients’ competing prioritization of other health concerns as hindering treatment initiation. They highlighted trust-building, interdisciplinary care, and direct provision of resources to facilitate completing referrals. ID and GI specialists described feeling it was within their scope to treat HCV but focused on distinct barriers to treatment. ID providers emphasized logistical barriers, including a shortage of referrals from diagnosing physicians and the fiscal repercussions of missed appointments, and felt leveraging navigators and patient networks could overcome stigma-related barriers to treatment initiation. GI providers focused on the lack of treatment initiation for patients with SUD across all specialties, stressing the importance of partnerships with addiction services, navigators, and other resources to facilitate scheduling and follow-up. Findings suggest that specialty-specific training and cross-collaboration may benefit providers in streamlining team-based workflows that expand HCV treatment access and increase treatment initiation. Specific opportunities are delineated (Table 3).

Table 3.

Unique Opportunities for HCV Specialties: Specialty Matters in HCV Elimination

Opportunities	PCPs	Addiction	Infectious Disease	Gastroenterology
Training	Promote Hep C training on:  • Communicating HCV to patients and managing reinfections.  • Available treatment options and referral creation.	Offer continuous training:  • Enhances team-based treatment.  • Helps staff effectively communicate HCV.	Endorse educational HCV training:  • Showed interest in teaching other specialties.  • Requested training to navigate medication interactions and reinfection.	Gastroenterology did not emphasize training Opportunities
Collaboration	Inform ways to establish collaborative care:  • Leveraging HCV navigators.  • Partnerships with pharmacist.  • Infectious disease specialist assistance.	Support relationships with:  • Pharmacists  • Social workers  • Counselors.	Elaborated the necessity for collaborative HCV care:  • Discussed how it can improve referral rates.  • Could assist PCPs unfamiliar with HCV care.  • Streamline medication delivery to patients.	Desire collaborative treatment efforts to:  • Work with addiction providers to treat HCV.  • Promote HCV care among PCPs.
Navigation	Support navigation with:  • Prior authorization processes.  • Scheduling HCV patients.	Help link patients to:  • Mental health services.  • Digital resources for communication enhancement.  • MetroCard or travel assistance for travel.	Patient navigators help overcome stigma and access barriers:  • Help coordinate appointments and visits.  • Lead outreach initiatives.  • Provides a space for patients to ask questions and convey concerns.	Supportive patient navigation can:  • Assist patients in navigating insurance processes.  • Promote lab work and proper follow up scheduling.
Infrastructure	Change prior authorization policies:  • Removal of specialty referral requirement.  • Enhance Outreach:  • Accessible decision aids for HCV patients.	Establish in-house labs:  • To streamline the diagnosis process.  • To avoid discouraging patients with travel inconveniences.	Supportive patient network facilitate care:  • Increase outreach bandwidth.  • Establishes a safe space for patients.	Open to flexible treatment options:  • Open door policies can help place patients in control of the assistance they need.  • All-at-once treatment can engage patients to seek HCV care.

Research has shown that PCPs continue to refer patients with HCV to specialists for treatment, at least in part due to a lack of familiarity with HCV management.^16,29 Our study reinforces those findings since interviewed PCPs felt unaware of training opportunities they could access despite wanting training on communicating HCV and potential treatment options with their patients. In contrast, addiction providers were aware of some training opportunities but felt they were neither recurring nor continuous, and specifically sought training that facilitated team-based treatment provision. While training opportunities, including those offered regionally,³⁰ vary in their content, they often focus on clinical factors,^31,32 including identifying patients for screening, interpreting test results, and selecting appropriate treatment regimens. Our findings suggest training opportunities may need to focus on how providers, especially PCPs, can communicate the urgency and ease of treatment to patients and how to overcome logistic barriers to providing treatment. Funded by the Centers for Disease Control and Prevention, the University of Washington developed a free self-guided educational website that offers continuing education and training for providing HCV treatment;³³ further research is needed to identify implementation strategies that effectively improve the reach and use of such resources.

Consistent with prior literature, providers in our study felt that SUD continues to influence the provision of HCV treatment, including through challenges to follow up posed by stigma,^29,34 competing priorities,³⁵ and provider-perceived financial and logistical repercussions of patients missing appointments.^36,37 Evidence suggests screening initiatives and outreach are essential for people who use drugs, and that patients with SUD can achieve acceptable rates of HCV treatment adherence.¹⁷ This supports current guideline recommendations that providers continue offering patients with SUD HCV treatment.³⁸ Additionally, the provision of HCV treatment for patients who use drugs can provide a public health benefit by teaching safe drug usage practices that can help reduce HCV transmission,^39,40 such as safe injection practices.^41,42

Providers noted varying strategies for overcoming perceived barriers to initiating care and follow-up. GI specialists advocated for increasing access to treatment through single-visit test and treat options. Addiction providers highlighted a need for vital diagnostic resources, including on-site phlebotomy that would facilitate the provision of HCV treatment. To combat the stigma surrounding people living with HCV and SUD, ID specialists specifically mentioned leveraging HCV navigators to facilitate care engagement, while addiction providers felt uniquely positioned to address patients’ competing health priorities. Models for rapid treatment initiation, including point-of-care confirmatory testing, are promising avenues for providing treatment to those in marginalized populations and may be useful and needed in these GI and addiction settings.^43,44 Furthermore, utilization of patient navigators can improve the prior authorization process and assist patients when accessing the healthcare system.^45–47

While providers have leveraged interdisciplinary care models and collaborative partnerships to optimize HCV treatment,²⁹ our study shows the potential to expand previous collaborations and provides insight into desired specialty-specific partnerships. PCPs sought collaborations with experienced peers and ID specialists while ID providers expressed an interest in sharing their expertise with other providers, including as trainers in formal educational initiatives. GI providers emphasized the potential benefits of collaborating with addiction treatment services, while addiction specialists valued care that included pharmacists, social workers, and counselors. Current models like Project ECHO (Extension for Community Healthcare Outcomes) have effectively facilitated collaborations between primary care and specialists, building capacity to treat HCV through regular videoconferencing, and have expanded to incorporate opioid use disorder and addiction medicine trainings. However, the reach of these programs is limited, and there remains a need to understand how to better engage primary care providers in these programs.^48–50 Regarding GI and addiction, one step to potentially eliminating HCV may be integrating addiction services in GI settings,⁵¹ similar to integration models used in primary care and infectious disease settings.^17,52–54 Some of the addiction providers we interviewed had participated in a study to assess opioid treatment program integrated facilitated telemedicine as an approach to manage HCV. ²¹The attributes, such as interdisciplinary care teams and the availability of mental health services, are provided in the supportive and destigmatizing environment of the opioid treatment program.⁵⁵ Implementation models that leverage champions may be particularly promising. Prior research suggests providers welcome professional champions to demonstrate to peers how to deliver HCV care. Specifically, they are seen to motivate action, challenge inaction, and address setting and specialty specific-challenges.⁵⁶ Champions can include peers and PWID, which can assist in dispelling myths and misinformation about HCV, while building trust and reducing stigma.⁵⁷ Future research is needed to confirm the feasibility, effectiveness and sustainability of enabling these specific collaborations.

Limitations

Although we sought to include providers from various clinical settings and ranging HCV treatment experiences, our sample derived from academic networks and primarily consisted of four clinical specialties that predominantly refer or directly treat patients with HCV. Despite sampling from diverse regions, our sample came from Western/Central New York, New York City, and Alabama. We did not evenly distribute the specialties sampled between those three geographical locations, which resulted in specialty clustering in certain regions. Also, participants had distinctive HCV-related research relationships in unique practice settings, meaning findings emerging from this study should not be interpreted as wholly representative of each specialty. This comparative qualitative analysis focused on findings unique to each specialty; similarities between specialties are reported elsewhere.⁹ Moreover, the qualitative approach identified concepts that emerged differentially among providers from different specialties but does not intend to quantify those differences. These factors may limit the transferability of findings. We did not include patient perspectives.

Conclusions

In order to reach the goal of HCV elimination, it is imperative to identify strategies to improve treatment provision that can be implemented by providers at the specialty level. Our findings provide valuable insights into the unique barriers experienced by providers of different specialties in initiating HCV treatment, and opportunities to overcome them. Opportunities to make specialty specific HCV related trainings more accessible, emphasize collaborative care between specialties as they request, and improve specialty specific practice infrastructure should be implemented to enhance HCV treatment initiation and facilitate its elimination.

Data Access, Responsibility, and Analysis:

CJG had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.