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. Author manuscript; available in PMC: 2022 Mar 1.
Published in final edited form as: Drug Alcohol Depend. 2021 Jan 11;220:108526. doi: 10.1016/j.drugalcdep.2021.108526

Patients at a Drug Detoxification Center Share Perspectives on How to Increase Hepatitis C Treatment Uptake: A Qualitative Study

Sabrina A ASSOUMOU 1,2, Carlos R SIAN 2, Christina M GEBEL 3, Benjamin P LINAS 1,2,3, Jeffrey H SAMET 3,4, Judith A BERNSTEIN 3
PMCID: PMC8064807  NIHMSID: NIHMS1673330  PMID: 33465604

Abstract

Background:

The US opioid crisis is associated with a surge in hepatitis C virus (HCV) infections among persons who inject drugs (PWID), and yet the uptake of HCV curative therapy among PWID is low.

Purpose:

To explore potential solutions to overcome barriers to HCV treatment uptake among individuals at a drug detoxification center.

Methods:

Qualitative study with in-depth interviews and thematic analysis of coded data.

Results:

Patients (N=24) had the following characteristics: mean age 37 years; 67% White, 13% Black, 8% Latinx, 4% Native Hawaiian/Pacific Islander, 8% other; 71% with a history of injecting drugs. Most patients with a positive HCV test had not pursued treatment due to few perceived immediate consequences from a positive test and possible complications arising in a distant poorly imagined future. Active substance use was a major barrier to HCV treatment uptake because of disruptions to routine activities. In addition, re-infection after treatment was perceived as inevitable. Patients had suggestions to improve HCV treatment uptake: high-intensity wraparound care characterized by frequent interactions with supportive services; same-day/walk-in options; low-barrier access to substance use treatment; assistance with navigating the health care system; attention to immediate needs, such as housing; and the opportunity to select an approach that best fits individual circumstances.

Conclusions:

Active substance use was a major barrier to treatment initiation. To improve uptake, affected individuals recommended that HCV treatment be integrated within substance use treatment programs. Such a model should incorporate patient education within low-barrier, high-intensity wraparound care, tailored to patients’ needs and priorities.

Keywords: Hepatitis C, persons who inject drugs, linkage to care, access to care, medications for opioid use disorder

1. INTRODUCTION

The US opioid overdose crisis has been associated with a surge in hepatitis C virus (HCV) infections among persons who inject drugs (PWID) (Zibbell et al., 2015). Despite the advent of curative therapy, HCV linkage to care and treatment uptake has been low in this population (Afdhal et al., 2014; Akyar et al., 2016). Given new HCV infections among PWID, the United States (US) is not on target to reach the World Health Organization’s (WHO) HCV elimination goals which include a 90% reduction in new infections (Razavi et al., 2020). Successfully addressing HCV infection necessitates dedicated efforts to develop, implement and tailor interventions specifically for PWID.

Prior studies have shown that HCV infection was defined relative to HIV which was perceived as a more serious condition (Davis et al., 2004). HCV treatment was often delayed because it was either not routinely offered by clinicians or not covered by insurance plans (Childs et al., 2019). Studies on HCV treatment uptake during the era of direct-acting antiviral therapy have not specifically elicited perspectives from persons at drug detoxification centers (Marshall et al., 2020).

The current study consisted of in-depth qualitative interviews to determine facilitators and barriers to HCV treatment uptake as the first step in developing a targeted intervention. We explored themes related to HCV screening and engagement in HCV treatment. Given that our study aimed to enroll persons who inject drugs, we selected the setting of a drug detoxification center, where the majority of patients have a history of injecting drugs (Assoumou et al., 2020). Drug detoxification centers provide medical management of withdrawal symptoms, group counseling, links to resources (CSAT, 2006), and assistance with transfer to transitional and long-term drug treatment facilities—useful resources if HCV treatment is desired.

2. METHODS

2.1. Conceptual framework and interview guide development

SAA, CRS, JAB and BPL used the Information-Motivation-Behavioral (IMB) skills theoretical model to develop a semi-structured interview guide (Fisher and Fisher, 1992). According to the IMB model, which is commonly used across a range of issues from engagement in HIV treatment to diabetes management (Starace et al, 2006; Mayberry & Osborn, 2014), behavioral change requires persons at-risk to have accurate information, motivation and behavioral skills in the form of self-efficacy (Figure 1).

Figure 1.

Figure 1.

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Conceptual model of hepatitis C treatment initiation mechanisms of action adapting Fisher et al.’s Information-Motivation-Behavioral (IMB) skills theoretical model.

HCV=hepatitis C

We also used the HCV risk perception and treatment uptake literature to develop the interview guide. For example, during the interferon era, barriers included the lack of HCV-related symptoms, the fear of treatment side effects, and limited knowledge about treatment options (Bajis et al., 2017). In addition, integrated care provided by a multidisciplinary team was thought to be beneficial, but little data exist during the new direct-acting antiviral era (Bajis et al., 2017; Ho et al., 2015; Zhou et al., 2016). The guide covered the following topics: (1) Perception of HCV risk and prior HCV testing experience; (2) Barriers and facilitators to HCV linkage to care and treatment initiation; and (3) Suggestions for developing interventions to improve HCV treatment uptake among PWID (Afdhal et al., 2013; Bajis et al., 2017; Bruneau et al., 2014; Kwiatkowski et al., 2002; Nunes et al., 2006; Ompad et al., 2002; Tsui et al., 2009).

2.2. Study design and participant recruitment

We invited patients admitted to the 50-bed Boston Treatment Center (BTC) for detoxification to participate in semi-structured in-depth interviews (November 2018--August 2019). Patients were eligible if they were ≥18 years of age; English speaking; and admitted to BTC with a history of self-reported drug use. Participants gave verbal informed consent. The study protocol was approved by the Boston University Medical Campus (BUMC) Institutional Review Board (IRB). We included all patients who agreed to participate since the facility cares for patients at-risk for HCV because of injection drug use, but also given the existence of other modes of acquisition such as sharing personal equipment and sexual contact (CDC, 2020).

2.3. Data Collection

In-person interviews were conducted in private rooms at BTC by author CRS and audio-recorded, after patients expressed consent to interviewing and recording. Interviews opened with a short questionnaire collecting demographic information, as well as self-reported substance use and sexual behaviors. Next, the interview transitioned to open-ended questions on barriers and facilitators to HCV treatment uptake. At the close, participants offered suggestions for an intervention to improve linkage to HCV treatment uptake. Data collection was completed when saturation was reached and no new information was obtained from participants (Morse, 1995). Interviews lasted approximately 45 to 60 minutes. All patients received a $20 gift card for their participation.

2.4. Data analysis

All interviews were professionally transcribed verbatim. CG, SAA, and IU used an open-coding framework to conduct a content analysis from transcribed interviews. CG, SAA, and IU independently reviewed three transcripts, chosen for their diversity in point of view and depth of responses. Once reviewed, CG, SAA, and IU met to compare preliminary codes and derive an initial version of the codebook. CG used this initial version to code three additional transcripts and reviewed potential new codes with the team. Once the codebook had reached saturation, CG coded the remaining transcripts. Codes were refined and applied to transcripts using NVivo (QSR International Pty Ltd., version 11, 2016). SAA, CRS, CG and JAB used a deliberative, consensual process to consolidate final codes and extract overarching themes (Vaismoradi et al., 2013).

3. RESULTS

Of 24 patients interviewed, 46% (11/24) were female with mean [SD] age of 37 [+/−10] years. Patients were predominantly White (67%); 13% identified as Black, 8% Latinx, 4% Native Hawaiian/Pacific Islander, and 8% other (Table 1). In terms of substance use, 67% had used heroin in the past 3 months, while 71% had a history of injecting drugs at least once in their lifetime (Table 2). Sixty three percent had a history of HCV by self-report. Over one-half (57%) reported unstable housing, defined as staying in a shelter, on the street, or with family or friends in the past 6 months, while 12% were living in a residential treatment facility. Less than half had completed high school (45%), while 20% reported completing some high school, and over one-half (58%) were unemployed (Table 1).

Table 1:

Patients interviewed at drug detoxification center - demographics and social history (n=24)

Characteristics n (%)
Race/ethnicity
 White 16 (66.7)
 Black or African American 3 (12.5)
 Latinx 2 (8.3)
 Native Hawaiian/Pacific Islander 1 (4.2)
 Other1 2 (8.3)
Gender
 Male 13 (54.2)
 Female 11 (45.8)
Educational attainment
 Some high school 5 (20.8)
 Completed high school or GED2 11 (45.8)
 Some college 8 (33.3)
Housing status, past 6 months
 House or apartment 7 (29.2)
 On the street 7 (29.2)
 Overnight shelter 4 (16.6)
 Residential treatment facility 3 (12.5)
 Other3 3 (12.5)
Employment
 Employed full-time (30+ hours per week) 4 (16.7)
 Employed part-time (<30 hours per week) 2 (8.3)
 Unemployed 14 (58.3)
 Disabled 4 (16.7)
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1

Black/Middle Eastern & Lebanese;

2

GED: graduate equivalency degree,

Friend or relative’s home

Table 2:

Substance use behaviors reported by patients at a drug detoxification (n=24)

Substance Use Behaviors n (%)
Drug use, past 3 months (categories are not mutually exclusive)
 Crack (“snow”) 18 (75)
 Marijuana (“pot, 420”) 17 (70.8)
 Alcohol 16 (66.6)
 Heroin 16 (66.6)
 Cocaine 16 (66.6)
 Downers or sedatives (Valium, Xanax) 12 (50)
 Crystal methamphetamine (“speed, ice, tina”) 7 (29.2)
 Prescribed painkillers 7 (29.2)
 Street methadone 3 (12.5)
 Viagra, Cialis, or Levitra 1 (4.2)
 Other drugs NOT prescribed to participant4 5 (20.8)
Frequency of drug injection, past 6 months
 4 or more times a day everyday 7 (29.2)
 2 to 3 times a day everyday 3 (12.5)
 Once a day everyday 1 (4.2)
 2 to 6 days a week 1 (4.2)
 Less than once a month 1 (4.2)
 Not injected in past month 4 (16.7)
 Never injected in lifetime 7 (29.2)
Any distributive or receptive syringe sharing, past month 7 (29.2)
Number of people with whom participant shared injection paraphernalia (cookers, cottons, rinse water), past month
 0 17 (70.8)
 1–2 5 (20.8)
 ≥3 2 (8.3)
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1

Benzodiazepine 2; methamphetamine 1; buprenorphine 2; alprazolam 2

Qualitative analysis themes

Eight categories of themes emerged. We found that:

1). Risk perception is based on unreliable factors, such as a partner’s appearance or a request for condom use.

Some patients appeared to have received public health messages about behaviors that increase HCV risk. For instance, patients acknowledged that sharing syringes would increase their risk for blood-borne infections. Nevertheless, some patients used unreliable factors to estimate risk. For instance, a partner who requested a condom was perceived as being high-risk, while another person who did not ask for a barrier prevention method was assumed to be low risk.

“[…]if the girl asked me to wear a condom, I would probably wear it. But most of the time, they don’t […] So, I take it as that means that they’re clean.”

(27-year-old, White male)

2). HCV is a common disease among PWID, and is perceived as a condition with few immediate consequences and possible complications arising in a poorly imagined distant future.

This theme had two components: perception of few immediate consequences from a positive test, and perception of HCV as a condition with possible complications arising in a poorly imagined distant future. Patients expressed the view that HCV was common among PWID. Given that complications were believed to occur in a distant future, many did not feel an urgency to address HCV right away. Instead, they felt the need to focus on competing priorities, such as using substances that severely impacted their daily experience.

“I always looked at Hep C like it was nothin’, you know? Every single Baby Boomer’s had it […] It doesn’t affect you ‘til later.”

(35-year-old, White female)

There was also the perception that HCV was an inevitable consequence of substance use, and it was not viewed as an urgent health condition.

“Everyone that was using IV drugs basically around that time, starting to get it [HCV]. Whether you shared or not, people saying, it was in the drugs. And it’s just like, almost inevitable if you were an IV user, you were gonna get it. So, and it was something they can cure and stuff. So, it was not really a big deal.”

(31-year-old, White male)

Patients seemed resigned to the reality that addiction was associated with infectious complications such as HCV and HIV, and premature deaths.

“Pretty much everybody I knew or know had hepatitis C[…]in a way […] It’s just one of those diseases that you don’t really think about because it’s - it’s not going to really do any damage until you get older […] that you’re lucky if you even, you know, live that long.”

(49-year-old, White female)

(3). Progression along the HCV treatment continuum of care is not the norm despite knowledge of positive testing and multiple interactions with the health care and drug treatment systems.

Despite receiving a positive result of HCV testing from multiple venues, patients did not follow-up.

“[…] I should have. I always meant to, I just always have an excuse not to […] I had plenty of appointments at the time, I had […] work, so that took up my whole day […]”

(28-year-old, White male)

(4). Active substance use is a major barrier to HCV treatment because of disruptions to routine activities.

Active substance use took precedence over other routine activities, including one’s personal health. Many described their daily experience spent trying to avoid withdrawal symptoms as well as a desire to stop substance use before seeking treatment for HCV.

“But when I’m using or, you know, rippin’ and runnin’, I don’t really care about my health. I don’t care about anything.”

(30-year-old, White female)

“And when you’re doin’ the drugs, you don’t want to do nothin’ else but the drugs, and somethin’s, like, stoppin’, you’re not gonna want to do that. And you’re thinking, okay, I’m sick right now. I gotta get un-sick before I can go to the appointment. Un-sick is everything before you do anything”

(35-year-old, White female)

The fear of experiencing withdrawal symptoms prevented the use of harm reduction measures and safe practices.

“When I’m using, I don’t care about if I go buy clean needles and if I’m sick that day and I need somethin’, and someone has, like, works or and it has been used, I really don’t care.”

(30-year-old, White female)

Patients expressed the reality that addiction took over their lives and that, in comparison, nothing else seemed to matter.

“Cause when I was using drugs, I don’t care about, like, myself, my body, my anything like that. So, I just put it aside.”

(26-year-old, White female)

(5). Re-infection is perceived as almost inevitable because of the low likelihood of future abstinence.

Patients believed that HCV re-infection from drug relapse was almost unavoidable. As drug use is a chronic illness, patients knew that relapse was a reality and could lead to repeat HCV infection.

“I went on a run afterwards, and I knew the way that I was using and the people I was using with that I was going to have it again. So to be honest with you, I was basically just waiting to hear them say that I was positive again.”

(33-year-old, White male)

Perception of re-infection’s inevitability was exacerbated by a belief that HCV treatment would only be covered once by health insurance or that a patient had to cease using substances before qualifying for treatment coverage.

“I’m hearing back and forth…I hear that Mass Health will only allow [HCV treatment] one time. And they will pay for only one time is what I’ve heard, and that it is very costly.”

(55-year-old, White female)

(6). A potential solution to improving HCV treatment uptake is low-barrier access to substance use treatment with high-intensity wraparound care and same-day/walk-in clinician visits.

Low-barrier access to substance use treatment

Some thought that access to substance use treatment through walk-in clinics or the use of injectable treatment formulations could serve as a bridge between facilities, such as drug detoxification centers and traditional clinical settings. Patients noted that non-traditional clinical settings like walk-in low-barrier substance use bridge clinics could improve linkage to care. A participant specifically referenced a walk-in low-barrier bridge clinic (FASTER PATHS) associated with the nearby medical center, where patients are offered substance use treatment such as medications for OUD.

“Oh, we couldn’t get you a bed, but you can follow up at Paths [walk-in low-barrier bridge clinic (FASTER PATHS) associated with the nearby medical center] tomorrow or the next day.”

(33-year-old, White male)

Another participant noted the use of long-acting injectables to help with remaining in recovery.

“[…] being able to leave and have […] a suboxone program set up. Like, now I have the shot set up so when I leave, I’m going to have the shot set up in the day program, so I feel a lot more safe leaving here knowing that I have that stuff set up.

(30-year-old, Black female)

High-intensity, wraparound care with same day/walk-in options

Patients described measures that would facilitate linkage and engagement in care, including personalized and high-intensity wraparound care characterized by frequent interactions with the goal of improving care delivery (Ghany et al., 2018). In the current study, some patients noted specific examples of one-on-one assistance provided by their health insurance programs, e.g. a Medicaid-sponsored community support program (CSP) offering intensive case management for high-risk individuals.

“With my CSP [community support program] worker, I had her phone number […], so we would text, I could text or call her at any hours [….] she’s like a regular everyday person [….] If your appointment is at this time, I’ll be here to pick you up and then we’ll go to your appointment and if I was looking for a job, she would bring me to the library and help me make my resume. And then bring me places to […] drop off applications or she would help me to get bus passes […]”

(32-year-old, Hispanic/Latinx female)

Assistance with healthcare-related tasks and appointments, applications to social security and criminal justice related-matters that might limit access to stable housing options were greatly appreciated. There was also a desire for walk-in options when patients could have immediate needs addressed, especially those related to substance use treatment.

“…more of like an open schedule…‘Cause I feel like anytime you call the doctors it’s like, ‘Oh, this one’s booked until, like, April and it will be, like, January. Or…, ‘We only have this time or this time.’”

(26-year-old, White female)

(7). Assistance with navigating the health care system and attention to concrete needs, such as housing and transportation, are important components of an intervention to improve HCV treatment uptake.

Participants underscored difficulty with navigating the health care system as a major barrier to accessing HCV treatment and assistance with how to begin the process was underscored as an important factor.

“I need a counselor or somebody to help me to do my things. Do what I need to do, step-by-step…I wouldn’t know where to start and when I have tried to get insurance, it was always stopped.”

(35-year-old, White female)

Patients also noted bureaucratic barriers to getting access to care, such as the requirement for identification cards to access substance use care. Assistance with getting the necessary documentation to enhance access to medical care would be an important component of an intervention.

“What I see a lot of addicts dealing with […] a lot of places and programs and whether it’s a holding, whether it’s a halfway house, whether it’s methadone treatment, whether it’s suboxone, whether it’s vivitrol, […] lot of these places, they want Mass IDs[….] They don’t have money to get their ID, to get it. […] what I think should be changed or not so much changed but made a lot easy for with addicts [….] Because I see a lot of addicts struggling and missing out on appointments […] because they don’t have their ID.”

(33-year-old, White male)

Patients also discussed the need to address transportation and some emphasized that the lack of access to HCV treatment in non-urban areas limited the ability of some individuals to initiate care.

“ I ended up havin’ the appointment out here in Boston and I live in Haverhill, Mass. […] So, eventually, like, the whole process of getting on a medication, it came to full […] stop, because there was no doctors that were available up in my area, and I couldn’t make it down here to Boston.”

(30-year-old, White female)

Patients noted that a successful intervention would need to incorporate measures to simultaneously address addiction as well as immediate needs, like housing.

“I mean homelessness [….] That’s usually a big part. […] So, I mean if I had a home to go back to, I’d probably go back to it. But you know, alcoholism and drug addiction, it usually sucks you dry. So, you don’t have any other option.”

(59-year-old, White male)

(8). Autonomy is an important element of any intervention aimed at improving HCV treatment uptake, as it enables patients to select the approach that best fits individual preferences and stage of readiness for change.

One participant noted the role of a community support program (CSP) worker through the insurance company to help with proposing options that individuals could consider.

“And so, I think that that’s why the CSP [community support program] worker is good as well too is ‘cause they more or less seek you out and give you the option and then you kind of just go from there if you want the help or not.”

(32-year-old, Latinx female)

Lack of options might cause some individuals to relapse into substance use. Therefore, a successful program would need to include patients’ valued attention to self-determination in being offered alternative approaches.

“I was kind of forced into going back to the Salvation Army […] it’s like your last resort thing, it’s like some people don’t take it. Some people go back on the street, go use for a few more days or a week or two, and then come back and try and do the same […]”

(27-year-old, White male)

4. DISCUSSION

Although HCV infection is common among individuals accessing care at drug and alcohol detoxification centers, we found that most patients had not received curative treatment. In the current study, active substance use was an important barrier to HCV care. Patients described a daily existence occupied by trying to prevent symptoms of withdrawal from substances, with little time to focus on HCV, an illness that most described as having no perceivable immediate symptoms or short-term effects. HCV treatment was also delayed because re-infection was often perceived as being inevitable, given the likelihood of substance use relapse.

Patients offered potential solutions, such as low-barrier access to substance use treatment in the form of walk-in same-day clinic visits (Figure 1). Patients also reinforced that this model should include high-intensity wraparound care with frequent interactions, assistance with navigating care and other needs, such as housing and transportation. Interviews revealed that education about HCV transmission and natural history should be an important component of any intervention to increase treatment uptake. Some patients had received many public health messages about harm reduction measures to decrease transmission, but perception of risk was at times still inaccurate. In addition, any intervention would also need to include specific information about treating early disease to prevent transmission to others, and the potential of long-term complications from chronic infection, including liver failure and malignancy. Furthermore, our findings on misperceptions related to risk, re-infection, and cost all underscore the importance of the “information” component of the IMB framework, including accurate information on risk for HCV acquisition and evidence-based measures to prevent re-infection and resources to cover treatment costs. These findings of a lack of urgency and an inevitability of re-infection are important, given the reality that there is urgency and that re-infection is not inevitable. HCV treatment has improved dramatically in recent times—in efficacy, in duration, and in the reduction of adverse reactions (Afdhal et al., 2014), but treatment uptake has been suboptimal among patients who actively inject drugs (Akyar et al., 2016). Reaching the WHO’s HCV elimination goals will require addressing HCV among PWID. Findings from our interviews provide a framework for potential approaches that might improve outcomes for high-risk individuals in non-standard medical settings.

Patients reinforced the importance of low-barrier access to OUD treatment (MOUD) as a key component to improving HCV treatment uptake. Low threshold facilities offering access to MOUD, described as multi-location clinical settings with flexible same-day treatment entry and follow-up, all within a harm-reduction framework (Jakubowski and Fox, 2020; Snow et al., 2019), could also be adapted to address complications of substance use, such as HCV. Our findings have programmatic implications, as patients clearly emphasized that potential solutions to tackling HCV among PWID include imbedding HCV treatment within existing substance use treatment programs. Within this framework, HCV treatment would be one of the components incorporated in the comprehensive care of patients with substance use disorder. This comprehensive approach is also supported by findings that MOUD, either in the form of methadone or buprenorphine, was associated with a 40–60% reduction in HCV incidence (Nolan et al., 2014; Tsui et al., 2014).

Drug detoxification centers are particularly useful locations for HCV-related studies as they provide access to patients who are ready to consider a path towards recovery, but might not feel comfortable in traditional health care settings (Madras et al., 2020). Prior studies at drug detoxification centers have included assessments related to HIV, HCV or other sexually transmitted infections as well as linkage to primary care (Assoumou et al., 2020; Lally et al, 2005; Saitz et al., 2013; Samet et al., 2003). Some challenges to implementing participants’ suggestions include competing priorities such as a lack of housing and resources.

Most prior studies have focused on barriers to HCV treatment initiation without specifically including an in-depth exploration of patients’ perspectives on interventions that would improve treatment uptake. For example, a study involving young PWID showed that major barriers to HCV treatment access included cost, the perceived lack of referral to treatment and care continuity (Skeer et al., 2018). Another recent study underscored the importance of offering HCV treatment at opioid treatment programs, but this publication did not delve into key elements of implementing such an approach (Falade-Nwulia et al., 2019). Our study adds to the current literature by incorporating patients’ perspectives to develop new models of care that do not rely completely on referrals to other facilities. These new models involve high-intensity wraparound care, respect for autonomy, patient navigation, attention to housing and other social supports. Such innovations have the potential to improve outcomes for this population.

Our findings are also in line with more recent studies that have shown that concurrent treatment of substance use and peer support are important components of a comprehensive approach to HCV therapy for persons who inject drugs. For example, a recent study including persons who inject drugs showed that HCV-infected patients on opioid agonist therapy can achieve high cure rates (Akiyama et al., 2019), and that peer driven approaches can increase HCV treatment uptake (Grebely et al., 2010). In addition to patient-level barriers, there are notable system and clinician level factors that might limit treatment uptake. For example, some clinicians might not offer treatment to patients with active substance use despite guidelines recommending that these patients should receive therapy (Afdhal et al., 2013; Kanwal et al., 2007).

There are limitations to any single-site study, although this location is the largest drug detoxification center in one of the epicenters of the opioid crisis. In addition, patients were predominantly White males, and interviews were carried out in English. These factors limited the range of racial and ethnic diversity of our sample.

In conclusion, we found that active substance use was a major barrier to HCV treatment uptake. The model of care suggested by patients would incorporate HCV treatment within existing substance use treatment programs. This framework would include high-intensity wraparound care with support to navigate the health care system and to address other social barriers. It would also assist patients to make informed decisions about a path to treatment that is consistent with their expressed needs and preferences. Patients underscored the importance of same-day walk-in clinic visits as well as low-barrier substance use and HCV treatments. Our findings contribute to the process of developing, implementing and testing an intervention to improve HCV treatment.

ACKNOWLEDGEMENTS

The authors would like to thank study participants and our research team for their contributions to this work. Special thanks to Imaan Umar for assistance with reviewing transcripts and Dr. Angela Bazzi for advice related to qualitative research. This work was supported by the National Institute of Drug Abuse [K23DA044085 to S.A.A, R01DA046527 to B.P.L, and P30DA040500 to B.P.L] and a Boston University School of Medicine Department of Medicine Career Investment Award to SAA. The content is solely the responsibility of the authors and does not necessarily represent the official views of National Institutes of Health.

Footnotes

Conflict of interest: The authors have no conflicts of interest to declare.

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