Enablers and barriers for the provision of community‐based HCV treatment: A case study of a real‐world practice

Abstract

Background Although the availability of fully funded direct‐acting antivirals (DAAs) and the eligibility of primary care providers (PCPs) to provide hepatitis C virus (HCV) have removed barriers related to access to hospital‐based HCV treatment in Australia, there are still many barriers to the provision of HCV treatment in community settings. There is a lack of knowledge regarding the barriers to, and enablers of HCV treatment in community settings in Australia. This study aimed to identify barriers and enablers for the provision of community‐based HCV treatment. Methods This study was a part of a mixed‐method case study of the Cure‐It programme. The programme was studied to better understand barriers and enablers experienced by stakeholders of such programmes. The programme is delivered through the Prince Charles Hospital in Brisbane, Australia, and aimed to improve access to HCV treatment in community settings. Data were collected using semi‐structured interviews with 12 healthcare providers and nine patients between July and December 2018. Purposive sampling was used to ensure diverse views were captured. The interview transcripts were analysed using inductive thematic analysis. Results Ease of access to specialist support, easy and high value treatment, co‐location with or providing other services and motivated patients enabled PCPs to be engaged with the Cure‐It programme. Several interconnected factors related to patients’ characteristics and health system acted synergistically to enable patients to initiate and complete treatment. These included a desire to remove HCV as a source of shame, having children, awareness of HCV consequences, access to DAAs for free, ease of access to general practices and drug and alcohol services, and access to a safe and enabling environment. The identified barriers were interconnected at the levels of patients, PCPs and primary care systems and acted synergistically to prevent patients and PCPs from becoming engaged with HCV treatment. PCPs’ related barriers included a lack of knowledge, their perception of HCV as a specialist area and of patients with HCV as ‘hard to manage’ patients along with the practice preferences and priorities. Patients’ related barriers included their socioeconomic characteristics, internalized stigma, perception of not being sick and lack of knowledge. Additionally, the unavailability of support for patients and existence of stigma in primary health care, along with poor communication between the hospital and primary care system, and the unavailability of FibroScan® in primary care discouraged PCPs and patients engagement specifically with the provision of community‐based HCV treatment. Conclusion Various strategies are needed to improve PCPs and patients’ knowledge and awareness of HCV treatment. Training and support for PCPs need to be easy to access and should cover both clinical and social aspect of HCV. Connecting PCPs to other related services may improve PCPs’ and patients’ engagement with HCV treatment.

Provider‐related barriers and enablers to the provision of hepatitis C treatment by general practitioners in Scotland: A behaviour change analysis

“…While our study was located within Scotland, the results align with findings from across the globe. Similar barriers and facilitators to GP prescribing have been reported from other countries, 30–34 emphasizing obstacles to sustainable models of GP‐led treatment endure in the face of simple, effective DAA regimens. However, this study also contributes new knowledge to the field by disentangling commonplace understandings of ‘HCV treatment’, and illuminating the complex and multifaceted nature of the task.…”

“…With this in mind, the constraints on GP time and capacity demand a pragmatic re‐examination of this ‘HCV treatment triumvirate’ in order to address obstinate barriers to change, rather than attempting to replicate existing provision. For example, the assessment of liver fibrosis for people living with HCV forms an integral and vital component of their care, but can present a significant barrier to treatment initiation in primary care settings 31,33,34 . Historically, the importance of fibrosis staging informed not only ongoing follow‐up and monitoring for cirrhosis and hepatocellular carcinoma, but was also predictive of treatment success, designating it a pre ‐treatment necessity 36 .…”

High Effectiveness of Broad Access Direct‐Acting Antiviral Therapy for Hepatitis C in an Australian Real‐World Cohort: The REACH‐C Study

“…( 19 ) Complex barriers to DAA prescribing have been identified by primary care practitioners including lack of knowledge, perceptions of HCV as a specialist area, and people with HCV being perceived as a challenge to manage. ( 25 , 26 ) Further work needs to be done to improve knowledge and awareness of HCV diagnosis and treatment in general practice.…”

Outcomes of community‐based hepatitis C treatment by general practitioners and nurses in Australia through remote specialist consultation

“…Community-based management of HCV is associated with higher treatment uptake than tertiary care referral and has allowed treatment for marginalised population groups in previous studies. 6,[17][18][19] Accordingly, adherence and follow-up testing can be a challenge. Despite this, emerging data suggest that community-based treatment in the DAA era is both clinically effective and acceptable to patients.…”

“…Despite this, emerging data suggest that community-based treatment in the DAA era is both clinically effective and acceptable to patients. 17,18 Key barriers to community-based HCV treatment have included a lack of knowledge or confidence managing HCV, an assumption that it is limited to specialist care and poor patient support and stigma. 18 The remote consultation process had been proposed as an innovative model to overcome some of these barriers and support community-based practitioners.…”