Accessing Hepatitis C Patients Who are Difficult to Reach

It Is Time to Overcome Barriers

P. Bruggmann


J Viral Hepat. 2012;19(12):829-835. 

In This Article

Abstract and Introduction


With the arrival of simple, efficient and safe interferon-free treatment regimens, hepatitis C virus (HCV) therapy will have the potential to be successfully used for the majority of infected patients and prevent the associated morbidity and mortality. With the current treatment uptake rates, only a very small proportion of HCV-infected patients are reached. Paradoxically, treatment rates are lowest in the most affected at-risk group – people who inject drugs (PWID) – which is the major driving force behind the spread of HCV infection. To conquer the increasing problem of HCV-related liver disease, many existing but modifiable obstacles, which prevent detection, assessment and treatment uptake, have to be overcome in this population. This review article summarizes the existing literature on the most relevant barriers preventing HCV care and describes measures to overcome these obstacles.


During the next decade, tolerability and efficacy of hepatitis C virus (HCV) therapy will improve remarkably.[1,2] With the expected interferon-free regimens, high treatment success rates for all genotypes will become available. Many barriers to treatment imposed by the side effects of interferon will disappear. However, one major barrier will remain, irrespective of increased efficacy and tolerability of future HCV treatment regimens: limited access to tests and therapy.

In the western world, the main driving force behind HCV infections is injecting drug use (IDU). Worldwide, about 10 million people who inject drugs (PWID) are HCV antibody positive. The mid-point HCV antibody prevalence in t\his at-risk group is 67.5%.[3]

People who inject drugs are affected by several comorbidities, such as alcohol dependence, HIV infections and mental diseases with concomitant chronic psychopharmacological medication. All of them compromise liver function and increase liver-related morbidity and mortality.[4–6] HCV, however, can be cured. The burden of advanced HCV-related liver disease among PWID is growing,[5,6] when it could in fact be reduced with higher treatment uptake rates.[7,8] Furthermore, mathematical models predict reduced transmission rates resulting from increased therapy rates.[9–11] Despite this, treatment uptake rates remain low in general[12] and in the drug-using population in particular.[13–17] With the current treatment uptake rates in the United States, antiviral treatments between 2002 and 2030 will prevent only 14% of liver-related deaths caused by HCV.[18] Hence, PWID as the major at-risk group and a virus reservoir are not yet reached well enough with HCV care. Besides developing highly efficient and well-tolerated HCV compounds, the main effort in global HCV care should focus on overcoming barriers to HCV testing, assessment and therapy. As PWID will be responsible for the main future burden of HCV-induced disease, improved access to this population should be the main goal.

To access patients, such as PWID, who are difficult to reach means breaking down barriers at healthcare system level, provider level, but also, indirectly, at individual patient level. Even if a person who uses drugs is ready for therapy, the provider (e.g. general practitioner (GP) or specialist) and/or the healthcare system are often not.[19] This review article gives an overview on modifiable factors preventing HCV care and describes different approaches and patient management settings to overcome these obstacles in the underserved population of PWID.