Perceived Barriers Related to Testing, Management and Treatment of HCV Infection Among Physicians Prescribing Opioid Agonist Therapy

The C-SCOPE Study

Alain H. Litwin; Martine Drolet; Chizoba Nwankwo; Martha Torrens; Andrej Kastelic; Stephan Walcher; Lorenzo Somaini; Emily Mulvihill; Jochen Ertl; Jason Grebely

Disclosures

J Viral Hepat. 2019;26(9):1094-1104. 

In This Article

Abstract and Introduction

Abstract

The aim of this analysis was to evaluate perceived barriers related to HCV testing, management and treatment among physicians practicing in clinics offering opioid agonist treatment (OAT). C-SCOPE was a study consisting of a self-administered survey among physicians practicing at clinics providing OAT in Australia, Canada, Europe and the United States between April and May 2017. A 5-point Likert scale (1 = not a barrier, 3 = moderate barrier, 5 = extreme barrier) was used to measure responses to perceived barriers for HCV testing, evaluation and treatment across the domains of the health system, clinic and patient. Among the 203 physicians enrolled (40% USA, 45% Europe, 14% Australia/Canada), 21% were addiction medicine specialists, 29% psychiatrists and 69% were metro/urban. OAT physicians in this study reported poor access to on-site venepuncture (35%), point-of-care HCV testing (16%), and noninvasive liver disease assessment (25%). Only 30% of OAT physicians reported personally treating HCV infection. Major perceived health system barriers to HCV management included the lack of funding for noninvasive liver disease testing, long wait times to see an HCV specialist, lack of funding for new HCV therapies, and reimbursement restrictions based on drug/alcohol use. Major perceived clinic barriers included the lack of peer support programmes and/or HCV case managers to facilitate linkage to care, the need to refer people off-site for noninvasive liver disease staging, the lack of support for on-site phlebotomy and the lack of on-site delivery of HCV therapy. This study highlights several important modifiable barriers to enhance HCV testing, evaluation and treatment among PWID attending OAT clinics.

Introduction

The global burden of hepatitis C virus (HCV) infection is significant, with over 71 million people living with HCV[1] and 6.1 million people with recent injecting drug use.[2] There is also a considerable burden of HCV among people with a history of injecting drug use and people receiving opioid agonist treatment (OAT) for opioid dependence.

High treatment completion and response to HCV therapy has been observed in people receiving OAT and people with recent injecting drug use.[3] The integration and co-location of care for HCV infection and OAT is associated with improved testing, linkage to treatment and retention in HCV care.[4–7] The high HCV prevalence among people who inject drugs (PWID) attending OAT clinics makes this an ideal setting for targeted strategies to enhance HCV care. However, there are still health system, structural, social, patient-level and provider-level barriers that are preventing broad uptake of HCV therapy among people receiving OAT or people with recent injecting drug use.[8–10]

In some countries, people receiving OAT and people with recent drug use are still ineligible[11] or considered unsuitable by practitioners[12] to receive direct-acting antivirals (DAAs) , due to concerns of poor adherence, ongoing substance use, lower responses to therapy, medication price and the risk of reinfection.[9,12] In studies of general practitioners, a lack of confidence in initiating interferon-based HCV treatment appears to have driven the low HCV screening, evaluation and treatment rates among this provider group.[13] Low case numbers and inadequate HCV knowledge are important factors, with one study suggesting that primary care providers tend to underestimate efficacy and tolerability, and overestimate duration of DAAs,[14] although many report a desire for more HCV education.[15] Although qualitative interviews with providers have identified barriers to HCV care,[16,17] there are very few studies that have quantified potential modifiable barriers among physicians prescribing OAT.

The C-SCOPE study was an international cross-sectional study to evaluate clinic procedures and services, barriers, competency and attitudes towards HCV care among physicians practicing at clinics providing OAT.[18] The aim of this analysis was to evaluate perceived barriers related to HCV testing, management and treatment among physicians prescribing OAT in the C-SCOPE study.

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