4 June 2026
Madeline McCrary sees pregnancy as a major missed opportunity in hepatitis C care. An infectious diseases physician at Washington University, Madeline works to close the gap between diagnosis and treatment during pregnancy – a time when people are often highly engaged with healthcare, yet too many are diagnosed with hepatitis C and never supported to start treatment.
As one of the first recipients of the INHSU Fellowship Program, Madeline is hoping to strengthen community-engaged approaches and learn how to better structure and share what is working more broadly.
The INHSU Fellowship Program is a nine-month initiative supporting early and mid-career professionals working to improve health outcomes for women who use drugs through mentorship, training and global collaboration.
Can you tell us a bit about yourself, your work, and how it connects with women who use drugs?
I am a physician specialising in infectious diseases and addiction medicine, and my main area of focus has been hepatitis C, particularly treatment during pregnancy.
In the US, starting in 2020, there is supposed to be universal screening for hepatitis C during pregnancy, with linkage to care. But what we see in practice is that people are diagnosed and then not treated, especially postpartum, where referrals simply do not happen.
A large proportion of the patients we identify use drugs or have used drugs in the past, so a lot of my work is focused on improving access to care for that group.
What led you into this area of work?
I got really interested in hepatitis C later in my training, when I was an infectious diseases fellow. We were identifying people with hepatitis C all the time in the hospital, but then doing absolutely nothing about it. People would leave without treatment and often never get treated.
So during my fellowship, I started a program to coordinate care and link people to treatment while they were still in the hospital. That was really where I got my feet wet, and I became excited about the potential of that work.
Then I learned that hepatitis C can be transmitted during pregnancy, and that reminded me of HIV and hepatitis B. These are infections where we have clear approaches in pregnancy, but with hepatitis C, the response has often been that it can wait.
Looking into it more, I realised how powerful hepatitis C treatment can be. It is eight to twelve weeks, with more than a 95 percent chance of cure. That kind of achievable goal can be really motivating, especially at a time like pregnancy when people are already engaged in care.
It felt like a huge missed opportunity, not just to treat people, but to support motivation at a really important moment, particularly when people may be facing challenges that feel much harder to tackle, like housing instability, chronic illness or interpersonal violence.
What are the most pressing gaps you are seeing for women who use drugs?
There are multiple points during pregnancy and after where people are engaging with the healthcare system, including prenatal care, emergency visits, labour and delivery and postpartum.
But we are not really leveraging those opportunities.
Instead, the default approach is often to send a referral for treatment, which then gets lost.
So we are diagnosing people, but not actually getting them into care.
What challenges do you face in your work?
A big challenge is simply being able to reach people.
We might have lab results, but phone numbers are out of date, phones are disconnected, or people are not regularly engaged in care. So even when we identify someone who needs treatment, there are real barriers to getting that information to them and bringing them into care.
We have used telemedicine, though that can be difficult if people do not have access to phones. The next step is thinking about how to better support frontline obstetric providers, because they are the ones seeing patients in the moment.
What is working well in your setting?
We have built a system that tries to engage people at multiple time points, rather than relying on a single opportunity.
A lot of people have not been offered hepatitis C treatment before, or were told they could not be treated, so being able to offer it at different points is important.
We now have a program that runs across our health system in Missouri and Illinois, where we can offer treatment during pregnancy or arrange it postpartum. If we cannot reach someone at one point, or they are unsure, there are other opportunities to come back to it.
At a local level, if someone presents to labour and delivery, they can be seen in the hospital and we can bring medications directly to their bedside.
Across these touchpoints, we have been able to get more people started on treatment. Even if someone is not ready right away, having access to medication and knowing it is an option makes a difference.
What does good gender-responsive care look like to you?
Pregnancy can be an important opportunity to engage people in care, and that is what initially drew me to this work.
But it is also a time when there can be a lot of paternalism in medicine. Decisions are often made without fully considering what matters to the person themselves.
With hepatitis C, one thing we have not always taken into account is how people feel about the possibility of transmission to their baby. Even though the risk is low, that idea can be very psychologically impactful, and for many people it is a key driver for wanting treatment.
Good gender-responsive care means recognising that, treating people like adults, and giving them the information and choice to make decisions about their own care.
What does being selected for this fellowship mean to you?
I was really excited to be selected.
Most of the work I have done has been in my own setting, trying things and seeing what works, and I am interested in learning how to structure that work so it can be shared more broadly.
I am also interested in strengthening community-engaged approaches, and making sure the programs we build reflect what people actually need.
What change would you most like to see in the next few years?
I would like to see more awareness that hepatitis C treatment during pregnancy is possible.
Right now, a lot of people, both patients and providers, assume it is not, and that limits access. Even google and AI say it’s not recommended.
If that changes, I think it could make a real difference.
The Fellowship program is supported by a grant from AbbVie, we thank them for their support of this program. Supporters have no control over content, tone, emphasis, allocation of funds, or selection of recipients.
