Theme: Social Science & Policy Research Year: 2018
As the cost of direct-acting antiviral medication falls and eligibility criteria are relaxed, an
increasing number of people who use drugs (PWUD) will become eligible for HCV treatment.
Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment
uptake in this population, we seek to clarify the conceptual underpinnings of access to HCV
care and treatment with a view to informing research and practice.
Integrating the Candidacy Framework (Dixon-Woods et al., 2006) with insights from the
Behavioural Model for Vulnerable Populations (Gelberg et al., 2000) and Social-ecological
theory (Bronfenbrenner, 1979), and using practical examples from the HCV literature, we
present a theoretical framework to guide efforts to understand, investigate and intervene
upon barriers and facilitators to HCV care in PWUD.
Candidacy describes access to care as a jointly negotiated product of the alignment among
individuals, health professionals and health systems. Individuals must identify their
candidacy for services and work to stake this claim; health professionals serve as
gatekeepers, adjudicating candidacies within the context of localised operating conditions.
Repeated interactions build experiential knowledge, influencing the identification and
assertion of candidacy across the life course. Our review identifies intervention targets
across multiple levels, from individuals (HCV illness and treatment perceptions) to health
professionals (skills in managing population-specific needs), service environments
(institutional culture and availability of integrated care), health systems (insurance structure),
and beyond (social determinants and macro-level policy). It also highlights the many
potential sources of disengagement throughout a treatment journey, and the centrality of
therapeutic relationships in the pursuit of care.
Traditional notions of eligibility – a theoretical right to treatment – fail to reflect how patient
experiences intersect with health services and systems to shape opportunities for HCV care.
The candidacy framework can help guide research and practice to expand access in this
Disclosure of Interest Statement:
Julie Bruneau receives advisor fees from Gilead Sciences and Merck and holds a research
grant from Gilead Sciences, outside of this current work.