“Not just one box that you tick off”. Deconstructing the hepatitis C care cascade in the interferon-free direct acting antiviral era – areas for improvement from the client perspective

Background: To achieve hepatitis C viral (HCV) elimination targets set by the World Health Organisation, pillars of the HCV care cascade are often referenced to track progress. Utilising the HCV care cascade as a framework, the aim of this qualitative study was to explore the complex ‘cascade experiences’ among people who inject drugs (PWID) with attention to the intersection of PWID agency and structural determinants in the healthcare system. Methods: Participants were sampled from the ETHOS Engage cohort (n=1,443). Inclusion criteria were: informed consent, aged >18 years, history of injection drug use and persons who injected in the prior six months or were currently receiving opioid agonist therapy (OAT). 34 semi-structured interviews were conducted with participants who had received (n=21) or had not received HCV treatment (n=13) to identify barriers and facilitators to HCV care. An in-depth analysis was conducted on five case studies to better understand participant experiences ‘behind the cascade pillars’. Results: Participants ‘housed’ at the ‘HCV RNA diagnosed pillar’ (n=2; Will; Julie) withheld their HCV diagnoses in healthcare settings, fearing that status disclosure would lead to stigmatising experiences when requesting benzodiazepines. Among participants who had completed treatment (n=3; Corey; John; Nora) two were unsure of their HCV status >6months post-treatment. Ongoing feelings of frustration and shame were expressed in this ‘post-cure care pillar’ due to a perceived lack of quality care from clinic services and continued uneasiness of discussing drug use and reinfection while receiving OAT. Both categories described mostly tenuous therapeutic relationships with their doctors and recommended task-shifting to nurses and trusted case workers for ongoing care. Conclusion: The care cascade offers a linear, snapshot analysis of clinical targets. Our findings illuminate structural barriers not visible behind its ‘static’ pillars, presenting insights into experiences among PWID otherwise dismissed as ‘disengaged’ or ‘lost to follow-up’. Disclosure of Interest Statement: ADM has nothing to declare. JR has nothing to declare. JG is a consultant/advisor and has received research grants from AbbVie, Cepheid, Gilead, and Merck outside the submitted work. CT has received speaker fees from Abbvie and Gilead and grant funding from Merck.

Download abstract Watch video