Theme: Clinical Research Year: 2023
Background:
Peer support can facilitate hepatitis C (HCV) treatment. The Oregon HOPE trial tested peer-facilitated telemedicine intervention for HCV treatment (TeleHepC) versus peer-facilitated community referral (“enhanced usual care” [EUC]) in rural people who use drugs (PWUD), but not everyone initiated treatment. This analysis compares barriers to treatment initiation between groups.
Methods:
A convergent mixed method design was employed. The quantitative component utilized descriptive statistics to analyze responses to the multiple-choice question “why did you not initiate treatment?” The qualitative component utilized thematic analysis to identify semantic themes through a realist, inductive approach to create an individual-level analysis of field notes written by peers.
Results:
102/203 randomized participants did not initiate HCV treatment. Treatment noninitiation was greater among EUC versus TeleHepC participants (85.2% vs 15.8%, p<0.001), but gender and age were similar between arms (62.7% male vs. 61.4% male; mean age 42.8 [SD 10.4] vs. 43.1 [SD 11.9] years). Reasons for non-initiation among respondents (all EUC participants) included “No primary care provider” (27/38, 71%), “Primary care would not refer,” (7/38, 18%) “Healthcare stigma related to using drugs,” (7/38, 18%) and “No local provider” (1/38, 2.6%).
Review of peer-authored field notes identified barriers to the linkage to care and treatment initiation steps of the HCV care cascade. Linkage barriers were the greatest drivers of non-initiation: Access to providers, relocation, communication lapses, insurance and competing illnesses contributed in additive ways. Treatment initiation barriers occurred when providers declined to prescribe, due to preference or stigma (EUC participants only) or prescription was conditional on further studies (both arms). After prescription, incarceration and insurance processes remained barriers.
Conclusions:
Despite peer support, treatment non-initiation was common. Limited access to primary and other healthcare was the predominant barrier. TeleHepC overcame this barrier but provider decisions, insurance systems and incarceration remain barriers to HCV treatment initiation.