Integration of Hepatitis C Treatment into Primary Care Practices: A Qualitative Study in Four New England States

CONTEXT: Over 2.7 million people in the US are living with chronic hepatitis C virus (HCV), and 75% are unaware they are infected. Since 2012, there have been more deaths due to HCV than to all 60 other reportable infectious diseases combined. Primary care is well-suited to conducting HCV screening, which is recommended for all adults at least once, during pregnancy, and periodically for those with risk factors. With introduction of direct acting antivirals offering a simpler regimen than previous options, there is increasing call to treat in primary care as well.

OBJECTIVE: To explore facilitators of and barriers to HCV screening and treatment in primary care practices.

STUDY DESIGN: Qualitative, individual virtual interviews with primary care providers and staff.

ANALYSIS: Immersion/crystallization qualitative data analysis of interview transcripts, with notetaking and data sorting leading to data interpretation.

SETTING: Selected primary care practices in 4 New England states.

POPULATION: Primary care practice providers and staff involved in HCV screening, and treatment or referral.

INSTRUMENT: Semi-structured, open-ended question guide.

OUTCOMES: Data on

1. primary care provider/staff attitudes toward HCV care;

2. processes related to medication prior authorizations, screening, treatment, patient adherence.

RESULTS: 46 interviews at 14 primary care sites. Most interviewees asserted HCV screening and treatment belong in primary care due to trust between these providers and patients, and reduced treatment cascade barriers that can occur with referral to specialty care. Barriers to treatment in primary care include: competing clinical priorities and scheduling; insufficient knowledge and confidence; structural barriers (e.g. prior authorization; poor patient access to labs and imaging); provider and patient reluctance due to disease stigma; and social determinants of health (e.g. transportation, housing instability). Facilitators include: joy in curing patients of disease; a stigma-free practice setting; making HCV care routine; clinical support relationships within or external to the practice; collaborating with pharmacists; onsite/reflex lab testing; and EMR reminders.

CONCLUSIONS: Despite persistent challenges to systematic HCV screening and treatment in primary care, interviewees indicated with proper clinical, administrative, and technical supports, treatment within primary care is feasible, highly beneficial to patients, and well worth the effort.