A Qualitative Study of Barriers to Hepatitis C Treatment Among People Living with HIV and Hepatitis C in the Era of Transition to Direct-Acting Agents

Abstract

Background. Rates of treatment uptake for hepatitis C virus (HCV) among people coinfected with human immunodeficiency virus (HIV) have historically been low, the result of numerous barriers to treatment. Although better-tolerated all-oral direct-acting agents (DAAs) are expected to improve rates of treatment uptake, some of the barriers to treatment might persist and continue to suppress rates of treatment uptake in the future. We performed a qualitative study to help elucidate which barriers to HCV treatment might persist in the DAA era. Methods. In-depth, semistructured interviews were performed with a cohort of HIV/HCV-coinfected patients who had not completed HCV treatment (n = 16) as well as with their primary care providers (n = 8), with a focus on challenges relevant to the transition to DAA-based regimens. Interview transcripts were analyzed using an inductive thematic analysis approach. Data were first coded in ATLAS.ti using an open coding process. Once several emerging themes were repeated across >1 participant, descriptive codes and subcodes for each theme were defined. Memos were developed and diagramming was performed to evaluate relationships between themes. Results. We found 2 distinct subsets of patients, primarily distinguished by their level of knowledge of HCV. One group of patients was well-informed about HCV and HCV therapy. The major barrier for this group had been the side effect profile of in-terferon. In the second group, the primary barrier to treatment was a low level of knowledge of HCV. Multiple factors reinforced this lack of knowledge, including a lack of awareness of HCV in the community, a lack of education about HCV after diagnosis, socioeconomic disadvantage, and competing psychiatric and medical concerns, namely HIV. Providers expressed optimism in the DAAs, although this was tempered by concerns about the ongoing relevance of many of the socioeconomic and psychiatric barriers to care and concerns over the high cost of the DAAs. Conclusion. There is a large population of HIV/HCV-coinfected patients who will continue to face significant barriers to HCV treatment. Intensive efforts to educate HIV/HCV-coinfected patients about HCV and support them through treatment will be critical to ensure widespread success of the DAAs.