Identifying barriers and facilitators along the hepatitis C care cascade to inform human-centered design of contextualized treatment protocols for vulnerable populations in Austin, Texas: a qualitative study.

BACKGROUND: Hepatitis C virus (HCV) is a leading cause of liver-related mortality and morbidity. Despite effective direct acting antivirals and a simplified treatment algorithm, limited access to HCV treatment in vulnerable populations, including people experiencing homelessness (PEH) and people who inject drugs (PWID), hinders global elimination. Adapting the evidence-based, simplified HCV treatment algorithm to the organizational and contextual realities of non-traditional clinic settings serving vulnerable populations can help overcome specific barriers to HCV care. The first phase of the Erase Hep C study aimed to identify barriers and facilitators specific to these vulnerable populations to design the site-specific, simplified treatment protocols. METHODS: Forty-two semi-structured qualitative interviews, guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework, were conducted with clinic staff, community-based organizations providing screening and linkage to care, and patients diagnosed with HCV, to identify contextual barriers and facilitators to treatment at a local community health center's Health Care for the Homeless program in Austin, Texas. Audio-recorded interviews were systematically analyzed using thematic analysis informed by the PRISM framework and design thinking, to anchor barriers and facilitators along the HCV care cascade. Findings were fed into human-centered design workshops to co-design, with clinic staff, site-specific, simplified HCV treatment protocols. RESULTS: The specific needs of PEH and PWID patient populations informed barriers and facilitators of HCV care. Barriers included tracking patients who miss critical appointments or labs, medication access and adherence, and patient HCV knowledge. Clinical teams leveraged existing facilitators and incorporated solutions to barriers into clinic workflows to improve care coordination and medication access. Actionable solutions included augmenting existing staff roles, employing HCV care navigation throughout the cascade, and standardizing medication adherence counseling. CONCLUSIONS: Clinic staff identified HCV care facilitators to leverage, and designed actionable solutions to address barriers, to incorporate into site-specific treatment protocols to improve patient HCV outcomes. Methods used to incorporate staff and patient experiential knowledge into the design of contextualized treatment protocols in non-traditional clinic settings could serve as a model for future implementation research. The next phase of the study is protocol implementation and patient enrollment into a single-arm trial to achieve HCV cure.

Mitigating the HIV and Viral Hepatitis Workforce Crisis Through Development of an HIV/Hepatitis C Coinfection Mobile Application.

A decline in the HIV workforce has led to a crisis of insufficient expertise to manage people with HIV (PWH), roughly a quarter of whom are coinfected with hepatitis C. Task shifting to nonspecialist providers can contribute to solving the HIV workforce shortage problem, but nonspecialist providers require sufficient training and support to acquire and retain the necessary knowledge and skills. Digital tools including mobile applications (apps) and telementoring which utilizes telecommunication technology for education and skill acquisition can be used for professional development. Described is the development and dissemination of a mobile app specifically for providers managing HIV/HCV coinfection in the United States. The app, through provider professional development, facilitates access to curative HCV treatment in PWH, encourages integration of HCV care into primary care and contributes to national goals to eliminate HIV and viral hepatitis by 2030.

Qualitative Evaluation of a Program to Integrate Hepatitis C Care Into HIV Care Inclusive of Task Shifting to Nonspecialist Providers.

The treatment and cure of hepatitis C (HCV) in people with HIV is particularly important as progression of their liver disease is quicker compared with those who have HCV monoinfection. Innovative approaches are needed to maximize access to curative HCV treatment. Integration of HCV care into HIV primary care with education and support of nonspecialist providers via telementoring offers a solution to specialist workforce shortages. Using focus group qualitative methodology, health care workers' perspectives regarding this approach, particularly with the Extension for Community Healthcare Outcomes (ECHO) telementoring model, were obtained and are described. Successful integration of HCV care into HIV primary care has demonstrated benefits to patients, including allowing them to remain in their medical home for care. Factors beyond disease that influence their health and wellbeing must also be considered.

Accessing Care During the COVID-19 Pandemic Using Telemedicine: Perspectives From People With HIV.

The COVID-19 pandemic has resulted in a steep increase in telemedicine implementation and use. Data are lacking on telemedicine use in marginalized and underserved groups including people with HIV (PWH). The Ryan White HIV/AIDS Program (RWHAP) is the largest single provider of HIV care in the United States (U.S.) and the southern part of the country remains the epicenter of the HIV epidemic. This study recruited PWH from RWHAP clinics across South Texas. To ascertain their perspectives on utilizing telemedicine for HIV care during the COVID-19 pandemic, a survey instrument derived from validated instruments was used. Descriptive statistics were used for client characteristics, quality of telemedicine care, and COVID-19 impact. Wilcoxon Rank Sum and Kruskal-Wallis tests were assessed associations of telemedicine care quality and COVID-19 impact between client groups. Among 246 eligible PWH, 122 clients completed the survey with a response rate of 50%. Clients were predominantly Hispanic males. Significant differences in perception of telemedicine care and the impact of COVID-19 by gender, age, language, and race/ethnicity were observed. Older PWHIV used telemedicine more than younger clients (p = .01). English speakers indicated more impact of the COVID-19 pandemic on daily life than Spanish speakers (p = .02). Worry about the pandemic was most evident among non-Hispanic Black and Hispanic PWH (p = .03). Overall, telemedicine was found to be a favorable and acceptable mechanism of HIV care delivery by PWH in a Southern state during the COVID-19 pandemic.

Hepatitis C Knowledge, Attitudes, and Perceptions Among People With HIV in South Texas.

Direct-acting antivirals are overwhelmingly effective in curing hepatitis C (HCV). Barriers to HCV treatment exist for those co-infected with both HIV and HCV. Southern states represent the epicenter of the HIV epidemic in the United States. This study assessed HCV knowledge, attitudes, and perceptions in 318 co-infected individuals attending Ryan White HIV/AIDS Program (RWHAP) clinics in three South Texas cities. Two groups were compared, those tested for HCV and aware of their results (Group 1) and those uncertain if they were tested or tested and unaware of their results (Group 2). HCV knowledge was poor overall. Group 1 had a significantly higher mean HCV knowledge score than Group 2 by t-test (48.6 vs. 38.8; p < .01), but not by multivariable linear regression (p=.14). Factors predictive of greater HCV knowledge included self-identification as lesbian, gay, bisexual, transgender, queer and post high school educational attainment. Significantly more in Group 1 compared with Group 2 agreed that HCV medications would keep a person healthier for longer. Spanish speakers were more likely to disagree with a statement that people of color receive the same treatment for hepatitis C as white people. Study limitations identified include poor generalizability to people with HIV (PWH) receiving care in non-RWHAP settings and rural communities. Despite limitations, this study augments the paucity of information about knowledge, attitudes, and perceptions of HCV in PWH and can inform interventions to combat barriers to HCV treatment and to maximize opportunities for HCV screening, diagnosis, and linkage to curative care.

Development, implementation, and feasibility of site-specific hepatitis C virus treatment workflows for treating vulnerable, high-risk populations: protocol of the Erase Hep C study - a prospective single-arm intervention trial.

BACKGROUND: Hepatitis C virus (HCV) is the leading indication for liver transplantation and liver-related mortality. The development of direct-acting antivirals (DAA) and a simplified treatment algorithm with a > 97% cure rate should make global elimination of HCV an achievable goal. Yet, vulnerable populations with high rates of HCV still have limited access to treatment. By designing locally contextualized site-specific HCV treatment workflows, we aim to cure HCV in vulnerable, high-risk populations, including people experiencing homelessness (PEH) and people who inject drugs (PWID), in Austin, TX, USA. METHODS: Our implementation science study will utilize a qualitative and design thinking approach to characterize patient and systemic barriers and facilitators to HCV treatment in vulnerable, high-risk populations seeking care across seven diverse primary care clinics serving PEHs and PWIDs. Qualitative interviews guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework will identify barriers and facilitators by leveraging knowledge and experience from both clinic staff and patients. Data synthesized using thematic analysis and design thinking will feed into workshops with clinic stakeholders for idea generation to design site-specific HCV treatment workflows. Providers will be trained on the use of a simplified HCV treatment algorithm with DAAs and clinic staff on the new site-specific HCV treatment workflows. These workflows will be implemented by the seven diverse primary care clinics serving vulnerable, high-risk populations. Implementation and clinical outcomes will be measured using data collected through interviews with staff as well as through medical chart review. DISCUSSION: Our study provides a model of how to contextualize and implement site-specific HCV treatment workflows targeting vulnerable, high-risk populations in other geographic locations. This model can be adopted for future implementation research programs aiming to develop and implement site-specific treatment workflows for vulnerable, high-risk populations and in primary care clinical settings for other disease states beyond just HCV. TRIAL REGISTRATION: Registered on ClinicalTrials.gov on July, 14, 2022. Identifier: NCT05460130 .