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HCV in Underserved Communities
Breaking Barriers: HCV Management in People Who Use Drugs and Other Underserved Communities

Released: November 25, 2024

Expiration: November 24, 2025

Mark S. Sulkowski
Mark S. Sulkowski, MD, FIDSA, FAASLD
Activity Information

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Key Takeaways
  • Adopting a same-day test-and-treat approach with point-of-care testing and rapid treatment initiation at accessible locations (eg, addiction treatment centers, federally qualified health centers, syringe services programs) can be an effective strategy to improve HCV treatment uptake.

Chronic hepatitis C virus (HCV) is a serious infection that can lead to liver failure, hepatocellular carcinoma, and death. Fortunately, most people with HCV can achieve a cure with safe and effective oral, direct-acting antiviral therapy, typically requiring only 8-12 weeks of treatment.

In Baltimore, where I practice, we have a well-established clinic that operates with an amazing multidisciplinary team of nurses, pharmacists, case managers, and peer navigators. Collectively, this team has treated thousands of individuals with HCV and remains prepared to help more people achieve a cure.

However, more than a decade after the introduction of direct-acting antiviral regimens, thousands of individuals with untreated chronic HCV infection remain in our city. These individuals are at continued risk of liver disease progression and virus transmission. This raises 2 critical questions: What are the barriers to care, and how can these barriers be addressed?

Barriers to HCV Care
Traditional care models are often ineffective in addressing the needs of the 2.45 million people in the United States with untreated, active HCV infection. Many of these individuals are from underserved communities and face significant daily challenges, such as food insecurity, housing instability, mental health disorders, and substance use disorders, including active injection drug use. Although HCV is a life-threatening condition, it is mainly asymptomatic, and many people with untreated HCV infection struggle to prioritize treatment amid their daily obstacles.

A Recent Case
Recently, as an attending physician on the inpatient infectious disease consult service, I cared for a young person with endocarditis requiring 6 weeks of intravenous antibiotics. They also had untreated HCV infection and an active opioid use disorder; they expressed interest in treatment for both conditions. At first glance, initiating HCV treatment concurrently with the intravenous antibiotics appeared straightforward. However, initiating rapid HCV treatment for this patient proved to be a significant challenge.

Current recommendations support treating all individuals with active HCV infection, so our team worked quickly to secure prior authorization for treatment. According to the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) simplified HCV treatment guidelines, HCV genotype testing and confirmation of chronic infection are not needed to initiate treatment. But prior authorization is another story, and required us to obtain these extra tests and information to secure the HCV therapy.

Ultimately, the patient was discharged from the hospital before obtaining prior authorization. Although the plan was to complete their antibiotic therapy at a skilled nursing facility, they left the facility prematurely with a self-directed discharge due to inadequately treated opioid withdrawal. Despite extensive efforts, reconnecting them to care has been unsuccessful. This patient case underscores a critical question: What could we have done differently?

How to Overcome Barriers
The first step in overcoming barriers is to ensure that point-of-care diagnostic tests are accessible that can confirm active HCV infection without delays of several days or weeks. 

The next step is removing barriers to initiating curative HCV therapy. Rapid initiation of antiviral treatment can reduce the time from diagnosis to receiving medications from weeks or months to mere hours. This same-day test-and-treat approach is recommended by the AASLD/IDSA guidelines, acknowledging the inadequacy of standard care models for underserved populations, such as people who use drugs. 

Meeting People Where They Are
A fundamental aspect of rapid initiation models is implementing them in locations where people with active HCV infection are most likely to engage with care. These settings include inpatient hospital wards, addiction treatment centers, federally qualified health centers, emergency departments, syringe services programs, or even locations such as highway underpasses in the community.

Studies conducted across the United States and in other countries demonstrate that these approaches work. These strategies not only cure more people than traditional clinic referrals, but also can provide comprehensive care, such as treatment for opioid use disorder and wound infections, and help address social determinants of health such as food and housing insecurity.

Implementing these strategies will not be easy and will require significant effort and coordination. However, to achieve our goal of eliminating HCV as a public health threat, we need to modify our current standard-of-care models to meet the needs of our patients.

Learn More
To learn more about overcoming barriers to HCV screening among people who use drugs, join me, plus my colleague Stacey B. Trooskin, MD, PhD, MPH, and patient advocate Ronni Marks, at our virtual workshop.

Your Thoughts?
What strategies have you found most effective in addressing barriers to care for people who use drugs who have chronic HCV infection? Join the discussion by leaving a comment below.