Bryce, Kathleen; (2024) Identifying barriers and enablers to hepatitis C direct-acting antiviral treatment initiation in the UK. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background Hepatitis C virus (HCV) infection remains a major cause of poor health outcomes despite the availability of direct-acting antiviral (DAA) treatment. Treatment initiation is particularly low in marginalised groups. I aimed to assess barriers and enablers to DAA treatment initiation. Methods I conducted a systematic review and meta-analysis in UK-comparable settings to identify barriers and enablers to DAA treatment. I then analysed clinical data on patients approved for DAA treatment, from an Operational Delivery Network (ODN) patient management system to determine factors associated with time to treatment initiation. I conducted a prospective cohort study of participants attending assessment clinic with linkage to treatment initiation data. Finally, I undertook qualitative interviews with people who had delayed or declined treatment (and healthcare providers) to explore experiences of accessing HCV care. Results Unstable housing, active injecting drug use, lower socioeconomic status and female sex/gender were significantly negatively associated with DAA treatment initiation in meta-analysis. Increasing age and liver fibrosis, previous HCV treatment and opioid substitution for people who inject drugs were positively associated with uptake. In qualitative studies, stigmatising healthcare experiences were important barriers, whereas peer support and integrated care were enablers. In the ODN analysis, rates of DAA treatment initiation fell over time. Assessment in prison or drug services, being UK-born and harmful alcohol use were associated with lower treatment initiation rates. In the longitudinal cohort, socioeconomic disadvantage, stigma and poor mental health were prevalent, but most started treatment. Interviews found that adverse life experiences, negative healthcare encounters and stigma were major barriers to engaging with care. Positive relationships with providers and stability in drug use and housing were enabling. Conclusion My mixed methods thesis described significant remaining barriers to DAA treatment initiation, and identified enablers to engagement. My findings will inform care pathway adaptations to improve treatment initiation and health outcomes.

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