1. Core Competency 6: Overcoming Barriers Related to HCV Care
Lesson 3: Access to and Utilization of Health Care
July 2017

2. Barriers along the HCV Care Continuum
Clinical outcomes is affected by socio–economic, cultural, demographic factors which are related to various points of care throughout the HCV care continuum.
This figure displays the barriers to HCV care along the HCV care continuum.
The Barriers for Primary Prevention are: Lack of Syringe Access Programs; untreated mental health/substance use disorder(s); and Inadequate patient education on harm reduction strategies.
The barriers for Testing and Diagnosis are: Poor awareness about testing and treatment options; transportation barriers, and no health insurance
The barriers for Chronic Infection Identification are: Lack of health facility infrastructure; no referrals to HCV care; poor provider-patient communication, and poor healthcare follow-up
The barriers for Treatment are: Lack of prescription coverage/high treatment cost; reinfection, mixed infection, superinfection; Support and resources for patient to complete treatment; and Low HCV provider reimbursement.
The barriers for sustained viral response are: Limited resources and supports to prevent reinfection; inadequate harm reduction counselling regarding reinfection; and competing comorbid conditions.

3. Lesson Objectives Describe system structural barriers to HCV care
Understand the financial barriers to HCV care
Discuss recommendations for overcoming barriers related to access and utilization of health care

4. System Structural Barriers

5. System Structural Barriers1
Defined by availability of the health care system
Exist internally or externally to health facility
Can act independently
Can act simultaneously with financial barriers
Also referred to as system-level or environmental barriers2,3
According to Carrillo et al (2011), a structural barrier is defined by the availability of the health care system. Structural barriers exists both internally and externally to the health care facility. They can also act or stand alone or can act simultaneously with other barriers such as financial barriers.
Some literature may also refer to system level barriers as environmental barriers. These environmental barriers include lack of access to basic needs like housing, transportation, child care, primary healthcare and health insurance.
Structural barriers, system level barriers or environmental barriers may all be used interchangeably. Health facility infrastructure, access to basic needs, child care, transportation, health insurance, and knowledge about HCV testing and treatment options are common attributes of system structural barriers.

6. Examples of System Structural Barriers1-3
Limited access to coordinated services
Hours of operation
Waiting times
Transportation and travel time
Telephone access to providers
Child care
Limited health insurance coverage
Safety in socially and economically distressed neighborhoods
Examples of structural barriers include not having access to coordinated services including the facility's hours of operation, excessive waiting times, transportation to medical services, a patient’s telephone access to their provider and child care for patients that need to bring their them to appointments.
Health insurance coverage is a major barrier to accessing health care services.
For clinics and health facilitates located in socially and economically distressed neighborhood, safety can be another to care.
The barriers listed here can affect the continuity of care, especially if multiple steps or locations are required in order to for patients to see specialist or have test performed.

7. Additional System Structural Barriers2
Limited infrastructure for HCV assessment and treatment
Limited provider knowledge about HCV testing and treatment
Low HCV provider reimbursement
Limited resources for needed substance use or mental health therapy
Limited CBO resources for patient support (e.g., SAP/SSP)
Other literature refer to structural barriers as systems-level barriers. Accessibility of testing locations and waiting are similarly listed as examples of systems-level barriers. Structural barriers and systems-level barriers can be used interchangeably or combined as system structural barriers as we have presented in this curriculum.
In relationship to HCV care, Grebely et al (2013), have identified to following systems-level barriers:
Limited infrastructure for providing HCV assessment and treatment. This limitation is often seen in substance abuse treatment facilities and primary care settings for marginalized populations.
Limited knowledge about testing and treatment
Limited accessibility of testing locations
Long wait time for care
High cost of treatment
Low reimbursement rates for HCV care providers

8. Historical Barriers to Engagement in HCV Care2
U.S. and Canadian studies showed 1-7% HIV/HCV co-infected persons received HCV treatment
Barriers included:
Unwillingness to accept referral to HCV care
Unwillingness to undergo treatment
Homelessness
Substance use
Psychosocial concerns
Despite medical breakthrough in treatment for HCV, engagement in HCV care remains low. As reported by Greby et al (2013), studies conducted in the US and Canada show that only 1 percent to 7 percent of HIV/HCV co-infected persons have been treated for HCV. The majority of these untreated patients are people who inject drugs. Accepting referrals to HCV providers, willingness to take treatment, homelessness, substance use and psychosocial conditions are the leading barriers for non-engaged patients. Data from this study is prior to 2013, before better treatment options for HCV became available, however this is important as some of these historical barriers may impact current patient-provider relationships in HCV care.

9. Recommendations for Mitigating System Structural Barriers5-8
Transportation solutions
Localized clinic
Bus tickets/transportation reimbursement
On-site labs
Case management
HIV primary care model
On-site clinical pharmacist
Co-located services
Patients are less likely to receive care if it not accessible. The location of clinic, transportation to and from appointments are all important. In Durham County, North Carolina transportation was identified as critical barriers for patient accessing HIV, STD and Hepatitis care. When reliable and affordable transportation option were present along with an available appointment, patients were more likely to show up at the clinic. Patient in this study indicated that their friends did not have cars and could not offer them rides to medical appointment and if a family member had a care, they either did not have time or charged for rides. Other patients were limited in physical ability to take public transportation. Due to comorbidities, some patients indicated being too sick to ride the bus.
Solutions for the transportation barrier in NC include having a localized clinic downtown with an on-site lab, providing bus tickets to patients or ensuring they will be able to get a ride or walk to the clinic and also making the clinic services available during the same hours the busses run.
The HIV primary care model has been explored as a recommended approach to HCV care and treatment. Cachay et al (2013), suggests that incorporating an on-site clinical pharmacist may enhance treatment adherence and increase patient safety regarding drug-to-drug interactions, especially for co-infected patients. Multi-disciplinary teams and co-located patient services are beneficial to overcoming system structural barriers.

10. The SHAPE Intervention8
HCV screening integrated into an HIV program within a correctional facility
Offered HCV education and testing to inmates
2,716 inmates were screened for HCV and HIV
Of those, 21% had a positive HCV antibody result
The SHAPE – Screening for Hepatitis C as a Prevention Enhancement for HIV was pilot intervention in a Massachusetts correctional facility. Since evidence and implementation of HIV prevention and screening of inmates currently exist, the integration of HCV screening and treatment in incarcerated populations are warranted. The SHAPE intervention provided HCV education and HCV testing to inmates into an already established HIV program.
2,716 inmates were screened for HCV and HIV.
122 inmates had a positive HCV antibody.
Matching data to the correctional facility records to those of the Massachusetts Department of Heath Surveillance data showed that about 38% or 31 inmates had a HCV-related test resulted after their release, suggesting linkage to ongoing HCV care. This highlights that HCV services integrated into an HIV care model can have the potential to help overcome barriers to receiving HCV care and treatment.

11. Considerations for Agency Capacity for HCV Care1,3-5,7-9
Cost for specimen collection and testing
Staffing and personnel time
Availability of support services
Culturally safe and competent care
Even though the SHAPE intervention was conducted in a correctional facility, the incorporation of HCV screening and testing within existing HIV programs can be applied to other settings. This study highlights some important factors that agencies should consider in regards for HCV screening and care. Given that the SHAPE intervention was tested in an already established HIV program, implementation cost were low.
These include the cost related to specimen collection and testing; adequate staffing and dedicated personnel time to administer tests, provide patient education, and help linkages and referrals. As discussed in previous slides, agencies should also consider what support services are needed such as transportation support, child care, case management and psychosocial services. Agencies also need to ensure they have the ability to provide culturally safe and competent care.

12. Financial Barriers

13. HCV Treatment Payment Options
Medicaid – coverage depends on the state
Medicaid Managed Care – depends on state and plan
Medicare Part D
Tricare/VA Benefits
Private Insurance – coverage depends on the plan
AIDS Drug Assistance Program (ADAP) – coverage depends on state or territory10,11
Address from a barriers and opportunities perspective

14. States Differ in Coverage for HCV Treatment12
Some states are requiring a period of abstinence from drug and alcohol use as a condition for payment for DAAs
Some states require that DAAs be prescribed by, or in consultation with, specific provider types or holders of state-recognized HCV treatment certificates in order for payments to be provided for the drugs
Many states have set HCV disease stage (elevated fibrosis staging) requirements for DAA payment approval

15. Resources: Patient Medication Assistance Programs
RxAssist – medication assistance resource center
Partnership for Prescription Assistance
_of_participating_programs
Patient Assistance Network (PAN) Foundation
resources
NeedyMeds

16. References – 1
Carrillo JE, Carrillo VA, Perez HR, Salas-Lopez D, Natale-Pereira A, Byron AT. Defining and targeting health care access barriers. J Health Care Poor Underserved May;22(2):
Grebely J, Oser M, Taylor LE, Dore GJ. Breaking down the barriers to hepatitis C virus (HCV) treatment among individuals with HCV/HIV coinfection: action required at the system, provider, and patient levels. J Infect Dis Mar;207 Suppl 1:S19-25.
Mehta SH, Thomas DL, Sulkowski MS, Safaein M, Vlahov D, Strathdee SA. A framework for understanding factors that affect access and utilization of treatment for hepatitis C virus infection among HCV-mono-infected and HIV/HCV-co-infected injection drug users. AIDS Oct;19 Suppl 3:S
Cachay ER, Hill L, Wyles D, et al. The hepatitis C cascade of care among HIV infected patients: a call to address ongoing barriers to care. PLoS One Jul 18;9(7):e
Kolman M, DeCoster M, Proeschold-Bell RJ, Hunter GA, Bartlett J, Seña AC. The increasing impact of human immunodeficiency virus infections, sexually transmitted diseases, and viral hepatitis in Durham County, North Carolina: a call for coordinated and integrated services. N C Med J Nov-Dec;72(6):
Cachay ER, Hill L, Ballard C, et al. Increasing hepatitis C treatment uptake among HIV-infected patients using an HIV primary care model. AIDS Res Ther Mar 28;10(1):9.
Evon DM, Golin CE, Fried MW, Keefe FJ. Chronic hepatitis C and antiviral treatment regimens: where can psychology contribute? J Consult Clin Psychol Apr;81(2):
Cocoros N, Nettle E, Church D, et al. Screening for Hepatitis C as a Prevention Enhancement (SHAPE) for HIV: an integration pilot initiative in a Massachusetts county correctional facility. Public Health Rep Jan-Feb;129 Suppl 1:5-11.
Milne R, Drost A, Wallace B, et al. From principles to practice: description of a novel equity-based HCV primary care treatment model for PWID. Int J Drug Policy Oct;26(10):

17. References – 2
Community Access National Network (CANN) – HIV/HCV Co-infection Watch: April Accessed April 26,
HRSA HIV/AIDS Bureau. Part B: AIDS Drug Assistance Program. January Accessed April 26, 2017.
Center for Medicaid & Medicare Services. Medicaid.gov. HCV Communication: Assuring Medicaid Beneficiaries Access to Hepatitis C (HCV) Drugs. November 5, Accessed April 26, 2017.

18. Authors and Funders
This presentation was prepared by John Nelson, PhD, CNS, CPNP; Veronica Jones, MPH, CHES; and Elizabeth Lazo, MPH, CHES (AETC National Coordinating Resource Center) in July 2017.
This presentation is part of a curriculum developed by the AETC Program for the project: Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Co-infected People of Color (HRSA ), funded by the Secretary's Minority AIDS Initiative through the Health Resources and Services Administration HIV/AIDS Bureau. 

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