Barriers and facilitators for accessing HCV care in PWID: a qualitative study using an intersectional approach

Background: France has planned to eliminate hepatitis C virus (HCV) by 2025. Although expanded access to DAA treatment has improved patients’ care pathways, challenges remain among people who inject drugs (PWID): high prevalence, insufficient access to testing and treatment; particularly among women who face specific barriers. The aim of the BALADS (BArrières et Leviers à l'Accès au Dépistage et aux Soins de l'hépatite C chez les PQID) study was to identify barriers and facilitators to accessing HCV care (prevention, testing, treatment) using an intersectional approach.

Methods: Twenty-seven semi-structured interviews were conducted with PWID (13 men, 14 women) at 3 harm reduction facilities in Marseille, from March to October 2022. Participants were over 18 years of age, French-speakers, injected psychoactive substances, HCV positive or negative status. Interviews were analysed using thematic content analysis and intersectional approach, taking into account gender and injection drug use issues. We also used the socio-ecological model of health to classify barriers and facilitators at individual and structural levels.

Results: The main barriers identified by men (median age 43) and women (median age 44) who inject drugs were: precariousness, lack of health insurance, self-stigmatization, perceived stigmatization from healthcare providers, and criminalisation of drug use. Moreover, women who inject drugs reported additional barriers such as: stigmatization related to motherhood and sex work, discrimination by healthcare providers, negative experiences with men in harm reduction facilities, and sexual and gender-based violence during lifetime. The main levers identified by men and women were peer support, the role of peer workers and access to harm reduction services, particularly outreach. Specifically, women reported empowerment in their injection practices as a strategy to protect themselves from infectious diseases.

Conclusions: PWID still face both individual and structural barriers to accessing HCV prevention, testing and treatment. The negative experiences of women who inject drugs, such as stigmatization, contribute to keeping them away from care. To reach the 2025 target, it seems essential to adapt harm reduction services to women and offering them dedicated interventions to overcome gender-specific barriers. Improving the HCV care cascade for this key population will help to tackle HCV transmission including in the general population.