Context specific factors that impact on the optimal scale up of hepatitis C testing and treatment in the UK

Background: Hepatitis C is a blood borne virus that can damage the liver if left untreated. Scale up of community based HCV testing and treatment for people who inject drugs (PWID) is critical to eliminate HCV as a public health threat in the UK. In England the national scale up was undertaken by regional Operational Delivery Networks (ODN's). The current study is a qualitative evaluation of the factors impacting optimal delivery of HCV testing and treatment in England.

Methods: The study will conduct up to 30 semi-structured interviews with staff from 4 ODN's across England. Participants will include, (1) ODN clinical leads, (2) HCV Specialist Nurses, (3) pharmacists, (4) peers, and (5) staff who run services e.g. prisons/drug treatment/syringe provision. To date 9 interviews have been completed across two ODN's. Reflective Thematic Analysis has been used to identify patterns in the data.

Results: Several emerging themes have developed. Participants suggest that the approach has been successful, with a nurse-led specialist mobile community service model, facilitated by peer workers. Minimising the steps from HCV diagnosis to treatment initiation, involving the co-location of experts and specialist diagnostic equipment, are suggested to be key features that ensure rapid access to treatment. An important facilitator, as participants describe a "small window of opportunity" during which service users are motivated to engage. However, there remains various barriers. Participants indicate that since implementation, it is becoming harder to find the required HCV cases to meet elimination criteria. For example, participants suggest that the strategy is focused on an insufficient number of settings, and dispensing options are limited. Additionally, participants suggest that the availability of harm reduction services is sub-optimal, which reduces the opportunity of the strategy to reach people, especially in rural areas. Furthermore, participants describe several individual level barriers ("legacy of interferon", stigma, and conspiracy theories) as reducing service users willingness to engage.

Conclusions: Despite large improvements in the number of people tested and accessing HCV treatment, the identification of additional HCV cases may require the expansion of testing to other community settings, as well as facilitating their staff to take a more active role. The provision of training could facilitate positive cultural change among staff and PWID, increasing buy in to support or engage with HCV testing and treatment. There is also a need to improve access to, and increase the range of current harm reduction services available to support the scale up, and to reinforce the impact of testing and treatment as prevention. In addition, a wider range of available testing options and medication dispensing routes, could increase service user engagement and retention in treatment, especially for those in rural communities or for those experiencing homelessness.