Table 2 Themes of barriers and facilitators identified along the hepatitis C care cascade, with illustrative excerpts from staff and patient interviews

Given diagnosis and offered treatment

 Competing priorities^A

“Sometimes with our patients, what you can do today is what you’re going to get done” (Clinic Staff)

“Once in a great while I have a patient who says ‘I have a lot going on right now, I don’t really think I’m ready for it’.” (Provider)

 Patient-Provider Relationship (waiting till patient can succeed)^B

“I always offer it, but if they’re not ready, I don’t push. Because a lot of it is engagement, and I don’t want to scare them. So, if they’re on the fence, I can usually say ‘yeah, this is really good, knowledge is power, you should know what’s going on’ so you see which direction they’re in. But if they’re not ready, that’s totally fine. (Provider)

Treatment accepted

 Low health literacy^A

“I didn’t know what it was…I didn’t know if it was serious or not. I had no information as to what it was, or what it can do to you. I was in the dark about it, so I didn’t care either which way because I didn’t know what it would do to me. I had no knowledge of what it is, so, it didn’t bother me much, but I was worried about it.” (Patient)

 Patient motivation^B

“I like my life. I want to get treated as fast as possible. I don’t [want to] infect anybody else…I want to get it over with.” (Patient who had been a PWID)

 Breaking down the care cascade^B

“I’ll go and I’ll speak to them, and give them this packet, go over, we have a timeline, a breakdown of like, you sign papers this day, you get labs this day, your medication this day. Go over with them what the program looks like.” (Clinic Staff)

Getting funding for treatment

 Cumbersome funding process^A

“I think one of the major delays still is the time required for the prescription assistance program to kick in.” (Clinic Staff)

 Medication coverage^B

“Once they get [MAP], their visits are covered and medication is covered through the pharmacy. So that definitely keeps them going…I have this coverage that’s helping me get my medication, get my visits, so I’m here.” (Clinic Staff)

Treatment initiated

 Characteristics of the PEH and PWID populations^A

“There’s the obvious barriers with patients experiencing homelessness, a lot of times they have coexisting mental health issues, substance abuse issues…mak[ing] it harder to remember that you have an appointment or remember to take your meds or having somewhere to secure your medication. Their stuff gets stolen, they lose things, they don’t have transportation, they don’t have phones. All those things with the homeless population are a huge barrier.” (Clinic Staff)

 Medication replacement^B

“[The patient] lost some of his [medication]. But he showed up right away, and we were able to get the drug company to replace them quickly enough to where I don’t think he missed very many days.” (Clinic Staff)

 Corollary care^B

“If you’re on suboxone [buprenorphine]…you want to live longer…you want to stop hurting yourself. So, I think…a lot of people will say, I want to get clean and sober because I don’t want to die or I want my body to be okay, I want my body to last. And so, I think it goes along with hep[atitis] C too. Like I want to take care of myself now.” (Patient)

 Care environment^B

“Everybody here, we have the same goals in mind for our patients, and really [want to] see them all succeed and get their treatment.” (Clinic Staff)

End of first month

 Medication adherence^A

“…Reasons patients don’t complete treatment and some do experience side effects and don’t have anyone to talk to, or aren’t willing to complete it and stop…” (Provider)

“The reason that people miss doses, or just stop entirely, will be because of some sort of side effect. The majority of the time, they’re not common side effects and I don’t really know if they even are true side effects of the medication, or just kind of something that happened around the same time, and the patient is just saying that that’s what it’s from.” (Clinic Staff)

 Care coordination^B

“If we saw them…remember you got to come in this day for your appointment and for your hep[atitis] C meds, your second bottle’s due…if I ever saw them walk by I would always remind them.” (Clinic Staff)

 Patient-provider relationship^B

“Please call me, so that you don’t have to suffer alone.” (Clinic Staff)

End of treatment

 Psychosocial resources^B

“At CareConnections clinic there’s more resources: a counselor, wound care nurse, a foot doctor…a social worker, and a community health worker.” (Provider)

“For the access of everything that’s being offered on a day-to-day basis, food, social service, and any other specified services that one may need, on his medical situation, mental health.” (Patient at Sunrise)

SVR12

 Returning to the clinic for labs^A

“The single biggest reason for lack of SVR12 is the fact that patients don’t show up for the appointment. And I think that we as providers don’t do enough messaging on it, either. Most of us know that treatment completion labs, the last day of the treatment, portends treatment success, they’re highly correlated with SVR12.” (Provider)

 Patient motivation^B

“He tells me that I was cured. That I didn’t have [hepatitis C] anymore…That made me feel good! I achieved something…That’s the way I looked at it.” (Patient who achieved SVR12)