Digestive Diseases and Sciences

, Volume 64, Issue 10, pp 3001–3012 | Cite as

Determinants of Hepatitis C Treatment Adherence and Treatment Completion Among Veterans in the Direct Acting Antiviral Era

  • Krupa PatelEmail author
  • Susan L. Zickmund
  • Harleigh Jones
  • Andrea Reid
  • Linda Calgaro
  • Arielle Otero
  • Tami Coppler
  • Shari S. Rogal
Original Article



Despite the availability of direct acting antiviral medications (DAAs), there are ongoing concerns about adherence to hepatitis C virus (HCV) treatment. We sought to understand the barriers to and facilitators of DAA adherence in the Veteran population.


Patients completed semi-structured interviews focused on barriers to and facilitators of HCV treatment adherence both pre- and post-DAA treatment. Adherence was assessed via provider pill count and self-report. Thematic analyses were conducted in the qualitative software program Atlas.ti in order to understand anticipated barriers to and facilitators of treatment adherence and completion. Charts were reviewed for clinical data and sustained virologic response (SVR12).


Of 40 patients, 15 had cirrhosis and 10 had prior interferon-based treatment. Pre-treatment interviews revealed anticipated barriers to adherence such as side effects (n = 21) and forgetting pills (n = 11). Most patients (n = 27) reported following provider advice, and others had unique reasons not to (e.g., feeling like a “guinea pig”). Post-treatment interviews uncovered facilitators of treatment including wanting to cure HCV (n = 17), positive results (n = 18), and minimal side effects (n = 15). Three patients (8%) did not complete therapy (whom we further elaborate on) and 6 (15%) missed doses but completed treatment. SVR12 was achieved by all participants who completed therapy (93%). Patients who did not complete therapy or missed doses were all treatment naïve, mostly non-cirrhotic (8 of 9), and often anticipated concerns with forgetting their medications.


This qualitative study uncovered several unanticipated determinants of HCV treatment completion and provides rationale for several targeted interventions such as incorporating structured positive reinforcement.


Interferon-free Compliance Patient-centered Reminders Relapse 



The funding was provided by Gilead Sciences.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest to report related to this study.


  1. 1.
    Davis GL, et al. Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression. Gastroenterology. 2010;138:513–521.CrossRefGoogle Scholar
  2. 2.
    Bansal S, et al. Impact of all oral anti-hepatitis C virus therapy: a meta-analysis. World J Hepatol. 2015;7:806–813.CrossRefGoogle Scholar
  3. 3.
    Yin S, et al. Sofosbuvir-based regimens for chronic hepatitis C in a well-insured US population: patient characteristics, treatment adherence, effectiveness, and health care costs, 2013–2015. J Manag Care Spec Pharm. 2019;25:195–210.Google Scholar
  4. 4.
    Canamares Orbis I, et al. Self-reported experience in patients treated with hepatitis C direct acting antivirals. Farm Hosp. 2016;40:569–578.Google Scholar
  5. 5.
    Miotto N, et al. Predictors of early discontinuation of interferon-free direct antiviral agents in patients with hepatitis C virus and advanced liver fibrosis: results of a real-life cohort. Eur J Gastroenterol Hepatol. 2017;29:1149–1154.CrossRefGoogle Scholar
  6. 6.
    Mason K, et al. Understanding real-world adherence in the directly acting antiviral era: a prospective evaluation of adherence among people with a history of drug use at a community-based program in Toronto, Canada. Int J Drug Policy. 2017;47:202–208.CrossRefGoogle Scholar
  7. 7.
    Evon DM, et al. Adherence during antiviral treatment regimens for chronic hepatitis C: a qualitative study of patient-reported facilitators and barriers. J Clin Gastroenterol. 2015;49:e41–e50.CrossRefGoogle Scholar
  8. 8.
    Swan D, et al. Barriers to and facilitators of hepatitis C testing, management, and treatment among current and former injecting drug users: a qualitative exploration. AIDS Patient Care STDS. 2010;24:753–762.CrossRefGoogle Scholar
  9. 9.
    Blasiole JA, et al. Mental and physical symptoms associated with lower social support for patients with hepatitis C. World J Gastroenterol. 2006;12:4665–4672.CrossRefGoogle Scholar
  10. 10.
    Bruggmann P, Litwin AH. Models of care for the management of hepatitis C virus among people who inject drugs: one size does not fit all. Clin Infect Dis. 2013;57:S56–S61.CrossRefGoogle Scholar
  11. 11.
    Groessl EJ, et al. Increasing antiviral treatment through integrated hepatitis C care: a randomized multicenter trial. Contemp Clin Trials. 2013;35:97–107.CrossRefGoogle Scholar
  12. 12.
    Alavi M, et al. Assessment and treatment of hepatitis C virus infection among people who inject drugs in the opioid substitution setting: ETHOS study. Clin Infect Dis. 2013;57:S62–S69.CrossRefGoogle Scholar
  13. 13.
    Sublette VA, et al. The Hepatitis C treatment experience: patients’ perceptions of the facilitators of and barriers to uptake, adherence and completion. Psychol Health. 2015;30:987–1004.CrossRefGoogle Scholar
  14. 14.
    Skeer MR, et al. ‘Hep C’s like the common cold’: understanding barriers along the HCV care continuum among young people who inject drugs. Drug Alcohol Depend. 2018;190:246–254.CrossRefGoogle Scholar
  15. 15.
    Proeschold-Bell RJ, et al. An integrated alcohol abuse and medical treatment model for patients with hepatitis C. Dig Dis Sci. 2012;57:1083–1091. Scholar
  16. 16.
    Evon DM, et al. Psychometric properties of the PROMIS short form measures in a US cohort of 961 patients with chronic hepatitis C prescribed direct acting antiviral therapy. Aliment Pharmacol Ther. 2018;47:1001–1011.CrossRefGoogle Scholar
  17. 17.
    Mellinger JL, Volk ML. Multidisciplinary management of patients with cirrhosis: a need for care coordination. Clin Gastroenterol Hepatol. 2013;11:217–223.CrossRefGoogle Scholar
  18. 18.
    Crabtree BF, Miller WL. Doing Qualitative Research. Research Methods for Primary Care, vol. xvi. Newbury Park: Sage Publications; 1992:276.Google Scholar
  19. 19.
    Vallet-Pichard A, et al. FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection comparison with liver biopsy and fibrotest. Hepatology. 2007;46:32–36.CrossRefGoogle Scholar
  20. 20.
    Charlson M, et al. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47:1245–1251.CrossRefGoogle Scholar
  21. 21.
    Charlson ME, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.CrossRefGoogle Scholar
  22. 22.
    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174.CrossRefGoogle Scholar
  23. 23.
    Troyen A, Brennan AL, William S. Analysis of “Real World” Sovaldi® (sofosbuvir) Use and Discontinuation Rates. CVS Health, 2014.Google Scholar
  24. 24.
    Beck KR, Kim NJ, Khalili M. Direct acting antivirals improve HCV treatment initiation and adherence among underserved African Americans. Ann Hepatol. 2018;17:413–418.CrossRefGoogle Scholar
  25. 25.
    Rich ZC, et al. Facilitators of HCV treatment adherence among people who inject drugs: a systematic qualitative review and implications for scale up of direct acting antivirals. BMC Public Health. 2016;16:994.CrossRefGoogle Scholar
  26. 26.
    Enriquez M, McKinsey DS. Strategies to improve HIV treatment adherence in developed countries: clinical management at the individual level. HIV AIDS (Auckl). 2011;3:45–51.Google Scholar
  27. 27.
    Rogal SS, et al. Primary care and hepatology provider-perceived barriers to and facilitators of hepatitis c treatment candidacy and adherence. Dig Dis Sci. 2017;62:1933–1943. Scholar
  28. 28.
    Norton BL, et al. High HCV cure rates for people who use drugs treated with direct acting antiviral therapy at an urban primary care clinic. Int J Drug Policy. 2017;47:196–201.CrossRefGoogle Scholar
  29. 29.
    Grebely J, et al. Sofosbuvir-based direct-acting antiviral therapies for HCV in people receiving opioid substitution therapy: an analysis of phase 3 studies. Open Forum Infect Dis. 2018;5:ofy001.Google Scholar
  30. 30.
    Read P, et al. Delivering direct acting antiviral therapy for hepatitis C to highly marginalised and current drug injecting populations in a targeted primary health care setting. Int J Drug Policy. 2017;47:209–215.CrossRefGoogle Scholar
  31. 31.
    Schutz A, et al. Directly observed therapy of chronic hepatitis C with ledipasvir/sofosbuvir in people who inject drugs at risk of nonadherence to direct-acting antivirals. J Viral Hepat. 2018;25:870–873.CrossRefGoogle Scholar
  32. 32.
    Stein MR, et al. Concurrent group treatment for hepatitis C: implementation and outcomes in a methadone maintenance treatment program. J Subst Abuse Treat. 2012;43:424–432.CrossRefGoogle Scholar
  33. 33.
    Bielen R, et al. Belgian experience with direct acting antivirals in people who inject drugs. Drug Alcohol Depend. 2017;177:214–220.CrossRefGoogle Scholar
  34. 34.
    Carrion JA, et al. A multidisciplinary support programme increases the efficiency of pegylated interferon alfa-2a and ribavirin in hepatitis C. J Hepatol. 2013;59:926–933.CrossRefGoogle Scholar
  35. 35.
    Larrey D, et al. Education by a nurse increases response of patients with chronic hepatitis C to therapy with peginterferon-alpha2a and ribavirin. Clin Gastroenterol Hepatol. 2011;9:781–785.CrossRefGoogle Scholar
  36. 36.
    Kretchy IA, Owusu-Daaku FT, Danquah SA. Mental health in hypertension: assessing symptoms of anxiety, depression and stress on anti-hypertensive medication adherence. Int J Ment Health Syst. 2014;8:25.CrossRefGoogle Scholar
  37. 37.
    Crowley MJ, et al. Medication non-adherence after myocardial infarction: an exploration of modifying factors. J Gen Intern Med. 2015;30:83–90.CrossRefGoogle Scholar
  38. 38.
    Badawy SM, et al. Health-related quality of life and adherence to hydroxyurea in adolescents and young adults with sickle cell disease. Pediatr Blood Cancer. 2017;64:6.CrossRefGoogle Scholar
  39. 39.
    Shuper PA, et al. Differential predictors of ART adherence among HIV-monoinfected versus HIV/HCV-coinfected individuals. AIDS Care. 2016;28:954–962.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of General Internal MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care SystemSalt Lake CityUSA
  3. 3.Division of Epidemiology, Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUSA
  4. 4.VA Pittsburgh Healthcare SystemPittsburghUSA
  5. 5.Gastroenterology, Hepatology, and Nutrition SectionWashington DC VA Medical CenterWashingtonUSA
  6. 6.Division of Gastroenterology, Hepatology, and NutritionUniversity of PittsburghPittsburghUSA
  7. 7.Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare SystemPittsburghUSA
  8. 8.Department of SurgeryUniversity of PittsburghPittsburghUSA

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