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

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Abstract

Background

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.

Methods

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).

Results

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.

Conclusions

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

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Funding

The funding was provided by Gilead Sciences.

Author information

Authors and Affiliations

  1. Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Krupa Patel

  2. Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, UT, USA

    Susan L. Zickmund

  3. Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA

    Susan L. Zickmund

  4. VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Harleigh Jones, Linda Calgaro, Arielle Otero, Tami Coppler & Shari S. Rogal

  5. Gastroenterology, Hepatology, and Nutrition Section, Washington DC VA Medical Center, Washington, DC, USA

    Andrea Reid

  6. Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA

    Shari S. Rogal

  7. Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

    Shari S. Rogal

  8. Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Shari S. Rogal

Authors
  1. Krupa Patel
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  2. Susan L. Zickmund
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  4. Andrea Reid
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Correspondence to Krupa Patel.

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Appendix: Semi-structured Questions

Appendix: Semi-structured Questions

Pre-treatment Patient Interview Questions

  1. 1.

    What are some of the challenges that you have experienced in having hepatitis C?

  2. 2.

    What are some of your motivations for seeking treatment for hepatitis C?

  3. 3.

    Tell me about challenges you have encountered in getting treatment for hepatitis C?

  4. 4.

    What challenges are you are anticipating when it comes to taking the hepatitis C treatments?

    1. a.

      If you had prior hepatitis C treatments what were the challenges with those regimens?

  5. 5.

    What are some ways in which your provider could help your treatment regimens?

  6. 6.

    What obstacles do you think you might encounter that would prevent you from staying in your hepatitis C treatment?

  7. 7.

    In your opinion, what would make treatment easier for you?

    1. a.

      What are some things that your health care provider could do to make treatment easier?

    2. b.

      What types of treatment options would you prefer?

    3. c.

      What locations would you prefer to receive treatment in?

  8. 8.

    What are some examples of times you have not taken medications that were prescribed to you? Do you forget to take your medication? If so, how often do you forget to take your medications?

    1. a.

      What are some of the things that lead to you forgetting your medications?

    2. b.

      What helps you remember to take your medications?

  9. 9.

    Who do you view as your primary hepatitis C provider (i.e., nurse, doctor, expert in hepatitis C)

    1. a.

      How much do you trust your primary hepatitis C provider?

    2. b.

      Would you rather see a different provider, why?

  10. 10.

    Are there any reasons you would not follow the advice of a provider?

    1. a.

      What are those reasons?

    2. b.

      Why would you choose not to follow your provider’s advice?

  11. 11.

    Have you experienced any form of stigma during your interactions with your providers? Tell me about those experiences.

  12. 12.

    Is there anything else that you would like to share, that we have not talked about today about your hepatitis C treatment?

Thank you for sharing your thoughts and feelings with us about your hepatitis C treatment.

Post-treatment Patient Interview Questions

  1. 1.

    How do you feel your hepatitis C treatments went?

    1. a.

      Why do you feel that way?

  2. 2.

    What challenges, if any, did you experience in taking the medications?

  3. 3.

    Did you forget to take any of the pills?

    1. a.

      If so, what factors contributed to you not taking some of the pills?

    2. b.

      If so, what would have helped you be more consistent with taking your medication?

  4. 4.

    Can you share who you considered to be your providers?

    1. a.

      Did you have multiple providers or was there one person?

  5. 5.

    How satisfied were you with the care you received from your provider(s)?

  6. 6.

    Please tell me about how you contacted your provider(s) concerning questions or issues about hepatitis C or your treatment?

    1. a.

      How long do you wait to hear back from that provider(s)?

    2. b.

      Do you feel this amount of time is just right or to long? Why?

    3. c.

      Is it important for you to reach a nurse or doctor immediately? Why?

  7. 7.

    In what ways did the visits to the provider(s) help you with your treatment?

    1. a.

      In what ways, if any, were those visits burdensome?

  8. 8.

    Should there have been more or less appointments?

    1. a.

      If so, why?

  9. 9.

    In your opinion, what could your provider(s) have done differently to improve your experience?

  10. 10.

    How much do you trust your hepatitis C provider(s)?

    1. a.

      What, if anything, could have improved your trust, in your provider(s)?

  11. 11.

    What are the biggest obstacles you have faced in initiating treatment?

  12. 12.

    Do you recall having any concerns about how to initiate treatment?

    1. a.

      If so, what were those concerns?

    2. b.

      If not, what made you feel confident in initiating treatment?

  13. 13.

    What challenges have you faced with staying in treatment for hepatitis C?

  14. 14.

    What is difficult about your treatment for hepatitis C?

  15. 15.

    If you did have obstacles, who did you speak to about these obstacles?

    1. a.

      Why did you feel like this was the best person to talk to?

  16. 16.

    Is there anything about hepatitis C screening, treatment, or communication with health care provider(s) that we didn’t discuss today that you would like to mention?

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Patel, K., Zickmund, S.L., Jones, H. et al. Determinants of Hepatitis C Treatment Adherence and Treatment Completion Among Veterans in the Direct Acting Antiviral Era. Dig Dis Sci 64, 3001–3012 (2019). https://doi.org/10.1007/s10620-019-05590-x

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  • DOI: https://doi.org/10.1007/s10620-019-05590-x

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