Abstract
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Substance Use Disorder Treatment Providers’ Knowledge and Opinions Toward Testing and Treatment of Chronic Hepatitis C in Rural North Carolina
Associated Data
Abstract
Poor access to care has made western North Carolina vulnerable to an outbreak of hepatitis C viral infection (HCV), particularly among persons who inject drugs (PWID). As substance use disorder (SUD) treatment providers could potentially improve linkage to HCV testing and treatment, we sought to understand SUD providers, clinic and client characteristics; referral patterns; HCV knowledge; willingness to participate in additional trainings; and local linkage-to-care pathways for treatment of substance use and HCV. Online survey data were collected from 78 SUD providers serving PWID in eight western rural North Carolina counties. Providers’ attitudes toward working with HCV+ clients were very positive. One-third of providers reported a low fund of knowledge regarding HCV, HCV treatment, and financial assistance opportunities. Non-prescribing providers rarely initiated discussions about HCV testing/treatment, but were receptive to training. Respondents indicated that HCV testing and treatment were best delivered at local health departments or primary care clinics but were open to other venues where PWID access care. The vast majority of prescribing and non-prescribing providers expressed interest in obtaining training in HCV treatments, how to obtain HCV medications and topics on advanced liver disease. Data from prescribing and non-prescribing SUD providers suggest opportunities to develop or expand integrated care models for HCV testing/treatment in PWID in rural Appalachian North Carolina.
Introduction
Rural Healthy People 2020 identified “access to health care” as the top rural health priority in the United States (US) (Bolin et al., 2015). While 20% of the US population lives in rural areas (Ratcliffe et al., 2016), only 9% of the nation’s physicians practice there (Council of State Governments, 2011), leaving residents of rural counties with suboptimal access to care for physical and mental health conditions (Ratcliffe et al., 2016). Rates of preventable infectious and chronic diseases in the Appalachian region mirror those of developing nations (Hotez, 2008). At the southernmost boundary of Appalachia, the far western counties of North Carolina (NC) have many of the same social and structural characteristics that contributed to outbreaks of bloodborne pathogens among persons who inject drugs (PWID) in Scott County, Indiana (Peters et al., 2016) and Cabell County, West Virginia (Atkins et al., 2020; Peters et al., 2016). This section of NC has been identified as extremely vulnerable for outbreaks of hepatitis C viral infection (HCV) or human immunodeficiency virus (HIV) among PWID (Schalkoff et al., 2020; Suryaprasad et al., 2014; Van Handel et al., 2016). Thus, two concurrent, synergistic public health crises affect western NC: injection drug use and a high risk for outbreaks of bloodborne infections (Perlman & Jordan, 2018; Stephens et al., 2017).
Rates of injection drug use have reached epidemic proportions in the US (Suryaprasad et al., 2014). This national trend is highly evident in rural NC, where rates of use and overdoses are higher than the national average (Havens et al., 2013; North Carolina Department of Health and Human Services, 2019). Medication-assisted treatment (MAT) for PWID can be effective in mitigating these outcomes (North Carolina Department of Health and Human Services, 2019), but until January 2021 (Department of Health and Human Services, 2021), medical providers had to complete training and obtain a special waiver in order to prescribe buprenorphine (Department of Health and Human Services, 2021). MAT also does not address the underlying psychological and social antecedents of drug use that need to be addressed (Moody et al., 2017; Mravčík et al., 2013; Zhang et al., 2008). Barriers to care at the system, provider, and patient level, including geography, distance, lack of transportation, being uninsured and social stigma, all impede optimal care for PWID (Litwin, Drolet, et al., 2019).
Due to multiple factors, PWID living in rural areas are at increased risk for contracting bloodborne infectious diseases. The rate of HCV infection in NC grew at least 3.5-fold from 2010-2017 (North Carolina Department of Health and Human Services, 2019). This increase in the Central Appalachian region coincided with a 21% increase in treatment admissions for opioid dependence (Zibbell et al., 2015). Given these statistics, recent initiatives are addressing service needs, recognizing that a combination of contributing factors may lead to a public health emergency. The lack of providers trained to test and treat HCV in rural western NC creates yet another barrier to early detection, harm reduction, and treatment of this life-threatening disease (Ghany & Morgan, 2020). Therefore, uncovering additional opportunities to train providers who have frequent contact with PWID will be essential to expand new linkage to care models for PWID to mitigate the negative health consequences of the opioid epidemic.
Deficits in substance use disorder (SUD) treatment options has prompted multiple stakeholders to undertake widespread training initiatives in western NC to help reverse opioid addiction and overdose trends (North Carolina Department of Health and Human Services, 2019). Using approaches modeled on Extension for Community Healthcare Outcomes (Project ECHO), academic medical centers have trained and coached rural primary care providers to prescribe HCV treatment in rural areas (North Carolina CHAMP Program, 2020). Models of integrated care delivery for opioid use disorders, HCV, and HIV are being studied and early results find high acceptance for co-located care among practitioners (Falade-Nwulia et al., 2020; Rich et al., 2018). Recently, a large, national randomized, pragmatic trial showed that PWID could be successfully cured of HCV when treatment was delivered in opioid treatment clinics and community health centers (Litwin, Jost, et al., 2019). Combined, these studies show that HCV test/treat are feasible for PWID in historically non-traditional locations (Rich et al., 2018).
As part of the aforementioned initiatives to advance HCV testing and treatment among underserved rural western NC residents, we collected information from SUD treatment providers who serve PWID in eight counties in this area. The goal of this cross-sectional survey study was to synthesize information from providers who work with clients with SUD to better characterize current opinions, practices, referral patterns, HCV knowledge, training needs, and local linkage to care pathways for HCV testing and treatment in order to better serve PWID residing in rural western NC.
Methods
Study Design and Cohort
A list of potential participants, including SUD providers serving any of eight counties in western NC, was developed in coordination with the NC Department of Health & Human Services (NC DHHS) and one of the main public managed care organizations (Vaya Health) overseeing services for mental health and substance use disorders in the eight-counties. An introductory cover letter was sent as an individualized email to 231 potential providers associated with Vaya Health, 26 providers with buprenorphine licenses and 11 independent providers (total number sent=268). Recipients were permitted to forward the email to other potential participants or electronic mailing lists. To be eligible, a participant had to be providing SUD services in at least one of the eight study counties (Cherokee, Graham, Clay, Swain, Macon, Jackson, Haywood, and/or Transylvania). Participants provided consent and completed the survey online via a secure portal (Qualtrics, Provo, UT). The survey was confidential. Participants could provide an e-mail address and receive a $20 Amazon gift card as an incentive. The study was approved by a local Institutional Review Board.
Survey Data Collection
Survey items were developed by the study team and reviewed by several community stakeholders to gather information from SUD providers in the sample region. Domains of interest included: practice type and existing services offered; client characteristics and patterns of opioid use; provider knowledge of HCV testing, treatment guidelines, and participation in harm reduction training; provider communication regarding HCV screening, treatment, and harm reduction; provider referral patterns with clients at risk for HCV; availability of HCV testing and treatment at their practice; opinions about best locations for clients to receive HCV testing and treatment; and interest in training about HCV, HCV treatment, liver disease, cirrhosis.
To gauge attitudes toward caring for people with HCV, ten items were selected from a validated instrument measuring HCV-associated stigma among providers (Richmond et al., 2007). Items were scored on a 5-point Likert scale (1=“strongly agree” to 5=“strongly disagree”) reflecting four subscales: compassion toward people with HCV (2 items); willingness to provide care for people with HCV (3 items); fear of contracting HCV (2 items); and attitudes toward people with HCV (3 items). Means were computed for each subscale. Lower scores indicate greater compassion and greater willingness to provide care; higher scores indicate lower fear of contracting HCV and lower hostility toward people with HCV.
Statistical analyses
Although primarily descriptive, we compared prescribers to non-prescribers by using Fisher’s Exact test on non-ordinal categorical variables and Cochrane-Armitage tests on ordered categorical variables. P-values less than 0.05 were considered statistically significant. Analyses were performed using SAS Version 9.4 (SAS Institute, Cary, NC).
Results
Characteristics of Study Respondents
Of 268 original email invitations sent to potential respondents, 103 (38.4%) completed the survey. Twenty-two were not healthcare providers and three had missing data; those 25 respondents were excluded from analyses. Characteristics of the various clinic environments are provided in Table 1. Our sample included 14 prescribers, 8 of whom identified as non-psychiatric physicians, 5 were non-psychiatric nurse practitioners (NPs) or physician assistants (PAs), and one was a psychiatric advanced practice provider; several providers worked in more than one county and more than one type of clinic/center. All 14 prescribers were certified to prescribe buprenorphine and 12 had previously written a buprenorphine prescription. Eleven prescribers considered themselves to be dedicated “substance use disorder (SUD) treatment providers.” Among the 64 non-prescribing providers, most (56%) held master’s degrees and the majority (56%) indicated their role was as a therapist/counselor or peer support counselor (n=36). Ten respondents were in leadership positions as directors/managers. Non-prescribers included Licensed Clinical Addiction Specialists (LCAS, n=19), Licensed Clinical Social Workers (LCSW, n=14) and Licensed Counselors (n=7).
Table 1.
Study Respondent and Clinic Characteristics by Prescribing Status
| Prescribers (n=14) N (%) | Non-Prescribers (n=64) N (%) | |
|---|---|---|
| Age (years) a | ||
| 18-34 | 1 (7) | 22 (37) |
| 35-54 | 6 (43) | 27 (45) |
| 55-84 | 7 (50) | 11 (18) |
| Sex b | ||
| Male | 5 (36) | 23 (39) |
| Female | 9 (64) | 35 (59) |
| Unknown | 0 (0) | 1 (1) |
| Race c | ||
| White | 13 (93) | 58 (97) |
| Other | 1 (7) | 2 (3) |
| County of Practice and RUCC code d | ||
| Haywood (RUCC 2) | 6 (43) | 34 (53) |
| Jackson (RUCC 6) | 6 (43) | 22 (34) |
| Cherokee (RUCC 9) | 3 (21) | 21 (33) |
| Macon (RUCC 7) | 3 (21) | 21 (33) |
| Swain (RUCC 8) | 6 (43) | 17 (27) |
| Graham (RUCC 9) | 3 (21) | 17 (27) |
| Clay (RUCC 9) | 2 (14) | 13 (20) |
| Transylvania ((RUCC 6) | 2 (14) | 5 (7) |
| Multiple Counties | 4 (29) | 28 (44) |
| Description of clinic(s) / center(s) e | ||
| Outpatient clinic serving patients with mental health/substance use disorders that offer Medication-Assisted Treatment (MAT) for Opioid Use Disorder | 6 (43) | 38 (59) |
| Outpatient clinic serving patients with mental health/substance use disorders that do NOT offer MAT for Opioid Use Disorder | 0 (0) | 13 (20) |
| Family Medicine or Internal Medicine Practice that offers MAT for Opioid Use Disorder, such as an office-based opioid treatment (OBOT) center | 6 (43) | 1 (2) |
| Family Medicine or Internal Medicine Practice Clinic that does NOT offer MAT for Opioid Use Disorder | 2 (14) | 2 (3) |
| Inpatient medical detoxification | 2 (14) | 9 (14) |
| Methadone Clinic offering buprenorphine products | 2 (14) | 0 (0) |
| Othere | 2 (14) | 13 (20) |
NOTE: Percentages reflect number of participants in each provider subgroup who endorsed the item divided by the number of participants who responded to the question within each provider subgroup.
Among the 14 prescribers, all of whom had a waiver to prescribe buprenorphine, 12 had prescribed MAT for patients with opioid use disorder (OUD). Seventy percent of non-prescribers (n=45) had referred a client with OUD for MAT. Of those who had not made a MAT referral, the majority indicated that they had not had a client whom they thought needed MAT but would refer if appropriate (n=45; 42%). For others, it was not within their purview to refer for MAT (n=8) or there were no local MAT programs (n=2). Providers’ attitudes toward working with clients with HCV were quite positive (Supplemental Table 1). Overall, providers reported feeling compassion for individuals who contracted HCV regardless of mode of transmission, high willingness to treat individuals with HCV, low fear of contracting HCV, and low levels of negative emotion toward people with HCV on average. Providers had differing opinions about prescribing opioids for pain relief to people who inject drugs.
Client Characteristics
When asked to estimate what proportion of their clients had an OUD, most providers indicated less than 25% (Suppl Fig. 1). Estimates of injection opioid use were similarly low; 50% of providers believed less than 25% of their clients were injecting opioids. Providers believed that clients who injected drugs were most likely self-administering non-prescription opioids (e.g., heroin, fentanyl) or non-opioid drugs (e.g., cocaine, methamphetamine).
Providers’ Hepatitis C Knowledge and Behaviors
Approximately one-third of respondents, mostly non-prescribers, indicated a low fund of knowledge regarding HCV and curative DAA treatments (Table 2). At least 20% of respondents were unsure about the cure rate, treatment durations, number of pills and financial assistance opportunities afforded to uninsured clients with HCV. Of the non-prescribing providers, 42% do not speak often with their clients about HCV testing or treatment but the vast majority of prescribing providers (86%) “often” or “always” discuss HCV. A notable proportion of respondents (57% of prescribers, 27% of non-prescribers) reported never having been trained on specific harm reduction techniques, and 50% of prescribers and 36% of non-prescribers reported that they “never” or “sometimes” discuss harm reduction techniques with clients who inject drugs. If faced with the knowledge that a drug-injecting client had never been tested for HCV, 79% of prescribers were able to test for HCV in the clinic where they work, whereas only 30% of non-prescribers had this option. Only one prescriber could actually treat HCV+ clients who were actively injecting drugs in their clinic; the remainder needed to refer out.
Table 2.
Hepatitis C Knowledge, Communications, Training, and Referral Patterns
| Prescribers N (%) | Non-Prescribers a N (%) | p-value | |
|---|---|---|---|
| Knowledge of hepatitis C (HCV) virus, testing, screening | 0.17 | ||
| Nothing | 0 (0) | 2 (3) | |
| A little bit | 2 (14) | 18(29) | |
| A moderate amount | 8 (57) | 32 (51) | |
| A great deal | 4 (29) | 11 (17) | |
| Knowledge of current HCV treatments b | 0.16 | ||
| Nothing | 0 (0) | 9 (15) | |
| A little bit | 5 (36) | 25 (41) | |
| A moderate amount | 7 (50) | 21 (34) | |
| A great deal | 2 (14) | 6 (10) | |
| Knowledge that new HCV medications can cure HCV in over 90% of patients | 0.28 | ||
| Truec | 13 (93) | 44 (70) | |
| False | 0 (0) | 4 (6) | |
| I don’t know | 1 (7) | 15 (24) | |
| Knowledge that some new HCV medications only require 1 pill per day for 8 weeks | 0.68 | ||
| Truec | 9 (64) | 44 (70) | |
| False | 1 (7) | 3 (5) | |
| I don’t know | 4 (29) | 16 (25) | |
| Knowledge that patients in financial need can obtain free HCV medications through a pharmaceutical company | 0.76 | ||
| Truec | 10 (71) | 37 (59) | |
| False | 0 (0) | 3 (5) | |
| I don’t know | 4 (29) | 23 (37) | |
| Frequency of talking about HCV, screening or treatment with clients with history of injection drug use d | 0.07 | ||
| Never | 0 (0) | 6 (10) | |
| Sometimes | 2 (14) | 20 (32) | |
| Often | 5 (36) | 17 (27) | |
| Always | 7 (50) | 19 (31) | |
| Has participated in formal, specific harm reduction training on practical techniques to discuss safer ways to use drugs and prevent the spread of HCV with clients | 0.05 | ||
| Yes | 6 (43) | 46 (73) | |
| No | 8 (57) | 17 (27) | |
| With client with history of injection drug use and never tested for HCV, do you: b | .005 | ||
| Offer to test for HCV in your clinic | 11 (79) | 18 (30) | |
| Make a direct referral for HCV testing outside your clinic | 1 (7) | 17 (28) | |
| Encourage client to get tested somewhere, but do not make a direct referral | 1 (7) | 22 (36) | |
| I don’t really discuss HCV testing | 1 (7) | 4 (7) | |
| If you identify a client who is injecting and they knows they are infected with hepatitis C, do you: d | 0.13 | ||
| Offer to treat them for hepatitis C in your clinic | 1 (7) | 7 (11) | |
| Make a direct referral to a medical provider or clinic for HCV treatment | 10 (71) | 26 (43) | |
| Encourage the client to get treated, but do not make a direct referral | 1 (7) | 21 (34) | |
| I don’t really discuss HCV treatment | 1 (7) | 3 (5) | |
| I don’t recommend HCV treatment to patients who are actively injecting | 1 (7) | 1 (2) | |
| I don’t know where to send my clients for HCV treatment | 0 (0) | 3 (5) |
NOTE: Percentages reflect number of participants in each provider subgroup who endorsed the item divided by the number of participants who answered the item within each provider subgroup. Prescriber n=14.
The frequency of talking about harm reduction (i.e., defined as a ‘set of practical strategies to reduce negative consequences associated with drug use, such as HCV, HIV, overdose) with clients who inject drugs was: Never: Prescriber: 1; Non-Prescriber: 8; Sometimes: Prescriber: 6; Non-Prescriber: 15; Often: Prescriber: 5; Non-Prescriber: 18; Always: Prescriber: 2; Non-Prescriber: 22.
Seventy-seven percent of non-prescribing providers said they would either make a direct referral for HCV treatment (n=26) or encourage the patient to get treated without making a direct referral (n=21). The remaining providers who did not routinely discuss HCV treatment with clients worked in a variety of SUD treatment settings, were mainly therapists or peer supports, and had a low fund of knowledge regarding HCV treatment.
The availability of HCV testing and treatment in respondents’ clinics is presented in Table 3. Only 5 prescribers have HCV treatment available in the clinic where they work. Three prescribers (i.e., 2 physician/directors, 1 NP/PA) who responded “no” or “I don’t know” to whether HCV testing was available in their clinics worked in outpatient mental health/SUD clinics, inpatient detox units, or residential treatment centers. The remaining 9 prescribers worked in family/internal medicine clinics (n=5), inpatient detox units (n=2), outpatient mental health/SUD clinics (n=3), and residential treatments (n=1).
Table 3.
Availability of HCV Testing and Treatment Within Clinics/Centers and Opinions of Testing/Treatment Center in Local Areas
| Prescribers N (%) | Non-Prescribers N (%) | p-value | |
|---|---|---|---|
| Is HCV testing/screening available in your clinic? a | 0.11 | ||
| Yes | 11 (79) | 32 (52) | |
| No | 2 (14) | 26 (42) | |
| I don’t know | 1 (7) | 4 (6) | |
| Is HCV treatment available in your clinic? b | 0.06 | ||
| Yes | 5 (36) | 6* (10) | |
| No | 8 (57) | 47 (75) | |
| I don’t know | 1 (7) | 10 (16) | |
| Best place for people who inject drugs to get tested for HCV c | .002 | ||
| Local health department | 1 (7) | 34 (54) | |
| Primary care, family medicine, internal medicine clinic | 6 (43) | 10 (16) | |
| Community federally qualified health center (FQHC) | 1 (7) | 2 (3) | |
| Large hospital or medical center that specializes in Hepatitis C care | 0 (0) | 1 (2) | |
| At an outpatient substance use clinic that they attend, if testing were available | 2 (14) | 8 (13) | |
| At the MAT/OTP clinic they attend if testing were available | 0 (0) | 5 (8) | |
| All of the above | 3 (21) | 2 (3) | |
| A specific location based on vicinity (eg, Native American facility, Western North Carolina AIDS Project) | 1 (7) | 1 (2) | |
| Best place for people who inject drugs to get treated for HCV? c | .0002 | ||
| Local health department | 1 (7) | 25 (41) | |
| Primary care, family medicine, internal medicine clinic | 5 (36) | 11 (18) | |
| Community federally qualified health center (FQHC) | 1 (7) | 7 (11) | |
| Large hospital or medical center that specializes in Hep C care | 0 (0) | 1 (2) | |
| At their substance use clinic, if treatment were available | 2 (14) | 9 (15) | |
| At the MAT/OTP clinic they attend, if treatment were available | 0 (0) | 8 (13) | |
| Gastroenterologist/Infectious Disease | 3 (21) | 0 (0) | |
| Anywhere treatment is offered and based on client willingness to attend | 2 (14) | 0 (0) |
NOTE: Percentages reflect number of participants in each provider subgroup who endorsed the item divided by the number of participants who answered the item within each provider subgroup. Prescriber.
Prescribers identified primary care clinics as the ideal location for HCV testing and treatment (36%) but were open to other venues including SUD clinics, “anywhere offered,” and gastroenterology or infectious disease clinics. Non-prescribers expressed openness to HCV testing and treatment occurring in a variety of venues, with the largest number naming local health departments (41%) and primary care clinics (18%) as the best locations for HCV testing and/or treatment. Smaller percentages of non-prescribers indicated that clients should receive HCV testing and/or treatment at a local federally qualified health centers or SUD treatment clinic. Few respondents wanted to send their clients to larger medical centers that specialize in HCV care for testing or treatment.
There were six non-prescribers (mostly therapists) who worked in facilities that already offer HCV treatment; five were in outpatient mental health/SUD clinics that offer MAT. Their favored HCV testing and treatment sites included the local health department, primary care, and outpatient SUD or MAT clinics that patients already attend.
HCV Training Needs
Ten of 14 prescribing providers expressed interest in receiving training on HCV treatment (71%) while four declined additional training as they were already treating HCV in their clinical practice (a SUD/MAT clinic, primary care venue that offers MAT, a methadone clinic, and a Native American healthcare facility; Table 4). Seven (50%) were interested in learning how to obtain DAA medications and treat clients with HCV and four were interested in learning more about liver disease. The vast majority of non-prescribers were equally interested in learning about liver disease (56%), DAA therapy (85%), and how to obtain medications to treat clients with HCV (84%).
Table 4.
Training Preferences Related to HCV, Treatment and Liver Disease
| Prescribers N (%) | Non-Prescribersa N (%) | p-value | |
|---|---|---|---|
| Treatment for hepatitis C | 10b (71) | 52 (85) | 0.25 |
| How to obtain medication and treat my hepatitis C+ clients | 7 (50) | 51 (84) | 0.01 |
| Prevention of hepatitis C | 5 (36) | 35 (57) | 0.23 |
| Risk factors for contracting and transmitting hepatitis C | 5 (36) | 33 (54) | 0.25 |
| I already know a lot about hepatitis C and do not need any more training | 5 (36) | 2 (3) | 0.002 |
| Liver Disease, Cirrhosis, Liver Transplant | 4 (29) | 34 (56) | 0.08 |
| Knowing about hepatitis C is not very important to my job and so I do not need training | 0 (0) | 1 (2) | 1.0 |
NOTE:
Discussion
These survey results yielded new insights about the context of HCV care provision among SUD treatment providers in rural western NC, the southernmost boundary of Appalachia. We identified remediable knowledge gaps regarding harm reduction techniques among prescribers and HCV testing and treatment among non-prescribers. Opinions and preferred referral patterns for HCV testing and treatment elucidated linkage-to-care barriers and potential opportunities to develop co-located or integrated care models to provide HCV treatment alongside outpatient or inpatient SUD treatment.
All 14 prescribing providers have buprenorphine waivers and 12 of the 14 are providing MAT, suggesting a strong uptake of this important OUD treatment modality. Prescribers felt fairly well-informed regarding various aspects of HCV testing and treatment, and 80% frequently spoke about HCV testing or treatment with clients with a history of injection drug use. However, only half had participated in trainings about specific harm reduction techniques in order to effectively communicate safer ways to inject drugs and prevent the spread of HCV. In contrast, non-prescribers seemed less confident in their knowledge or patient education skills regarding HCV testing or treatment, but more of them (73%) had participated in formal, specific harm reduction training. While these differences may reflect traditional and complementary roles of prescribers and non-prescribers on treatment teams, cross-training in harm reduction techniques and basic HCV treatment education would ensure uniform messaging to clients and raise the quality of care offered.
North Carolina has various training opportunities available. Prescribing providers who currently do not treat HCV are ideal candidates for the statewide tele-mentoring CHAMPS program which includes mentored training and support for the comprehensive management of persons with HCV for novice treaters. Training on harm reduction and safer injection drug use are offered through the NC Harm Reduction Coalition, a non-profit organization with a statewide reach (http://www.nchrc.org/).
With regard to HCV testing locations, respondents generally supported testing availability in multiple locations where feasible, consistent with other evidence-based recommendations (Alavi et al., 2019; Litwin, Jost, et al., 2019). Prescribing providers endorsed testing primarily in internal/family medicine clinics but also the possibility of HCV testing occurring “anywhere” or in outpatient SUD clinics if feasible. Non-prescribing respondents endorsed HCV testing in local health departments, followed by internal/family medicine clinics and potentially outpatient SUD clinics. These findings suggest openness and opportunities among providers to expand HCV testing into areas outside of traditional venues, that could include inpatient and outpatient SUD treatment programs, syringe service programs, or residential programs which may serve as primary points of care for PWIDs (Ghany & Morgan, 2020). HCV testing in novel SUD treatment venues not only circumvents local health department capacity issues, but may also increase testing rates and minimize loss to follow-up.
The top choice among prescribing providers for HCV treatment was family/internal medicine clinics, perhaps because several of them work in these clinics, although only 36% (5/14) provide HCV treatment in their clinics. Among non-prescribing providers, the top choice for HCV treatment was local health departments – yet to our knowledge, none of the health departments in the 8 counties reliably offer DAA treatment in-house. This discordance reveals a misperception about the scope of services available at health departments in rural settings which is often limited to wellness exams or basic management of chronic conditions. Therefore, HCV treatment services in health departments may have substantial logistical and administrative challenge in rural areas that are already struggling with basic healthcare delivery.
We observed an openness to providing HCV treatment in non-traditional locations, such as outpatient SUD or MAT clinics in order to expand access for PWID at frequent points of contact, consistent with recommendations (Ghany & Morgan, 2020; Schranz et al., 2018). Studies suggest that developing co-located HCV treatment opportunities within the context of outpatient SUD clinics, inpatient detox centers, or residential settings are viable options if SUD prescribing providers are willing, as these are ripe areas for future public health initiatives and investigation (Akiyama et al., 2019; Ghany & Morgan, 2020).
Finally, while the focus in rural areas has been on opioid injection drug use, SUD providers attest to treating clients with a broad range of substance use disorders. In fact, a greater number of clients are in need of effective treatment for alcohol, methamphetamine, and cocaine. Clients injecting other substances such as methamphetamine and using non-injection drugs (e.g., cocaine) are also at increased risk for HCV due to drug use paraphernalia (Elliott et al., 2016; Teles et al., 2018; Zule et al., 2016). Clients with alcohol use disorders require effective treatment to reduce risk of alcoholic cirrhosis, liver-related deaths and liver transplantations (National Institute on Alcohol Abuse and Alcoholism, 2020). Taken together, equitable public resources and policies need to encompass treatments for all substance use disorders in all people, not just those affected by opioid use (Muennig et al., 2018).
Several limitations are worth noting. The sampling methods used in the study were limited to providers covered under a single managed care company and public record of providers with buprenorphine waivers. Although the original email invitation was sent to 268 potential respondents and the response rate was 38%, the email recipients could forward the email to other potential participants, thus the true denominator and response rate is unknown. These results may not generalize to the entire population of SUD treatment providers in the sampling area. This sample contained only 14 prescribing providers, none of whom identified as psychiatrists, therefore, we cannot determine if psychiatrists working in outpatient or inpatient mental health/SUD clinics would be interested in mentored trainings to learn how to offer HCV treatment in their clinics. Finally, the sample was mostly comprised of non-prescribing behavioral health specialists who are essential to SUD behavioral treatment and linkage to MAT, HCV testing and treatment, but who cannot provide these latter services directly.
In conclusion, these data suggest that SUD providers are open to expanding HCV testing and treatment to various clinical locations to increase access to care for PWIDs although family/internal medicine and local health departments are currently the main go-to facilities (Ghany & Morgan, 2020). Several prescribing providers who do not yet treat HCV expressed interest in training on HCV treatment and obtaining DAA medications for their clients. This provides hope that it is possible to increase the pool of providers who can not only test, but treat HCV now that 8-week, one pill per day, highly effective treatments are available. Opportunities exist to provide training about HCV, DAA treatment, and liver disease that could increase patient-provider communication and referrals for HCV testing/treatment and for specific harm reduction techniques to communicate about safer drug practices (North Carolina Department of Health and Human Services, 2019). A call-to-action for future statewide programs could include wider expansion of HCV treatment into primary care and outpatient and inpatient SUD treatment centers through additional trainings for psychiatric providers through the CHAMP program (Marshall et al., 2020; Samuel et al., 2018); targeted strategies that address all stages of HCV care from screening through viral cure in community venues where PWIDs are more likely engaged in care (Frimpong et al., 2014; Grebely et al., 2019); and development and evaluation of co-located or integrated SUD/HCV treatment models as have been proven efficacious elsewhere (Akiyama et al., 2019; Ghany & Morgan, 2020; Schranz et al., 2018; Zeremski et al., 2013). Additional opportunities for HCV testing, treatment and training opportunities among SUD providers could be scaled up to improve the public and individual health of North Carolinians.
Supplementary Material
Supplemental figure
Supplemental table
Acknowledgments
The authors acknowledge the assistance of the North Carolina Department of Health and Human Services (NC DHHS) Division of Mental Health, Developmental Disabilities and Substance Abuse Services and Vaya Health for identification of study respondents. We also acknowledge the support of the NC DHHS Division of Public Health, Communicable Disease Branch and the Local Health Departments of North Carolina’s Local Health Director Region 1.
Funding source
This research was funded under a cooperative agreement (UG3DA044823) co-sponsored by the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, the Appalachian Regional Commission, and the Substance Abuse and Mental Health Services Administration (PI: Zule).
Disclosures
Donna M. Evon receives research funding from Gilead and Merck (paid to UNC). Christopher B. Hurt, Delesha M. Carpenter, Sarah K. Rhea, Caitlin M. Hennessy, and William A. Zule have no conflict of interests to disclose.
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Funding
Funders who supported this work.
Gilead and Merck
NIDA NIH HHS (2)
Grant ID: UG3 DA044823
Grant ID: UH3 DA044823
National Institute on Drug Abuse (1)
Grant ID: UG3/UH3 DA044823
