Received: 12 December 2018 | Revised: 18 March 2019 | Accepted: 9 April 2019 DOI: 10.1111/jvh.13119 ORIGINAL ARTICLE Perceived barriers related to testing, management and treatment of HCV infection among physicians prescribing opioid agonist therapy: The C‐SCOPE Study Alain H. Litwin1,2 | Martine Drolet3 | Chizoba Nwankwo4 | Martha Torrens5 | Andrej Kastelic6 | Stephan Walcher7 | Lorenzo Somaini8 | Emily Mulvihill9 | Jochen Ertl9 | Jason Grebely10 1 Department of Medicine, University of South Carolina School of Medicine ‐ Greenville and Prisma Health, Greenville, South Carolina 2 Clemson University School of Health Research, Clemson, South Carolina 3 Merck Canada Inc., Montreal, Canada 4 Merck & Co., Inc., Kenilworth, New Jersey 5 Department of Psychiatry, Institut de Neuropsiquiatria i Addiccions, Hospital del Mar Barcelona, IMIM (Institut Hospital del Mar d'Investigacions Mediques), Universitat Autònoma de Barcelona, Barcelona, Spain 6 National Centre for the Treatment of Drug Addiction in Ljubljana, Ljubljana, Slovenia 7 CONCEPT, Center for Addiction‐Medicine, Munich, Germany 8 Addiction Treatment Centre ‐ Ser.D ASL BI ‐ Local Health Unit, Biella, Italy 9 Kantar Health, New York, New York 10 The Kirby Institute, UNSW Sydney, Sydney, Australia Correspondence Jason Grebely, The Kirby Institute, UNSW Abstract Sydney, Wallace Wurth Building, UNSW The aim of this analysis was to evaluate perceived barriers related to HCV testing, NSW 2052 Sydney, Australia. Email: jgrebely@kirby.unsw.edu.au management and treatment among physicians practicing in clinics offering opioid ag‐ onist treatment (OAT). C‐SCOPE was a study consisting of a self‐administered survey Alain Litwin, University of South Carolina School of Medicine – Greenville, Clemson among physicians practicing at clinics providing OAT in Australia, Canada, Europe University School of Health Research, 701 and the United States between April and May 2017. A 5‐point Likert scale (1 = not a Grove Road, Greenville, SC 29605, United States. barrier, 3 = moderate barrier, 5 = extreme barrier) was used to measure responses to Emails: alitwin@ghs.org or alitwin@clemson. perceived barriers for HCV testing, evaluation and treatment across the domains of edu the health system, clinic and patient. Among the 203 physicians enrolled (40% USA, Funding information This research was supported by funding 45% Europe, 14% Australia/Canada), 21% were addiction medicine specialists, 29% from Merck Sharp & Dohme Corp., a psychiatrists and 69% were metro/urban. OAT physicians in this study reported poor subsidiary of Merck & Co., Inc., Kenilworth, N.J., U.S.A. The opinions expressed in this access to on‐site venepuncture (35%), point‐of‐care HCV testing (16%), and noninva‐ paper are those of the authors and do not sive liver disease assessment (25%). Only 30% of OAT physicians reported personally necessarily represent those of Merck Sharp & Dohme Corp., a subsidiary of Merck treating HCV infection. Major perceived health system barriers to HCV management & Co., Inc., Kenilworth, N.J., U.S.A. The included the lack of funding for noninvasive liver disease testing, long wait times to Kirby Institute is funded by the Australian Government Department of Health and Abbreviations: APRI, AST to platelet ratio; DAA, direct-acting antiviral; FIB‐4, fibrosis‐4; HCV, hepatitis C virus; OAT, opioid agonist treatment; OST, opioid substitution therapy; PWID, people who inject drugs. This is an open access article under the terms of the Creat​ive Commo​ns Attri​bution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2019 The Authors. Journal of Viral Hepatitis Published by John Wiley & Sons Ltd 1094 | wileyonlinelibrary.com/journal/jvh  J Viral Hepat. 2019;26:1094–1104. LITWIN et al. | 1095 Ageing. The views expressed in this publication do not necessarily represent the see an HCV specialist, lack of funding for new HCV therapies, and reimbursement position of the Australian Government. JG is restrictions based on drug/alcohol use. Major perceived clinic barriers included the supported by a National Health and Medical Research Council Career Development lack of peer support programmes and/or HCV case managers to facilitate linkage to Fellowship. care, the need to refer people off‐site for noninvasive liver disease staging, the lack of support for on‐site phlebotomy and the lack of on‐site delivery of HCV therapy. This study highlights several important modifiable barriers to enhance HCV testing, evaluation and treatment among PWID attending OAT clinics. KEYWORDS barriers, DAA, hepatitis C, opioid substitution therapy, OST, people who inject drugs, treatment 1 | I NTRO D U C TI O N 2 | M E TH O DS 2.1 | Study design, setting and participants The global burden of hepatitis C virus (HCV) infection is significant, with over 71 million people living with HCV 1 and 6.1 million people C‐SCOPE was an international cross‐sectional study that recruited with recent injecting drug use. 2 There is also a considerable burden physicians practicing at clinics providing OAT from Australia, Canada, of HCV among people with a history of injecting drug use and people Europe (Belgium, France, Germany, Italy, Portugal, Netherlands, receiving opioid agonist treatment (OAT) for opioid dependence. Spain, Sweden and the United Kingdom) and the United States (US) High treatment completion and response to HCV therapy has from 14 April 2017 to 22 May 2017.18 been observed in people receiving OAT and people with recent inject‐ Inclusion/exclusion criteria have been described in detail previ‐ ing drug use.3 The integration and co‐location of care for HCV infec‐ ously.18 Physicians must have spent at least 50% of time in clinics tion and OAT is associated with improved testing, linkage to treatment providing OAT treating patients or in management responsibilities, and retention in HCV care.4-7 The high HCV prevalence among people a minimum of 2 years treating patients in a clinic providing OAT, who inject drugs (PWID) attending OAT clinics makes this an ideal set‐ currently treating PWID with OAT, and working at a clinic, centre, ting for targeted strategies to enhance HCV care. However, there are department, or institution that is providing OAT and have been per‐ still health system, structural, social, patient‐level and provider‐level sonally certified or allowed to prescribe OAT (Australia, Portugal barriers that are preventing broad uptake of HCV therapy among peo‐ and the United States only). Physicians working at the same clinic, ple receiving OAT or people with recent injecting drug use.8-10 centre, department or institution as two previous qualified respon‐ In some countries, people receiving OAT and people with recent dents and those unwilling to comply with the study protocol were 11 drug use are still ineligible or considered unsuitable by practi‐ excluded. tioners 12 to receive direct‐acting antivirals (DAAs) , due to concerns Physicians were invited to participate via opt‐in online web pan‐ of poor adherence, ongoing substance use, lower responses to ther‐ els (M3 Global Research panel), research databases and/or public apy, medication price and the risk of reinfection.9,12 In studies of gen‐ and proprietary lists of clinics providing OAT in each country. The eral practitioners, a lack of confidence in initiating interferon‐based M3 Global Research panel is an actively managed double opt‐in on‐ HCV treatment appears to have driven the low HCV screening, eval‐ line panel, for which physicians firstly opt‐in via an initial recruit‐ uation and treatment rates among this provider group.13 Low case ment form and are then sent an automated email to confirm that numbers and inadequate HCV knowledge are important factors, they want to join the panel. Upon agreement to join the panel, M3 with one study suggesting that primary care providers tend to un‐ Global Research has a stringent verification process in order to con‐ derestimate efficacy and tolerability, and overestimate duration of firm a respondent’s practicing status. In the United States, 100% DAAs,14 although many report a desire for more HCV education.15 of panellists are verified using the American Medical Association Although qualitative interviews with providers have identified barri‐ database. 16,17 ers to HCV care, there are very few studies that have quantified Once identified, physicians were contacted via email or tele‐ potential modifiable barriers among physicians prescribing OAT. phone and screened against the inclusion/exclusion criteria. The C‐SCOPE study was an international cross‐sectional study Eligible physicians were invited to participate in an online survey to evaluate clinic procedures and services, barriers, competency and in their local language. Physicians were provided an email and link attitudes towards HCV care among physicians practicing at clinics to an online internet‐based survey. Approximately 2‐4 days after providing OAT.18 The aim of this analysis was to evaluate perceived the initial invitation, people who did not initially respond were barriers related to HCV testing, management and treatment among sent an e‐mail reminder. All participants gave written informed physicians prescribing OAT in the C‐SCOPE study. consent before study procedures started. Participating physicians 1096 | LITWIN et al. were compensated for participation according to fair market value 3 | R E S U LT S (from $90 to $165, depending on the country). Pearl IRB has de‐ termined this study meets the exemption requirements under 3.1 | Participant characteristics 45CFR46.101(b). 2 Among 660 physicians contacted for this study, 203 physicians were enrolled (Table 1). Among the 457 who did not enrol in the study, 2.2 | Study assessments 266 did not meet the inclusion criteria; 91 started the survey and did not complete it; and 100 were ‘over quota’ (by the time they re‐ As previously described,18 physicians completed a survey to assess sponded to the survey, the quota for the target sample size for their perceptions, self‐reported competency, and barriers related to the country had already been met). The characteristics of OAT prescrib‐ testing, management and treatment of HCV infection among those ers included in this study are highlighted in Table 1. being prescribed OAT. Where applicable, questions were adapted from previously published studies.9,19-24 The survey included information on physician characteristics 3.2 | Existing team members to support including region (Australia, Canada, Europe and the United States), agonist therapy within clinics providing OAT primary specialty, and number of years in practice, practice source The majority of physicians reported having nurses, nurse practi‐ of funding (public, private for profit, private not for profit), type of tioners and medical assistants (71%), addiction medicine specialists OAT institution (substance use clinic/centre, hospital department (70%), psychiatrists (61%), primary care physicians (56%) and social that treats people on OAT, OAT clinic/centre and other institution/ workers (55%) as part of the team providing support for OAT at their office that treats people on OAT), proportion of OAT therapy of‐ clinic (Figure S1). Only 27% of clinics had a HCV specialist (Infectious fered, OAT clinic setting (major metropolitan area, urban, suburb Diseases, Hepatology or Gastroenterology). Very few clinics had a of large city, small city and rural/small town), number of patients link‐to‐care coordinator (20%), peer support worker (16%) or HCV managed on OAT who are PWID in past 12 months, number of educator (10%). patients personally managed on OAT who are PWID with HCV in the past 12 months, and training received. The survey also in‐ cluded information on OAT clinic characteristics including compo‐ 3.3 | Availability of HCV diagnostic services sition of teams that support OAT within the clinic, availability of HCV training for staff, existence of protocols and guidelines put in Physicians reported a wide range of diagnostic services being place, availability and location (on‐site, affiliated off‐site, not affil‐ available to OAT providers, either on‐ or off‐site, with HCV test‐ iated off‐site) of HCV diagnostic services, availability and location ing (antibody and RNA) and noninvasive liver disease assessment of HCV assessments prior to or during treatment, support services being almost universally available (Figure 1 and Table S1). Only a offered to HCV patients, use of electronic health records. Lastly, minority of physicians reported having access to on‐site HCV anti‐ the survey included information on perceptions of barriers to body testing (40%), on‐site venipuncture (35%), quantitative (28%) HCV screening, testing and treatment (health system‐, clinic‐ and or qualitative (27%) HCV RNA testing, or liver disease assessment patients‐related barriers) and attitudes and perceptions towards (25%). In cases where HCV testing is performed off‐site, 97% of HCV management. the clinics received the HCV test results from the same location where the tests are performed indicating that patients need to return to their OAT clinic to receive their results. On‐site avail‐ 2.3 | Study outcomes and analysis ability of point‐of‐care fingerstick‐based (16%) and saliva‐based The availability of services for HCV testing and treatment at clinics (8%) testing was uncommon. A large proportion of physicians did among physicians who prescribe OAT were evaluated. Study end‐ not have access to point‐of‐care finger‐stick‐based (31%) or saliva‐ points also included physician‐perceived barriers regarding HCV based (38%) testing. testing, management and treatment of HCV for PWID. Physicians were asked to evaluate potential barriers for OAT patients to enter‐ 3.4 | Availability of testing protocols ing pathways to HCV care (ie testing and diagnosis), and to evalu‐ ate potential barriers to continuing pathways to HCV care (ie HCV A majority of physicians reported that their clinic has a protocol for treatment management). A 5‐point scale (1 = Not a barrier, 2 = Minor HCV screening and diagnosis (n = 75, 37%) or that published guide‐ barrier, 3 = Moderate barrier, 4 = Major barrier and 5 = Extreme bar‐ lines are followed (n = 87, 43%; data not shown). From those 162 rier) was used to measure barriers related to HCV testing, manage‐ physicians, 86% reported testing all patients with history of injection ment and treatment. Barriers were categorized into those reporting drug use and 82% reported that HCV‐positive people are referred greater than or equal to moderate barriers (eg moderate, major or for additional testing and assessment. However, only 56% of physi‐ extreme barriers). Analysis was performed using SAS 9.2 software cians reported testing all OAT patients for HCV at first visit, 58% of (SAS Institute Inc., Cary, NC, USA). physicians reported that patients are re‐tested on a regular basis, LITWIN et al. | 1097 TA B L E 1 Enrolment characteristics of physicians in the C‐SCOPE TA B L E 1 (Continued) study (n = 203) Variables Overall n (%) Variables Overall n (%) Are you aware of any documents/tools for the screening, diagnosis Region or treatment of HCV? Europe 92 (45%) Yes 148 (73%) United States 82 (40%) No 55 (27%) Canada 16 (8%) Have you obtained any information on screening, diagnosis or treat‐ ment of HCV infection in the past year? Australia 13 (6%) Yes 131 (65%) Primary specialty of physician No 72 (35%) Psychiatry 58 (29%) Have you attended training on HCV in the past year? Addiction Medicine 43 (21%) Yes 75 (37%) Addiction Psychiatry 40 (20%) No 128 (63%) General Practice/Family Medicine 39 (19%) Have you read or consulted the AASLD/IDSA, EASL or any other Internal Medicine 14 (7%) country specific guidelines? Neurology 6 (3%) Yes 76 (37%) Other physician specialty 3 (1%) No 127 (63%) Number of years in practice Note: Percentages indicate column percentages; OAT, opioid agonist Mean (SD) 11 (8) therapy; SD, standard deviation; Q1, first quartile; Q3, third, quartile. Median (Q1, Q3) 10 (5, 15) Type of funding and 57% of physicians reported that patients receive test results and Public 108 (53%) care referrals in one visit (Table S2). Private, for profit 60 (30%) Private, not for profit 35 (17%) 3.5 | Availability of electronic health records Type of OAT institution Substance use clinic/centre 77 (38%) Access to an electronic health record system was reported by 74% of physicians (n = 150), with: 40% of these reporting having elec‐ Hospital department that treats people on OAT 42 (21%) tronic alerts for patients who are eligible/need testing/re‐testing; Opioid agonist therapy clinic/centre 31 (15%) 30% reported that one of the elements of the system includes the Other institution/office that treats people on 54 (27%) OAT generation of reports for those who were tested and the names of those who were HCV positive; 23% reporting that the system Per cent of patients receiving OAT [mean (SD)] tracks, reports and facilitates reimbursement for HCV tests; and Methadone 42% (35) 14% report that the system provides an alert that patient is eligi‐ Buprenorphine 47% (35) ble for link‐to‐care services. Nearly half (42%) of the physicians Heroin or diacetyl‐morphine 4% (10) did not report any of the above elements for the electronic health Other OAT 7% (18) record system implemented in the clinic where they practice. Setting of OAT clinic Major metropolitan area, population >500 000 82 (40%) 3.6 | Availability of support services offered for Urban area, population between 100 000 and 59 (29%) 500 000 HCV testing and diagnosis Suburb of a large city, population >100 000 26 (13%) The most common support service offered to enhance testing/diagno‐ Small city, population between 30 000 and 27 (13%) sis was appointment scheduling for HCV specialist (75% of physicians 100 000 offered this service at their clinic) and informational posters to educate Rural or small town, population <30 000 9 (4%) patients on prevalence, risk factors and recommendations (71%). The Number of patients personally managed on OAT who are PWID least common support service was patient financial incentives to attend Mean (SD) 51 (101) HCV specialist appointments for testing/diagnosis (12%) (Table S3). Median (Q1, Q3) 20 (6, 50) Number of patients personally managed who are PWID with HCV 3.7 | Availability of assessments prior to Mean (SD) 24 (50) HCV treatment Median (Q1, Q3) 10 (2, 30) Physicians reported a wide range of pre‐treatment assessments (Continues) being available in OAT clinics (Figure S2). Standard HCV evaluation 1098 | LITWIN et al. Off-site (Not On-site Off-site (Affiliated) affiliated) Not available Don’t know HCV antibody testing 40% 35% 28% 1% 0% Venipuncture-based 35% 27% 25% 10% 6% Quantitative RNA testing (viral load) 28% 36% 33% 4% 2% Qualitative RNA testing 27% 36% 33% 4% 3% Assessment of liver disease (fibrosis 25% 34% 33% 5% 5% score) Fingerstick-based testing 16% 21% 20% 31% 16% Reflex testing 16% 28% 25% 18% 16% NS5A resistance testing 10% 20% 20% 19% 32% Saliva-based testing 8% 18% 19% 38% 19% FIGURE 1 Availability of diagnostic services in clinics offering OAT blood work was almost universally available. Although nearly half At the level of the clinic, the most common perceived barriers of physicians reported that their clinics have access to assessments to HCV screening and testing by OAT physicians included the lack such as creatinine (47%) or complete blood count (46%) available on‐ of peer support programmes for testing (39% ≥moderate), the lack site, the majority of patients had to be referred off‐site. However, of support staff to draw blood (38% ≥moderate), the requirement only a minority of physicians reported having access to on‐site non‐ for imaging outside the clinic (37% ≥moderate) and the fact that the invasive liver fibrosis assessment, including AST to Platelet Ratio clinic does not utilize case managers or link‐to‐care coordinators for (APRI) (24%), Fibroscan (14%) or Fibrosis‐4 (FIB‐4) Index (11%). HCV testing (37% ≥moderate; Figure 3B, Table S5). At the level of the patient, the most common perceived barri‐ ers to HCV screening and testing by OAT physicians included social 3.8 | Availability of services for HCV treatment circumstances/unstable housing/marginalized lifestyle (73% ≥mod‐ Only 30% of the OAT physicians in this study reported that they per‐ erate), patients not attending appointments (70% ≥moderate), lack sonally treat HCV infection. Thirty‐two per cent of physicians reported of knowledge of HCV and its treatment (70% ≥moderate), general that they refer patients to HCV specialists in the same clinic and 62% difficulty navigating through the system (69% ≥moderate), patient reported that they refer HCV patients to other institutions for treat‐ stigma (64% ≥moderate) and concerns with patient motivation to get ment. Overall, 26% of physicians reported that medication is dispensed tested (63% ≥moderate) (Figure 3C, Table S5). at the OAT clinic, but most often, HCV medication is dispensed off‐site. Other reported barriers included a lack of time for HCV testing The most common support services offered on‐site to enhance due to competing responsibilities (47% ≥moderate) and that visits HCV treatment included access to psychiatric treatment (66%) and are too short and do not allow enough time for testing (41% ≥mod‐ one‐on‐one education with peers/staff (52%) (Figure 2 and Table erate) (Table S5). S4). Other common support services offered on‐site included psy‐ choeducational support groups (44%), adherence support (42%), 3.10 | Physician perceived barriers for coordinator/counsellor for barriers such as financial, housing and HCV treatment food security (39%), directly observed therapy (35%) and HCV peer support (32%). At the level of the health system, the most common perceived barri‐ ers for HCV treatment by OAT physicians are that the patients can‐ not afford HCV treatment (65% ≥moderate, the United States only), 3.9 | Physician perceived barriers to HCV the lack of health system funding for new HCV medications to treat screening and testing HCV (60% ≥moderate) and the requirement for a period of absti‐ At the level of the health system, the most common perceived bar‐ nence from recent drug use for government reimbursement of HCV riers to HCV screening/testing by OAT physicians included a lack therapy (58% ≥moderate) (Figure 4A, Table S6). of health system funding for noninvasive methods of liver disease At the level of the clinic, the most common perceived barriers screening (63% ≥moderate; Figure 3A, Table S5). Other common to HCV treatment by OAT physicians are the lack of delivery of barriers included long wait times for patients to see an HCV spe‐ therapy on‐site (46% ≥moderate), case managers (44% ≥moderate) cialist (55% ≥moderate), patients not being able to afford diagnostic and of peer support programmes for treatment (42% ≥moderate) testing (the United States only) (44% ≥moderate), geographic dis‐ (Figure 4B, Table S6). tance to see an HCV specialist (41% ≥moderate) and lack of health The most common barriers for patients to continue the pathway system funding for HCV testing (40% ≥moderate). to HCV care are probably, according to physicians, the patients’ fear of LITWIN et al. | 1099 Off-site (not On-site Off-site (affiliated) affiliated) Not available Don’t know Access to psychiatric treatment such as for 66% 19% 16% 5% 2% anxiety and depression One-on-one education with peers or staff 52% 19% 14% 15% 4% Psychoeducational support groups (lead by staff) 44% 19% 19% 22% 3% Adherence support 42% 15% 13% 29% 6% Coordinator/counseling for barriers such as 39% 18% 17% 23% 7% financial, housing and food security Patient directly-observed for treatment at the OAT 35% 17% 13% 32% 7% dispensing setting HCV peer support staff 32% 21% 16% 29% 6% Social support groups such as community 31% 21% 19% 26% 6% cooking, art therapy Staff conducts off-site visits to home shelters 23% 13% 16% 42% 8% halfway houses Financial compensation, meal, or transportation vouchers or tokens provided to patients who 15% 10% 10% 54% 13% participate in support groups FIGURE 2 Availability of support services offered for HCV side effects and adverse events (71% ≥moderate and 65% ≥moderate), potential modifiable barriers to enhance HCV care in drug treatment the asymptomatic nature of the infection (67% ≥moderate), patients settings among an international sample of physicians who prescribe being unaware that new treatments for HCV exist (65% ≥moderate), OAT. difficulty in navigating the healthcare system (65% ≥moderate), con‐ The minority of OAT physicians in the C‐SCOPE study reported cerns around patient motivation to be treated for HCV (63% ≥moder‐ having access to on‐site HCV testing and liver disease assessment. ate), stigma experienced by patients (56% ≥moderate) and mistrust of Current testing algorithms involve detection of HCV antibodies to the healthcare system (50% ≥moderate) (Figure 4C, Table S6). confirm exposure, followed by HCV RNA testing to detect active infection. This two‐step pathway requires up to 5 visits to practi‐ tioners and off‐site phlebotomists, leading to a drop‐off in those 3.11 | Physician attitudes towards HCV treatment in receiving a diagnosis of active infection. 25 In studies from Australia, people receiving OST Canada, and the United States, among people testing anti‐HCV an‐ Physicians were asked a variety of questions about HCV treatment tibody positive, only 46‐73% of people received confirmatory HCV in people receiving OAT. The most common barriers identified in‐ RNA testing. 26-31 On‐site testing, point‐of‐care testing, dried‐blood cluded the perceived need for stable alcohol use (58% ≥moderate), spot testing and noninvasive liver disease assessment have also been 7,32-34 concerns of adherence (55% ≥moderate), requirement for stable shown to be effective to increase uptake of HCV testing and 33 OAT (52% ≥moderate) and the challenging and marginalized lives of linkage to HCV care. On‐site testing and care has the potential to patients (49% ≥moderate). Only 25% reported that treating patients reduce non‐attendance to off‐site phlebotomy, provides more im‐ for HCV infection in a clinic for substance use was a ≥moderate bar‐ mediate results to facilitate enhanced counselling, education and rier (Figure 5, Table S7). linkage to care, and provides a more effective referral mechanism (via on‐site care) as compared to referring patients off‐site.10,16,17,35- 38 In fact, the recent availability of finger‐stick HCV RNA testing 4 | D I S CU S S I O N with good diagnostic accuracy may further provide opportunity for exploring opportunities for on‐site diagnosis and linkage to treat‐ This study describes physician perceived barriers related to testing ment in a single‐visit.39-41 Further efforts are needed to integrate and treatment of HCV infection in an international sample of physi‐ and scale‐up HCV testing and linkage to treatment within drug treat‐ cians prescribing OAT. OAT physicians in this study reported poor ment clinics. access to strategies that have been demonstrated to improve HCV It is concerning that only a minority of OAT physicians reported testing and linkage to care, such as on‐site HCV testing, point‐of‐ having protocols in their clinics or follow published guidelines for care HCV testing, noninvasive liver disease assessment and elec‐ HCV testing. In previous work from the C‐SCOPE study among OAT tronic prompts for HCV testing. Further, less than one‐third of OAT providers, competency with respect to ensuring that people at‐risk physicians reported personally treating HCV infection, with the of HCV regularly screened self‐reported as less than average was majority referring HCV patients off‐site for treatment. This study shown to be associated with a lack of awareness of documents/ also highlighted the most common perceived barriers to testing and tools for the screening, diagnosis or treatment of HCV; not having treatment for HCV infection among OAT prescribers at the level of obtained information on screening, diagnosing or treatment of HCV; the system, clinic and patient. To our knowledge, this is one of the not having attended any training on HCV in the past year, and no first studies to comprehensively evaluate the relative importance of protocol in place for HCV testing.18 As such, strategies are required 1100 | LITWIN et al. % Rating moderate or greater barrier (A) Lack of health system funding for other non-invasive methods to 16% 21% 37% 20% 6% 63% assess fibrosis level (APRI, FIB-4, FibroSure/FibroTest) Lack of health system funding for FibroScan to assess liver disease 23% 20% 31% 20% 7% 58% severity Long wait ­mes for pa­ents to see a HCV specialist for 17% 29% 25% 26% 4% 55% tes­ng/diagnosing Lack of health system funding for imaging to assess liver disease 28% 23% 28% 17% 4% 49% severity Pa­ents cannot afford diagnos­c tes­ng for HCV (US only) 27% 29% 23% 15% 6% 44% Geographic distance to see a HCV specialist for tes­ng/diagnosing 34% 26% 28% 12% 0% 41% Lack of health system funding for HCV tes­ng 41% 19% 24% 15% 2% 40% Tes­ng for HCV inside the clinic is not reimbursed to the clinic 44% 19% 22% 13% 3% 37% Not a Minor Moderate Major Extreme barrier barrier barrier barrier barrier % Rating moderate (B) or greater barrier Clinic does not provide peer support 27% 34% 28% 9% 2% 39% programs for tes ng Clinic does not have sufficient support 42% 20% 24% 10% 5% 38% staff to draw blood Imaging to assess liver disease severity 37% (fibrosis score) requires referral outside the clinic 26% 36% 22% 12% 3% Clinic does not u lize case managers or link-to-care coordinators for HCV tes ng 27% 36% 24% 10% 3% 37% Tes ng for HCV requires referral outside the clinic 41% 28% 21% 7% 2% 31% Lack of training for clinic personnel related to tes ng/diagnosing 36% 33% 20% 10% 1% 31% Clinic does not have a protocol for HCV tes ng 40% 33% 19% 6% 1% 27% Not a barrier Minor Moderate Major Extreme barrier barrier barrier barrier % Rating moderate (C) or greater barrier Social circumstances/unstable housing/marginalized lifestyle 10% 16% 31% 30% 12% 73% Pa ents do not aƒend referral appointment for tes ng 7% 22% 35% 29% 6% 70% Pa ents lack of knowledge about HCV or its treatment 8% 22% 37% 28% 5% 70% Bureaucracy/Pa ents have difficulty naviga ng the health care system 8% 23% 36% 27% 6% 69% Pa ent s gma 8% 29% 34% 23% 6% 64% Pa ents are not mo vated to undergo tes ng 10% 28% 33% 26% 4% 63% Pa ents mistrust the healthcare community or have feelings of s gma za on 12% 33% 33% 19% 4% 56% Pa ents fear of diagnos c tes ng 12% 34% 35% 17% 1% 54% Pa ents do not wish to know if they have HCV 16% 34% 33% 14% 2% 49% Pa ents do not want to receive health care on-site at clinic 26% 33% 22% 17% 2% 41% Pa ents fear that there will be loss of confiden ality 32% 30% 22% 14% 3% 38% Not a Minor Moderate Major Extreme barrier barrier barrier barrier barrier F I G U R E 3 Perceived (A) health system‐related, (B) clinic‐related and (C) patient‐related barriers to HCV screening and testing among physicians prescribing opioid agonist treatment LITWIN et al. | 1101 % Rating moderate (A) or greater barrier Paents cannot afford treatment for HCV (US only) 17% 18% 27% 23% 15% 65% Lack of health system funding for new medicaons to treat HCV 17% 24% 34% 19% 7% 60% Paents treated with OAT need to be absnent for a specific me period to have access to treatment 14% 28% 34% 20% 4% 58% Limited availability of physicians that treat HCV 16% 33% 31% 15% 4% 51% Geographic distance to see an HCV specialist 25% 32% 27% 13% 2% 43% Not a barrier Minor Moderate Major Extreme barrier barrier barrier barrier (B) % Rating moderate or greater barrier Clinic does not dispense medicaon to treat HCV 32% 22% 34% 9% 3% 46% Clinic does not ulize case managers or link-to-care coordinators for HCV treatment 24% 32% 31% 11% 2% 44% Clinic does not provide peer support programs for treatment 24% 34% 30% 10% 2% 42% Treatment for HCV requires referral outside the clinic 24% 37% 25% 10% 3% 39% Clinic does not provide counseling or educaon for HCV treatment 32% 32% 26% 8% 2% 36% Lack of training for clinic personnel on HCV treatments 26% 39% 24% 10% 1% 35% Not a Minor Moderate Major Extreme barrier barrier barrier barrier barrier (C) % Rating moderate or greater barrier Paents fear side effects 8% 20% 43% 22% 7% 71% Paent does not feel any symptoms 12% 21% 36% 24% 7% 67% Paents fear of adverse events from HCV treatment 7% 28% 38% 24% 2% 65% Paents are unaware that new treatments for HCV exists 10% 26% 39% 20% 5% 65% Bureaucracy/ Paents have difficulty navigang the health care system 10% 26% 38% 19% 7% 65% Paents are not movated to be treated for HCV 6% 31% 37% 20% 6% 63% Paent self-sgma 13% 31% 33% 19% 3% 56% Paents mistrust the healthcare community or have feelings of sgmazaon 17% 33% 32% 16% 2% 50% Paents fear that there will be loss of confidenality 30% 31% 22% 15% 2% 39% Paents don’t want to receive health care on-site at clinic 29% 36% 23% 10% 1% 35% Not a Minor Moderate Major Extreme barrier barrier barrier barrier barrier FIGURE 4 Perceived (A) health system‐related, (B) clinic‐related and (C) patient‐related barriers to HCV treatment among physicians to improve HCV education and training about HCV testing and diag‐ At the level of the health system, major perceived barriers to HCV nosis among physicians practicing in clinics offering OAT. testing and treatment by OAT prescribers in the C‐SCOPE study in‐ Despite 74% of OAT physicians reporting access to an elec‐ cluded the lack of funding/access for diagnostic testing, for nonin‐ tronic health record, nearly half reported that they did not have vasive liver disease screening and for DAA treatment, as well as the elements which would enable them to create electronic alerts for requirement in some settings for a period of abstinence from drug patients who require testing or re‐testing. Clinician reminders to use in order to be eligible for the government reimbursement of HCV prompt HCV testing during clinical visits have been associated with therapy. Restrictions set by payers, including national governments 6 increased HCV testing rates. Innovative strategies to utilize existing and others, in response to the initially high list prices of DAA therapies electronic health records to facilitate enhanced screening and test‐ have been documented in a number of different jurisdictions.11,42,43 ing in drug treatment clinics should be explored. However, many governments/payers internally have begun to remove 1102 | LITWIN et al. % Rating moderate or greater barrier Patients should be stable with regard to alcohol abuse in order to 13% 29% 40% 14% 4% 58% receive treatment for HCV OAT patients are unlikely to adhere to treatment 17% 28% 37% 17% 1% 55% Patients should be stable with regard to OAT in order to receive 16% 32% 36% 15% 1% 52% treatment for HCV OAT patients are too challenging to treat because many have 21% 30% 32% 14% 3% 49% marginalized lives Not reimbursed adequately for HCV treatment 34% 24% 25% 13% 4% 42% Not certified to Rx HCV treatment 40% 19% 21% 11% 9% 41% Duration of office visit is too short to cover HCV treatment 25% 35% 25% 14% 1% 40% Have many other responsibilities such as managing drug addiction 27% 34% 26% 11% 3% 40% and other co-morbidities Regulations do not permit me to Rx HCV treatment 39% 22% 23% 9% 6% 39% OAT patients are too challenging to treat because many are 34% 28% 30% 7% 1% diagnosed with psychiatric co-morbidities 39% Need to review extensive medical records to verify prior test 29% 34% 25% 10% 1% results 36% Do not think it is relevant to treat patients for HCV in a clinic for 62% 13% 19% 5% 0% substance abuse 25% Not convinced of the benefit of treating HCV for PWID because 57% 21% 16% 6% 0% the majority of the patients are asymptomatic 23% Not convinced of the benefit of treating HCV for PWID as they are 57% 20% 17% 5% 0% more likely to die of overdose than HCV 23% Not convinced of the benefit of treating HCV for PWID due to re- infection rate 57% 24% 15% 4% 0% 19% Not a Minor Moderate Major Extreme barrier barrier barrier barrier barrier FIGURE 5 Physician attitudes towards perceived barriers to HCV treatment restrictions based on liver disease and recent drug use for the reim‐ report on‐site testing to be preferable to referral to off‐site phlebot‐ bursement of DAA therapies.43 Nevertheless, further work is needed omists and tertiary clinics 16,17,36-38 and that on‐site testing (includ‐ to address these systematic barriers to access for diagnostics and ing point‐of‐care HCV testing) can improve linkage to HCV testing 7,32-34 treatment. Given that HCV treatment is effective in people receiving and care,33 strategies to enhance access to simple on‐site OAT and people with ongoing drug use (either injecting or noninject‐ HCV and liver disease testing should be implemented. It is interest‐ ing),3 further work is also needed to ensure the removal of restrictions ing that a large proportion of participants reported a lack of access for the reimbursement of DAA therapy based on recent drug use. to noninvasive fibrosis assessments (eg APRI and FIB‐4) that can be At the level of the clinic, a lack of peer support programmes calculated from standard HCV blood work, suggesting that further and/or HCV case managers to facilitate linkage to care was noted education is needed about the potential utility of these tests to as‐ by OAT prescribers. There is evidence demonstrating the value of sess liver disease. The co‐location of care for HCV infection and OAT peer‐based HCV support programmes and HCV case managers for is associated with improved uptake of HCV testing and treatment, improving engagement in HCV testing and treatment.44-46,48 In a re‐ and improved retention in HCV care.4-7 As such, strategies to en‐ cent, randomized controlled trial, 144 people living with HCV‐HIV hance the co‐location of services for HCV care and OAT treatment co‐infection and with substance use disorders were randomized to should be explored given their potential to improve engagement in three treatment groups including usual care (n = 36), usual care plus HCV testing and management. cash incentives (n = 54) and usual care plus peer mentors (n = 54) to At the level of the patient, the most common perceived barri‐ evaluate the rate of HCV treatment uptake and cure. Overall, the ers to HCV screening and testing by OAT physicians included so‐ treatment uptake was higher in people randomized to peers (83%) cial circumstances (eg unstable housing), lack of attendance to or cash (76%, 41 of 54) compared to usual care (67%, 24 of 36), al‐ appointments, poor knowledge of HCV and its treatment (including though this was not statistically significant (P = 0.11). These results awareness of new treatments), fear of treatment side effects, the as‐ are encouraging, but further work is needed to evaluate peer‐based ymptomatic nature of HCV infection, difficulties navigating through strategies to enhance HCV testing and treatment uptake. the health system, stigma and mistrust of the healthcare system. At the level of the clinic, major perceived barriers to HCV testing These barriers reported by OAT prescribers are consistent with ep‐ and treatment by OAT prescribers in the C‐SCOPE study included idemiological studies and surveys of patients who inject drugs liv‐ the need to refer people off‐site for noninvasive liver disease stag‐ ing with HCV infection,9,10,17,37,38,49 albeit most studies have been in ing, the lack of support for on‐site phlebotomy and the lack of deliv‐ the interferon‐era. It is important to note that the relative ranking ery of HCV therapy on‐site. Given that both patients and providers of these barriers is based on the perceptions of OAT providers in LITWIN et al. | 1103 the C‐SCOPE study, not the opinions of people living with HCV in‐ ORCID fection. Further research is needed to better understand barriers to Jason Grebely https://orcid.org/0000-0002-1833-2017 HCV care among people who inject drugs in the DAA era. Several limitations must be considered in the interpretation of the current results. Study participants were recruited through REFERENCES opt‐in online web panels, research databases and/or public and proprietary lists of clinics providing OAT in each country, and thus 1. The Polaris Observatory HCV Collaborators. Global prevalence and possible selection bias may exist among those who chose to par‐ genotype distribution of hepatitis C virus infection in 2015: a mod‐ elling study. Lancet Gastroenterol Hepatol. 2017;2(3):161‐176. ticipate. However, it should be noted that the membership of the 2. Grebely J, Larney S, Peacock A, et al. Global, regional, and coun‐ US M3 Global Research panel closely matches the demographics of try‐level estimates of hepatitis C infection among people who have the American Medical Association statistics with respect to region, recently injected drugs. Addiction. 2018. age and gender, which provides some confidence in the observed 3. Hajarizadeh B, Cunningham EB, Reid H, Law M, Dore GJ, Grebely J. Direct‐acting antiviral treatment for hepatitis C among people who results. The survey data were also based on self‐report and thus sub‐ use or inject drugs: a systematic review and meta‐analysis. Lancet ject to recall bias. Finally, physicians prescribing OAT were recruited Gastroenterol Hepatol. 2018;3(11):754‐767. across several different geographical regions and countries and thus 4. Christensen S, Buggisch P, Mauss S, et al. Direct‐acting antiviral treat‐ there exists heterogeneity in the availability of healthcare services, ment of chronic HCV‐infected patients on opioid substitution therapy: Still a concern in clinical practice? Addiction. 2018;113(5):868‐882. education and training, and policies for HCV testing and treatment. 5. Nouch S, Gallagher L, Erickson M, et al. Factors associated with lost Irrespective of these limitations, to our knowledge, this is one of to follow‐up after hepatitis C treatment delivered by primary care the first studies to systematically evaluate perceived barriers related teams in an inner‐city multi‐site program, Vancouver, Canada. Int J to testing, management and treatment of HCV infection among an Drug Policy. 2018;59:76‐84. 6. Zhou K, Fitzpatrick T, Walsh N, et al. Interventions to optimise the international sample of physicians prescribing OAT. This study high‐ care continuum for chronic viral hepatitis: a systematic review and lights important modifiable barriers to enhance HCV care in drug meta‐analyses. Lancet Infect Dis. 2016;16:1409‐1422. treatment settings. Given the growing body of evidence of the ef‐ 7. Bajis S, Dore GJ, Hajarizadeh B, Cunningham EB, Maher L, Grebely fectiveness of different interventions to enhance HCV testing, link‐ J. Interventions to enhance testing, linkage to care and treatment uptake for hepatitis C virus infection among people who inject age to care and treatment,6,7 including among PWID,7 it is critical drugs: a systematic review. Int J Drug Policy. 2017;47:34‐46. to explore strategies to address these barriers. Moving forward, the 8. Scott N, Doyle JS, Wilson DP, et al. Reaching hepatitis C virus elim‐ challenge will be tailoring successful interventions to the particular ination targets requires health system interventions to enhance the jurisdiction and/or setting, given that models of care will differ and care cascade. Int J Drug Policy. 2017;47:107‐116. one size will not fit all. 23 9. Grebely J, Oser M, Taylor LE, Dore GJ. Breaking down the barriers to hepatitis C virus (HCV) treatment among individuals with HCV/ HIV coinfection: action required at the system, provider, and pa‐ tient levels. J Infect Dis. 2013;207(Suppl 1):S19‐S25. AC K N OW L E D G E M E N T S 10. Harris M, Rhodes T. Hepatitis C treatment access and uptake for The authors would like to thank the survey participants for their con‐ people who inject drugs: a review mapping the role of social factors. Harm Reduct J. 2013;10:7. tribution to the research. The authors acknowledge Errol J. Philip, PhD 11. Barua S, Greenwald R, Grebely J, Dore GJ, Swan T, Taylor LE. for assistance with literature review and writing, Debra Bronstein for Restrictions for Medicaid Reimbursement of Sofosbuvir for the assistance with the qualitative assessment of the survey and Joana Treatment of Hepatitis C Virus Infection in the United States. Ann Matos, PhD for assistance with revision of the manuscript. Intern Med. 2015;163(3):215‐223. 12. Asher AK, Portillo CJ, Cooper BA, Dawson‐Rose C, Vlahov D, Page KA. Clinicians’ views of hepatitis c virus treatment candidacy with C O N FL I C T O F I N T E R E S T direct‐acting antiviral regimens for people who inject drugs. Subst Use Misuse. 2016;51(9):1218‐1223. JG is a consultant/advisor and has received research grants from 13. Lambert SM, Page AN, Wittmann J, et al. General practitioner at‐ titudes to prescribing hepatitis C antiviral therapy in a community AbbVie, Cepheid, Gilead Sciences and Merck Sharp & Dohme Corp., setting. Aust J Prim Health. 2011;17(3):282‐287. a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. MT is a 14. Thomson M, Konerman MA, Choxi H, Lok AS. Primary care physi‐ consultant/advisor for Gilead Sciences and Merck Sharp & Dohme cian perspectives on hepatitis C management in the era of direct‐ Corp. AK is a consultant/advisor and/or speaker for Alkaloid, Carso, acting antiviral therapy. Dig Dis Sci. 2016;61(12):3460‐3468. 15. Rogal SS, McCarthy R, Reid A, et al. Primary care and hepatology Eli Lilly, Gillead Sciences, Medis/Mundipharma and Merck Sharp & provider‐perceived barriers to and facilitators of hepatitis C treat‐ Dohme Corp., a subsidiary of Merck & Co. SW is consultant/advisor ment candidacy and adherence. Dig Dis Sci. 2017;62(8):1933‐1943. for AbbVie, MSD/Merck, Gilead. EM, JE and RL are employees of 16. Harris M, Bonnington O, Harrison G, Hickman M, Irving W, HepCATT Kantar Health, paid consultants of Merck Sharp & Dohme Corp., a team. Understanding hepatitis C intervention success‐qualitative subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA. AL is a consult‐ findings from the HepCATT study. J Viral Hepat. 2018;25(7):762‐770. 17. Treloar C, Rance J, Dore GJ, Grebely J; Group ES. Barriers and facili‐ ant/advisor and has received research grants from AbbVie, Gilead tators for assessment and treatment of hepatitis C virus infection in Sciences and Merck Pharmaceuticals. JG, MT, AK, SW, LS and AL the opioid substitution treatment setting: insights from the ETHOS were consultants/advisors for this study. study. J Viral Hepat 2014;21(8):560‐567. 1104 | LITWIN et al. 18. Grebely J, Drolet M, Nwankwo C, et al. Perceptions and self‐reported 37. Treloar C, Rance J, Grebely J, Dore GJ. Client and staff experiences competency related to testing, management and treatment of hep‐ of a co‐located service for hepatitis C care in opioid substitution atitis C virus infection among physicians prescribing opioid agonist treatment settings in New South Wales, Australia. Drug Alcohol treatment: the C‐SCOPE Study. Int J Drug Policy. 2019;63:29‐38. Depend. 2013;133(2):529‐534. 19. Cox J, Graves L, Marks E, et al. Knowledge, attitudes and behaviours 38. Treloar C, Rance J; Group ES. How to build trustworthy hepatitis associated with the provision of hepatitis C care by Canadian family C services in an opioid treatment clinic? A qualitative study of cli‐ physicians. J Viral Hepat. 2011;18(7):e332‐e340. ents and health workers in a co‐located setting. Int J Drug Policy. 20. Grebely J, Robaeys G, Bruggmann P, et al. Recommendations for 2014;25(5):865‐870. the management of hepatitis C virus infection among people who 39. Grebely J, Applegate TL, Cunningham P, Feld JJ. Hepatitis C point‐ inject drugs. Int J Drug Policy. 2015;26(10):1028‐1038. of‐care diagnostics: in search of a single visit diagnosis. Expert Rev 21. Zeremski M, Zibbell JE, Martinez AD, Kritz S, Smith BD, Talal Mol Diagn. 2017;17(12):1109‐1115. AH. Hepatitis C virus control among persons who inject drugs 40. Grebely J, Lamoury FMJ, Hajarizadeh B, et al. Evaluation of the requires overcoming barriers to care. World J Gastroenterol. Xpert HCV Viral Load point‐of‐care assay from venepuncture‐col‐ 2013;19(44):7846‐7851. lected and finger‐stick capillary whole‐blood samples: a cohort 22. Arora S, Kalishman S, Thornton K, et al. Expanding access to hep‐ study. Lancet Gastroenterol Hepatol. 2017;2(7):514‐520. atitis C virus treatment–Extension for Community Healthcare 41. Lamoury FMJ, Bajis S, Hajarizadeh B, et al. Evaluation of the Outcomes (ECHO) project: disruptive innovation in specialty care. Xpert HCV viral load finger‐stick point‐of‐care assay. J Infect Dis. Hepatology. 2010;52(3):1124‐1133. 2018;217(12):1889‐1896. 23. Bruggmann P, Litwin AH. Models of care for the management of 42. Marshall AD, Cunningham EB, Nielsen S, et al. Restrictions for reim‐ hepatitis C virus among people who inject drugs: one size does not bursement of interferon‐free direct‐acting antiviral drugs for HCV fit all. Clin Infect Dis. 2013;57(Suppl 2):S56‐S61. infection in Europe. Lancet Gastroenterol Hepatol. 2018;3:125‐133. 24. Litwin AH, Kunins HV, Berg KM, et al. Hepatitis C management 43. Marshall AD, Pawlotsky JM, Lazarus JV, Aghemo A, Dore GJ, by addiction medicine physicians: results from a national survey. Grebely J. The removal of DAA restrictions in Europe ‐ One step J Subst Abuse Treat. 2007;33(1):99‐105. closer to eliminating HCV as a major public health threat. J Hepatol. 25. Institute TK. Annual Surveillance Report on HIV, viral hepatitis and 2018;69:1188‐1196. STIs in Australia 2017. Sydney: The Kirby Institute; 2017. 44. Trooskin SB, Poceta J, Towey CM, et al. Results from a geographically 26. Yehia BR, Schranz AJ, Umscheid CA, Lo Re V 3rd. The treatment focused, community‐based HCV Screening, linkage‐to‐care and pa‐ cascade for chronic hepatitis C virus infection in the United States: a tient navigation program. J Gen Intern Med. 2015;30(7):950‐957. systematic review and meta‐analysis. PLoS ONE. 2014;9(7):e101554. 45. Falade‐Nwulia O, Mehta SH, Lasola J, et al. Public health clinic‐ 27. Patel RC, Vellozzi C, Smith BD. Results of hepatitis C birth‐cohort based hepatitis C testing and linkage to care in baltimore. J Viral testing and linkage to care in selected U.S. Sites, 2012‐2014. Public Hepat. 2016;23(5):366‐374. Health Rep. 2016;131(Suppl 2):12‐19. 46. Ford MM, Johnson N, Desai P, Rude E, Laraque F. From care to 28. Mera J, Vellozzi C, Hariri S, et al. Identification and clinical man‐ cure: demonstrating a model of clinical patient navigation for hep‐ agement of persons with chronic hepatitis C virus infection atitis C care and treatment in high‐need patients. Clin Infect Dis. ‐ Cherokee Nation, 2012‐2015. MMWR Morb Mortal Wkly Rep. 2017;64(5):685‐691. 2016;65(18):461‐466. 47. Sulkowski M, Ward K, Falade-Nwulia O, et al. A Randomized 29. Snow K, Scott N, Clothier HJ, MacLachlan JH, Cowie B. Limited Controlled Trial of Cash Incentives or Peer Support to Increase provision of diagnostic services to Victorians living with hepatitis C HCV Treatment for Persons With HIV Who Use Drugs: The antibodies, 2001‐2012: a multi‐level modelling analysis. Aust N Z J CHAMPS Study. Open Forum for Infectious Diseases 2019 Apr Public Health. 2016. 9;6(4):ofz166.https​://doi.org/10.1093/ofid/ofz166 30. Janjua NZ, Kuo M, Yu A, et al. The population level cascade of 48. Crawford S, Bath N. Peer support models for people with a history care for hepatitis C in British Columbia, Canada: The BC Hepatitis of injecting drug use undertaking assessment and treatment for Testers Cohort (BC‐HTC). EBioMedicine. 2016;12:189‐195. hepatitis C virus infection. Clin Infect Dis. 2013;57(Suppl 2):S75‐S79. 31. Iversen J, Grebely J, Catlett B, Cunningham P, Dore GJ, Maher L. 49. Grebely J, Genoway KA, Raffa JD, et al. Barriers associated with Estimating the cascade of hepatitis C testing, care and treatment the treatment of hepatitis C virus infection among illicit drug users. among people who inject drugs in Australia. Int J Drug Policy. 2017. Drug Alcohol Depend. 2008;93(1–2):141‐147. 32. Coats JT, Dillon JF. The effect of introducing point‐of‐care or dried blood spot analysis on the uptake of hepatitis C virus testing in high‐risk populations: a systematic review of the literature. Int J S U P P O R T I N G I N FO R M AT I O N Drug Policy. 2015;26(11):1050‐1055. 33. Bottero J, Boyd A, Gozlan J, et al. Simultaneous human immuno‐ Additional supporting information may be found online in the deficiency virus‐hepatitis B‐Hepatitis C point‐of‐care tests improve Supporting Information section at the end of the article. outcomes in linkage‐to‐care: results of a randomized control trial in persons without healthcare coverage. Open Forum Infect Dis 2015;2(4):ofv162. How to cite this article: Litwin AH, Drolet M, Nwankwo C, 34. Beckwith CG, Kurth AE, Bazerman LB, et al. A pilot study of rapid hepatitis C virus testing in the Rhode Island Department of et al. Perceived barriers related to testing, management and Corrections. J Public Health (Oxf). 2016;38(1):130‐137. treatment of HCV infection among physicians prescribing 35. Treloar C, Newland J, Rance J, Hopwood M. Uptake and deliv‐ opioid agonist therapy: The C‐SCOPE Study. J Viral Hepat. ery of hepatitis C treatment in opiate substitution treatment: 2019;26:1094‐1104. https​://doi.org/10.1111/jvh.13119​ perceptions of clients and health professionals. J Viral Hepat. 2010;17(12):839‐844. 36. Harris M, Rhodes T, Martin A. Taming systems to create enabling environments for HCV treatment: negotiating trust in the drug and alcohol setting. Soc Sci Med. 2013;83:19‐26.