Enhancing healthcare engagement to increase access to hepatitis C treatment: a mixed-methods study of barriers, facilitators, and opportunities within populations of people who use drugs and sex workers in British Columbia, Canada

Hepatitis C virus (HCV) infection is largely asymptomatic, potentially fatal, and curable with new therapies. Canada has committed to eliminate HCV as a public health concern by 2030, but may not reach targets without treating high-burden populations extensively. People who use drugs (PWUD) and sex workers (SWs) have elevated risk for this blood-borne infection. Offering HCV care within primary care has been shown to increase access to HCV therapies, particularly for people facing structural barriers to care. However, few primary care practitioners (PCPs) treat HCV, incurring delays and loss to follow-up. Many PWUD and SWs face relational as well as structural barriers to care, such as a history of stigmatization or denied care. This thesis aims to promote timely stigma-free primary-level HCV therapy. First by estimating healthcare avoidance and its association with experiencing drug-use stigma in healthcare. Second, by describing healthcare experiences of PWUD and SW. Third, by investigating PCP concerns about treating HCV, particularly in treating PWUD and SW patients. Fourth, by leveraging the combined insights to develop accredited education for healthcare professionals to better understand how to build trust with PWUD and SW who have repeated stigma experiences. This mixed-methods study analyses cross-sectional survey data, and interview data with PWUD or SW, and PCPs. While PWUD’s and SWs’ concerns were dignity, confidentiality, fear, stigma, and having healthcare delayed or denied, PCPs were focused on medical histories of drug use and sexual activity needed for optimal treatment and harm reduction. While PCPs sought to convey non-judgment and frame drug-use as a normal activity, PWUD found such questioning intrusive when not directly related to their presenting health issue, creating mistrust. Such discrepancies in perspectives provide material for education. PWUD and SW had high healthcare avoidance driven by stigma in healthcare settings. Educating PCPs to provide non-stigmatizing encounters could result in better experiences for patients and PCPs, enhancing progress to HCV elimination. This thesis provides evidence of stigma as a key modifiable barrier to HCV care for PWUD and SW. It also links findings with a theory- and evidence-informed intervention strategy to improve delivery of care essential for achieving equitable HCV elimination.