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A Square Peg in a Round Hole: Treating Hepatitis C

The American Journal of Managed CareNovember 2023
Volume 29
Issue 11

The authors propose an investment in patient-centered care strategies to initiate and engage vulnerable populations with curative hepatitis C treatment.


Several barriers along the cascade of care reduce hepatitis C treatment access. We propose an investment in patient-centered care strategies to initiate and engage this vulnerable population with curative treatment, such as the implementation of community-based educational peer support groups. Barriers to implementing these patient-centered care strategies remain.

Am J Manag Care. 2023;29(11):e320-321. https://doi.org/10.37765/ajmc.2023.89457


Takeaway Points

  • We propose an investment in patient-centered care strategies.
  • Patient-centered care strategies aim to initiate and engage patients in care.
  • One patient-centered care strategy is the use of community-based educational peer support groups.
  • Barriers to implementing educational peer support groups remain.


The United States medical system is poorly aligned to treat patients with hepatitis C, much like a square peg in a round hole. Instead of addressing the myriad characteristics that constitute the whole person, providers see patients during preassigned and inflexible times to address singular medical concerns. New technologies have modified means of communication with providers; however, the structure of patient communication has remained stagnant and in favor of the busy provider. There have been tremendous advances in hepatitis C treatment,1 with little innovation of the patient experience.

Prescriptive authorities have expanded to allow advanced practitioners (eg, nurse practitioners, physician assistants) to prescribe hepatitis C treatment. Other essential aspects of the patient experience—time of day, ability to change appointments, and the check-in process—have remained quite the same. If a patient does not meet these expectations, they may be unable to initiate and engage in care. Patients with hepatitis C cite additional systems-level barriers such as lack of coordination between hepatitis C treatment providers and other providers.2 Considering these factors, it is quite possible to see why many patients with hepatitis C do not receive treatment.

Hepatitis C treatment is particularly inaccessible in rural areas because of geographic distance, lack of public transportation, and limited number of providers.3 The current system creates additional difficulties for subsets of patients who face social determinants of health, such as working parents, those who rely on others for transportation, and those with inconsistent working schedules.4 It is not inclusive of those who have internal barriers to appointment arrival. These multifaceted barriers must be addressed.

Patient-Centered Care

We propose that the medical system reorganize to center the whole patient. There are modifications that our current system could implement to increase access and to improve overall well-being—to provide patient-centered care. There is growing interest in the research field in the provision of low-barrier patient-centered care for hepatitis C treatment.5 Patient-centered care encompasses several patient care strategies; we focus on a few essential improvements to the health care system.

Of interest to practitioners, researchers, and patient populations alike is the use of peer support to enhance treatment outcomes.5,6 In one proposed model, groups of peers initiating hepatitis C treatment gather to receive educational materials and provide mutual support and accountability throughout the treatment process. The session could include a small group of patients who receive education on general health, viral transmission of hepatitis C, and other infectious processes associated with hepatitis C risk behaviors (eg, intravenous drug use) from trained medical staff. In addition, medical staff could provide education on hepatitis C therapies and expectations for patient engagement during the treatment process, including the importance of follow-up laboratory tests with associated instructions. These peer support groups can be delivered in a low-barrier setting (eg, community center) or via mobile device.7

It is also essential to address adjunctive treatment barriers; for example, lessening the inflexibility of appointment attendance by allowing extended appointment times, accommodating for tardiness or no-shows (eg, 30-minute grace period, walk-in blocks, double booking, video or phone visits), streamlining the screening and referral processes for comorbid illness such as substance use disorder,8 navigating check-in difficulties and transportation issues (eg, telehealth), and using literacy-appropriate education (eg, storytelling).9

Systems-level barriers will need to be addressed for successful implementation of these strategies, such as lack of insurance coverage, stigma, inequitable access to community spaces and/or technology in rural settings, and lack of treatment during incarceration. Future research is needed to assess the effectiveness, scalability, and acceptability of patient-centered interventions to treat hepatitis C tailored to specific needs, such as populations involved in the criminal justice system,10 the growing proportion of women with hepatitis C, and populations living in rural areas.

In the United States, systems-level changes to reduce barriers to hepatitis C treatment are needed. We propose an investment in patient-centered care strategies to initiate and engage this vulnerable population with curative treatment. 

Author Affiliations: MaineGeneral Health (EB), Augusta, ME; Department of Behavioral and Social Sciences, Brown University School of Public Health (AB), Providence, RI.

Source of Funding: None.

Author Disclosures: Elizabeth Bailey reports past service on the medical advisory committee for the New England Division of the American Liver Foundation and participation on the medical advisory board for the public health sector of AbbVie. The views and opinions expressed in this commentary are those of the authors and do not nexessarily reflect the views or positions of any entities of affiliation.

Authorship Information: Concept and design (EB, AB); acquisition of data (AB); analysis and interpretation of data (AB); drafting of the manuscript (AB); critical revision of the manuscript for important intellectual content (EB); and supervision (EB).

Address Correspondence to: Amelia Bailey, MPH, Department of Behavioral and Social Sciences, Brown University School of Public Health, Box G-S121-3, Providence, RI 02912. Email: amelia_bailey@brown.edu.


1. Manns MP, Maasoumy B. Breakthroughs in hepatitis C research: from discovery to cure. Nat Rev Gastroenterol Hepatol. 2022;19(8):533-550. doi:10.1038/s41575-022-00608-8

2. Tsui JI, Barry MP, Austin EJ, et al. ‘Treat my whole person, not just my condition’: qualitative explorations of hepatitis C care delivery preferences among people who inject drugs. Addict Sci Clin Pract. 2021;16(1):52. doi:10.1186/s13722-021-00260-8

3. Schranz AJ, Barrett J, Hurt CB, Malvestutto C, Miller WC. Challenges facing a rural opioid epidemic: treatment and prevention of HIV and hepatitis C. Curr HIV/AIDS Rep. 2018;15(3):245-254. doi:10.1007/s11904-018-0393-0

4. Dennis BB, Martin LJ, Naji L, et al. Sex-specific risk factors and health disparity among hepatitis C positive patients receiving pharmacotherapy for opioid use disorder: findings from a propensity matched analysis. J Addict Med. 2022;16(4):e248-e256. doi:10.1097/adm.0000000000000937

5. Abdelwadoud M, Mattingly TJ 2nd, Seguí HA, Gorman EF, Perfetto EM. Patient centeredness in hepatitis C direct-acting antiviral treatment delivery to people who inject drugs: a scoping review. Patient. 2021;14(5):471-484. doi:10.1007/s40271-020-00489-6

6. Goodyear T, Ti L, Carrieri P, Small W, Knight R. “Everybody living with a chronic disease is entitled to be cured”: challenges and opportunities in scaling up access to direct-acting antiviral hepatitis C virus treatment among people who inject drugs. Int J Drug Policy. 2020;81:102766. doi:10.1016/j.drugpo.2020.102766

7. Selfridge M, Cunningham EB, Milne R, et al. Direct-acting antiviral treatment for hepatitis C, reinfection and mortality among people attending an inner-city community health centre in Victoria, Canada. Int J Drug Policy. 2019;72:106-113. doi:10.1016/j.drugpo.2019.03.001

8. Sivakumar A, Madden L, DiDomizio E, Eller A, Villanueva M, Altice FL. Treatment of hepatitis C virus among people who inject drugs at a syringe service program during the COVID-19 response: the potential role of telehealth, medications for opioid use disorder and minimal demands on patients. Int J Drug Policy. 2022;101:103570. doi:10.1016/j.drugpo.2021.103570

9. Talal AH, Ding YX, Markatou M. Innovations in education: a prospective study of storytelling narratives to enhance hepatitis C virus knowledge among substance users. World J Hepatol. 2022;14(5):972-983. doi:10.4254/wjh.v14.i5.972

10. Alshuwaykh O, Kwo PY. Current and future strategies for the treatment of chronic hepatitis C. Clin Mol Hepatol. 2021;27(2):246-256. doi:10.3350/cmh.2020.0230

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