This is the first quantitative study in Georgia to examine barriers to HCV treatment among PWID, which represents a priority for the program. Mathematical modeling suggests that for countries with a large burden of injection drug use, HCV treatment for PWID is critical to achieving HCV elimination (Pitcher et al., 2019). We found that barriers to linkage to care among anti-HCV positive PWID include perceived high cost of care and a lack of information on what to do after a positive screening.
The eligibility criteria for HCV-infected individuals to enroll in the hepatitis C elimination program in Georgia are simple i.e., a person must be a citizen of Georgia aged ≥ 18 years. At the beginning of the program (April 28, 2015 to June 9, 2016) only patients with advanced liver fibrosis level were eligible for treatment (Mitruka et al., 2015). However, since June, 2016, the program has been expanded to all HCV-viremic individuals regardless of disease severity (Nasrullah et al., 2017). This expansion resulted in an increase in the number of enrolled individuals, but enrollment gradually declined after its peak in September 2016. Exact reasons for this decline are not known but high cost of diagnostics earlier in the program may be attributed to this decline. In our analysis, affordability of the program was the only independent predictor of linkage to care.
Although all PWID interviewed were utilizing HR services at the time they were screened, more than half of study participants were no longer receiving HR services at the time of interview. Disengagement with HR services was one of the factors associated with poor linkage to care. Research suggests engagement in opioid substitution therapy and other HR services increases linkage to care among PWID (Bouscaillou et al., 2018). Our data seem to correlate with this finding.
One important finding of this study was that more than 20% of respondents did not indicate they were informed of their test results by a HCW. Ensuring counseling to communicate screening test results and the need and procedure for follow-up viremia testing among those with positive screening results may result in increased linkage to care. Further, standardized counseling procedures need to be developed and implemented at all HR facilities to inform anti-HCV-positive patients about the need for HCV viremia testing to improve linkage to care.
This study is subject to limitations. Firstly, our findings are not representative of all PWID in the country. We were unable to include those PWID in our study who were not enrolled in HR service at the time of anti-HCV testing and who did not agree to provide NIN to be registered in the elimination program database. Individuals not enrolled in HR services are likely among the hardest to reach, and we were not able to survey this population. Secondly, these findings are self-reported and are subject to recall and social desirability biases. Another limitation of the study is different selection period for NLC and LC groups (longer selection period for NLC), which could lead to information bias, as awareness of the study participants could change over time.
Interventions to improve linkage to hepatitis C care among PWID have been identified by different studies. One study found increased enrollment rates and adherence to treatment among PWID with advanced liver fibrosis level when hepatitis C screening is done on-site (at the HR center) and when peer navigation services are available (Kikvidze et al., 2018).
Because of technical advisory group (TAG) recommendations in Georgia and our study findings, the government has made all diagnostics free of charge since September, 2018. Other services, such as on-site viremia testing and treatment have also been shown to be effective (Chihota et al., 2018), and could help the country to reach elimination.