Table 2 Evidence-based responses to representative examples of common narratives by PWID in the US on reasons to delay HCV treatment

I do not think my HCV is bad enough to warrant treatment now.

I know I am infected with HCV, but I am not worried about it now.

My doctor says my HCV is not bad enough to warrant treatment.

• Curing all HCV-infected PWID of HCV benefits individual and overall public health.

• Given the high rate of transmission of HCV through intravenous drug use, reducing HCV infection prevalence in the PWID population will reduce the overall epidemic

• Some Medicaid programs use sobriety and prescriber restrictions to limit treatment access, which may deter physicians from discussing HCV treatment with patients with limited liver fibrosis; however, these practices run counter to current guidelines on treating HCV among PWID

[40, 13, 41]

I am afraid of the side effects of HCV medication.

I want to avoid drug-related triggers.

• New direct-acting antiviral treatments are well-tolerated with limited side effects, even among individuals who are difficult to treat

• New treatments do not require injections that could be triggering for individuals in recovery from drug use.

[14]

I want to wait until I am done using drugs so I do not contract it again.

My doctor wants me to be more stable before I start treatment.

• PWID are adherent to HCV treatment and have low rates of reinfection

• Combining HCV treatment with medication assisted treatment for opioid use disorder or harm reduction services (e.g., syringe exchange) can support PWID in completing HCV treatment

• Curing all HIV-infected PWID of HCV benefits individual and overall public health.

[4, 42,43,44,45,46]

I am unable to get treatment while I am inside detox, jail or prison.

• HCV treatment availability in correctional settings varies, but research shows that it is feasible (though maintaining engagement in care post-release is a concern) and a growing number of facilities are providing therapy to incarcerated individuals {Beckman, 2016 #3713}

[47, 48]

The treatment is very expensive, so the insurance company want me to be clean before I start it.

Medicaid will only pay for HCV treatment once, so I need to be sure I am done using drugs before I start treatment.

• Testing and treating PWID for HCV is cost-effective

• Some states with known Medicaid reimbursement criteria limit treatment to those with advanced liver disease, and other states’ Medicaid reimbursement criteria require substance use screening and documentation for treatment; however, these limitations are not in line with current HCV treatment guidelines.

[49, 50, 8, 21, 13, 41, 7]