Table 2 Matrix of facilitators: themes and participant excerpts by Health Equity Implementation Framework element for HCV-positive, Black VA patients in the Southern USA

1)

HCV treatment regimen (daily pill for 12 weeks) and cost were acceptable to VA patients

No excerpt: When asked by the interviewer about pill form or cost of medicine at VA, all VA patients denied these being barriers. One exception is that pill form might require some medication management, which is addressed in the barriers section. The VA covered the cost of HCV treatment such that the medications would not cost money for VA patients.

2)

Having the ability to try the treatment first was unimportant because of high cure rate and few side effects.

P 1: I just want to try [the new HCV treatment]. Like I said, I want to eliminate this, you know. I want whatever works… I want to live a little longer. I have fourteen grandchildren so I want to be around for them.

3)

Positive clinical encounters regarding HCV occurred when providers explained what HCV was, the new treatment, side effects, next steps, and answered VA patient questions.

P 9: [The local primary care clinic] took some bloodwork and told me [I had HCV]. they got me in to see the doctor in [VA medical center], and they went over the stuff with me and they started me on the medication. It happened pretty fast…I have no complaints. At first it scared me…like being around my grandchildren and stuff…and then they explained to me this and that, and I can be with the grandkids. If I have a cut and they have a cut or something, it can infect my grandchildren…And so until I got on that medication make sure I did not visit my grandchildren too often. We talked, and I asked her how long it would take me—actually, she called and was setting this stuff up, an appointment up for me when I was there in the office with her…I am happy with how it happened… They did a lot of bloodwork, and then when they got me in there and got me the medicine and then they gave me the results from last month, they told me about the drop [in HCV viral load] I had in it last month and I was happy because at least they are taking care of me. [The provider] talked with me…sits down and talks with me every time I get there. I talk to her like I am talking to you. I like her.

4)

Wait time for an appointment was not an issue for any VA patient.

No excerpt: Once VA patients were offered a follow-up appointment to initiate HCV treatment, each VA patient denied that wait time for that specific appointment was too long. (Concerns about wait time to initiate treatment were expressed and reported in Table 3 findings of barriers).

5)

VA patients hoped there was no racial discrimination in VA

P 1: I hope color would not make a difference… If there’s a cure, then we should all have it. Black or white, it does not matter. Color does not matter.

6)

VA patients were optimistic about treatment.

P 7: (When asked about barriers to getting the HCV treatment): I do not know because I want to have it. I do not see anything really getting in my way.

7)

VA patients were eager for more HCV education and outreach.

P 8: Is [the treatment] going to work? Is it worth all the hassle going over there and getting medicine? One thing [that would make me likely to get the treatment] is if I am guaranteed it’s going to work. But I know that there is no guarantee. Another thing I would want to know more information on side effects… what I feel would be best would be for the VA to sit down one-on-one to discuss with a doctor that is familiar with the treatment, the side effects, and…if anybody that do this process get cured…you have different sites on the internet but the information is very limited.

8)

VA patients reported positive trust in some VA providers who encouraged HCV treatment.

P 5: [There is] a [VA] licensed practitioner, who I put all my trust in, she always kept me abreast of everything... She offered, she said I seemed to be a good candidate for this treatment, if I wanted to accept it. And after she found out about the treatment, she informed me…she’s up to date on everything. I thank God for her.

P 2: [What helped me decide to get treatment was my doctors] letting me know and telling me what medicine to take. I will do what the doctors told me to do. I trust them.

9)

VA patients perceived that most providers appeared to have a desire to help, reflected by being on time to appointments, explaining information in detail, and acting quickly on follow-up steps

P 5: I think that they go in and whoever the doctor is talks about the meds… hopefully they can get a practitioner like [my provider]. That makes a big difference when you have somebody that you are seeing that is actually concerned about you. Those that are there to receive a paycheck are not really worried about you, and I do not really find that with her. She does not have to be like that. She would call and say this is [provider], I am calling to check on you and see how you are doing. Many times I might forget to make an appointment, but she’ll call and remind me to check in with her. And that’s compassion, you know. You do not find that much.

10)

Some VA providers were perceived as not having or enacting racial biases.

P 5: I think I am going to give [VA providers] the benefit on that question [about racial discrimination]. We have caring physicians, practitioners that are caring enough to know that…people of color have been unproportionally less with benefits of medical advancement and they see that this availability now is even more available for minority for the white, Caucasian. So now it’s been given to them more freely than it was back in say the 70s.

11)

VA clinics offsets HCV stigma in society by protecting patient confidentiality and including HCV-positive patients in other general infectious disease clinics

P 6: (When asked about HCV stigma getting in the way of treatment) No… I go to the clinic and the woman calls my name. She calls my name, but they do not know what I am going back there for. That’s why I said I do not have no problems going to the doctor because it’s private.

12)

VA patients perceived VA used best medicine and genuinely wanted to help VA patients

No excerpt: When asked directly, “do you think the VA uses the best medicine and wants to help Veterans?”, each participant said yes.

13)

VA patients reported some HCV treatment materials circulating

P 4: The only information I have—have heard it on T.V., you know, commercials about Hep C.

14)

Positive testimonials about HCV treatment made VA patients more likely to want or to try the treatment

P 1: [My friend] just had [the treatment], and he was telling me that they treated him for twelve weeks with some medicine…It was through another clinic…his outcome was great…They were giving him some kind of pills, you know. And he told me, man, matter of fact he told me the other day, he said man, I got rid of that Hepatitis C in my blood… That made me feel great, you know. That made me want it even more, you know.

15)

Positive testimonials about healthcare in general made VA patients more open to HCV treatment

P 10: Most of my friends and family go to the hospital and see doctors…they go so it’s got to be positive. I go with my sister twice a week to [the doctor]. So most of my friends are up in age with me, and we all go to doctors and stuff so they go to the hospital…I go regularly when I need to be seen, you know.