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Hepatitis C virus HCV infection is a significant public health concern worldwide. Georgia is among the countries with a high burden of HCV infection. Despite notable progress, challenges to achieving targets persist. This qualitative study is aimed to better understand some of the barriers and facilitators to HCV testing and treatment services for PWID to inform HCV treatment policies and practices. The study instrument examined social, structural, and individual factors influencing HCV testing and treatment practices. The study found that along with structural factors such as political commitment, co-financing of diagnostic and monitoring tests, and friendly clinic environments, knowledge about HCV infection and elimination program benefits, and support from family and peers also play facilitating roles in accessing testing and treatment services. On the other hand, inability to co-pay for diagnostic tests, fear of side effects associated with treatment, poor knowledge about HCV infection, and lack of social support hampered testing and treatment practices among PWID. Findings from this study are important for increasing the effectiveness of this unique program that targets a population at high risk of HCV infection. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. An estimated 13 million people are infected with HCV in the European region \\\\\\\\\[ 1 \\\\\\\\\]. It has been estimated that A national population based survey conducted in found that 7. The study also revealed that use of injection drugs accounted for more than one third of cases among the general population \\\\\\\\\[ 4 \\\\\\\\\]. Similar to other countries, PWID in Georgia are particularly vulnerable to HCV infection due to risky behaviors and exposure to structural and environmental risk factors. In April , the Government of Georgia and partners i. Gilead Sciences, the pharmaceutical company that produces direct acting antiviral DAA HCV treatments, agreed to provide initial 5, courses of the antiviral medication sofosbuvir Sovaldi free-of-charge to support the program \\\\\\\\\[ 3 , 7 \\\\\\\\\]. Patients with severe liver disease i. The initial treatment regimens consisted of sofosbuvir in combination with pegylated interferon and ribavirin \\\\\\\\\[ 8 \\\\\\\\\]. By February , Gilead Sciences again agreed to provide 20, treatment courses of ledipasvir-sofosbuvir Harvoni annually at no cost \\\\\\\\\[ 3 \\\\\\\\\] and the patients began receiving the new DAA regimen. In the second phase of the program, the severe liver disease criterion was abolished and as of today the program is accessible to all citizens of Georgia with chronic HCV infection \\\\\\\\\[ 8 \\\\\\\\\]. If the diagnosis is confirmed further tests are required to determine liver fibrosis status and HCV genotyping. Number of tests are conducted during the course of treatment to monitor treatment progress and at the end to determine the treatment outcome. Pre-treatment diagnostics, treatment monitoring, and post-treatment laboratory tests were covered by the program and local governments with some co-financing required from patients. As for the rest of the population, cost sharing for diagnostics, monitoring, and post-treatment tests across the years is presented in Table 1 below. Drugs for HCV treatment were, and continue to be, fully covered by the program. Georgia made substantial progress in the first year of the Elimination Program. Between April and April , 27, people with HCV were enrolled in the program and 8, initiated treatment \\\\\\\\\[ 3 \\\\\\\\\]. Yet, as is the case with any new larger-scale program, implementation can be challenging, especially with PWID. Specifically, the research objectives were to 1 identify the societal, structural, and individual barriers and facilitators to HCV screening, completing diagnostic testing, and initiating HCV treatment services among PWID and 2 examine the perceived risk of HCV re-infection and its consequences among PWID. The health service utilization framework posits that health service utilization is influenced by characteristics of the health services, societal norms, and individual factors \\\\\\\\\[ 11 \\\\\\\\\]. We modified the framework and identified social, structural, and individual factors that may act as barriers or facilitators to using testing and treatment services Fig 1. Structural factors were defined as those over which a person has little control such as political will, policies, program resources, financial and geographical access barriers to service use, quality of care, and civil society organizations CSO activities. Individual factors include knowledge, attitudes, and beliefs regarding HCV infection, the Elimination Program in general, and HCV treatment specifically. Individual factors also include patient motivation and willingness, general lifestyle and drug use behavior, ability to pay, and satisfaction with services. Social and structural factors interact with each other and together influence individual factors. Prior to the recruitment of PWID we conducted key informant interviews with the individuals who had first-hand knowledge about the Hepatitis C Elimination Program implementation, successes, and challenges. The purpose of these interviews was to guide the PWID data collection tool development and complement the study findings by examining the views of health care planners and health care providers on policies, elimination program resources, and other structural factors. The key informants were identified through a snow-ball method. In total, seven key informants were interviewed face-to face by lead researchers in April This number was sufficient to gain a broad perspective of a situation from the representatives of divergent groups involved in the Hepatitis C program development and implementation. PWID were recruited from six cities of Georgia i. The target sample size was 40 PWID. We note that sample sizes in the 10s of participants are par for the course with qualitative studies \\\\\\\\\[ 12 \\\\\\\\\]. Indeed, 40 is robust for a qualitative study. After 40 PWIDs had been recruited and their interviews reviewed, coded, and analyzed, the team discuss whether there was a need for additional interviews. Given the breadth and depth of the information collected through those 40 interviews as well as redundancy in perspectives on the processes of interest, we concluded that our sample reached saturation with respect to our research questions. Eligibility criteria required that participants be 18 years of age or older, able to communicate in Georgian, and have injected drugs at least once during the six months prior to the study. PWID were recruited through harm reduction services using snowball sampling. In each harm reduction center, initial seeds were recruited and were asked to bring their peers to the study. The participants were especially encouraged to invite female injecting drug users. Experienced interviewers carried out face-to-face in-depth interviews with PWID in a private setting. Participants provided written informed consent for participation in the study. Semi-structured interview guides included open-ended questions and follow-up questions with probes relevant to the PWID experience. Demographic information was collected at the beginning of the interview. Interviews were audio recorded if the respondents granted their permission. Only one respondent refused to be audio-recorded. In this case detailed notes were taken by another data collector. Three members of the research team conducted an initial reading of all the transcripts to identify patterns and initial themes emerging from the data and themes that relate to the conceptual framework. After the initial reading, the research team utilized constant comparison to further develop a coding structure and a detailed code book. Two researchers coded all transcripts using a qualitative software QSR-Nvivo Additional codes that emerged were discussed as they came up and were added to the codebook upon agreement. The complete set of coded transcripts was reviewed by one researcher for discrepancies and inconsistencies. Any differences in the coding were resolved through group discussions, review of the transcripts, and re-coding. Thematic analysis was conducted according to the conceptual framework. In total, 40 current PWID participated in the study. Eight respondents had already completed HCV treatment, ten respondents were currently being treated for HCV, eighteen respondents were not involved in the program of which seven were not aware of their HCV status, and four respondents were on the waiting list for HCV treatment. The study failed to recruit any respondent who initiated and interrupted treatment. Demographic characteristics of the sample are presented in Table 2. The results are structured as follows: we first present facilitators and barriers of the decision to seek treatment and then adherence to treatment. Facilitators and barriers are further categorized by social, structural and individual factors. Findings from the key informants are presented along with those from the PWID. The Hepatitis C Elimination Program received strong political support from its early stages. As mentioned by the key informants, the Program became one of the most frequently cited topics by high government officials in their media appearances. The Program has been considered as one of the successes of Georgia health care system in — This is the same as having a new chance to live because it is a rather expensive program. I am fully aware of how much it costs, what is the price of the flacon of the medicine. I could not afford it. I had already gotten used to the fact that I had an incurable disease before the program was launched. We tolerate everything to bring the treatment course to an end. Many years ago, even during our advocacy efforts, we could not imagine such universal access to expensive medications, which are vitally important and grant patients a higher chance of being cured. All key informants cited that the current treatment regimen has fewer side effects and better treatment outcomes. PWID described other modes of transmission including dental procedures and sexual contact. The participants, including those who were not involved in the program, believed that the disease could be cured, only one PWID thought that the disease is incurable. Harm reduction networks were actively involved in directing patients to treatment sites. The information was also widely spread by peer educators:. The information is transmitted rather quickly by word of mouth, sometimes I say something to a patient and couple of days later some other person comes and repeats my words. They spread this information rather quickly. Respondents from the capital city frequently mentioned the contributions of CSOs in covering diagnostic test expenses. Respondents also admitted that even though they needed to pay some amount for clinical diagnostics and laboratory tests to monitor treatment outcomes, compared to the complete cost of HCV treatment, theirs was a small share. Compared to that, we pay a small portion. It is a minor share we pay, so let nobody say that this is a big amount for the tests. All patients, regardless of their desire and current involvement in HCV Elimination Program, admitted that such support is crucial. One participant who is no longer involved in treatment reported that if his family members had more information on the program and insisted on his treatment, he would probably have sought it. Of the eighteen respondents who were not enrolled in the program, eleven reported that they did not qualify for the program based on the initial enrolment criteria. However, some of the patients did not know about these changes while some of those who knew were still planning to apply for treatment. Additional tests are needed during treatment monitoring which also require patient contributions. As the respondents did not make clear distinctions between financial barriers associated with diagnostic, pre-treatment, and monitoring tests, we present these findings all together in the ability to pay section under the barriers to HCV treatment adherence. The share of co-financing from local governments varied by municipality, resulting in some degree of inequality between residents of different geographic areas. Several cases were identified where patients who did not seek HCV testing stated that they could not afford the costs associated with treatment:. It is not possible for me to start the treatment course now. Geographic barriers were mentioned as an obstacle for the patients living in the Kakheti region, where at the time of data collection, treatment facilities did not exist. This lack of facilities created an additional financial burden to PWID in that region because of associated travel costs to Tbilisi. Others thought that HCV testing is unnecessary because they considered themselves to be at low risk of contracting HCV due to safe injecting practices. At the same time, some admitted that if they were infected then they would seek treatment. I do not have to hurry. I will go there tomorrow; I will go there the day after tomorrow. Some patients expressed low interest in their health and the possibility of treatment. They were more preoccupied with other problems, even though they did not rule out the disease. Some expressed nihilism about the disease and its consequence:. Interestingly, these PWID were in contact with their peers who were under treatment and were aware of the program. Some of them had heard about unsuccessful cases, and were discouraged from initiating treatment. If I go there and they tell me that I have a terrible condition, when I know that I have no health problems, this will cause depression of course. Some participants not yet enrolled in HCV treatment believed that treatment may harm more than cure. Fear of side effects and damage to their liver discouraged them from initiating treatment. I saw some people feeling bad because of Interferon. I used to think I could die because of the treatment. This is fear, fear of death probably. I saw people who were on Interferon. They could hardly stand on their feet, they had fever. Service providers also indicated that there are misconceptions about the side effects of interferon treatment that hamper treatment initiation. Providers describe several cases where patients were reluctant to initiate interferon treatment out of fear of its side effects. These misconceptions are rooted by negative experiences with interferon side effects that are shared among peers. Successful treatment outcomes with the interferon regimen play an important role in reducing these misconceptions. They say it causes falling of hair and teeth. I explain to everyone that this is not the case, and I am an example of this. PWID not currently involved in the program are curious about whether a new generation drugs has been introduced and what will happen to their health if they resume using drugs after HCV treatment; they are eager to learn about treatment outcomes from their peers. All the participants, with the exception of one, did not feel stigmatized as a result of their positive HCV status. Among the participants currently not under treatment, none reported social stigma as a factor preventing them from treatment. Nevertheless, there are cases where participants do not wish to disclose their status and chose to hide it, because HCV is associated with drug injection. Although she did not report any stigmatized attitudes from treatment service providers during the treatment process, making a decision to start treatment was difficult nonetheless. Unless the organization CSO had offered I would not have been able to do that myself. Does it treat patients? Which other side effects does it have? According to the key informants, at the initial stages of the program implementation enrolment of individuals with severe liver damage did not deliver the desired results. Some patients with severe liver disease were not cured or died soon after treatment; news of such cases spread quickly through PWID networks. Moreover, patients and even health workers did not immediately understand why such an expensive program was offered to the Georgian population free of charge and were skeptical about it. Stakeholders believed that the Government needs to spend more time explaining the advantages of the HCV elimination program to the country as well as what motives the pharmaceutical company might have. Key informants identified several challenges that were encountered at the beginning of the program. The program start-up was preceded by an intensive preparatory stage, but doctors were informed that the program was to begin only one week prior to initiation of activities. Training was provided only after the program launched; however, since then doctors have received continuous technical support. Due to very intensive advertisement in media, patients rushed to get treatment and it was difficult to manage the processes. PWID respondents also indicated that such problems were gradually resolved in the process of the program implementation. The MoLHSA was responsive and eager to fix the problems in a timely manner to allow a smooth implementation of the program. Attitude of staff. Eight out of the ten PWID respondents who completed treatment or were in the process of being treated described treatment sites to be safe environments with friendly and responsive staff. Participants pointed out that positive patient-provider relationships promote adherence to treatment. They described how health professionals are an important support in this process. This was a big incentive to me. Waiting times. The patients recalled waiting times at the beginning of the program, with fewer lines now. They would describe 10—15 minutes waiting time in queues. The MoLHSA took steps to reduce the influx of patients to the facilities and started to manage the lines at the central level. Very few participants still mentioned lengthy waiting times during the treatment process; however, this was not considered as a barrier to receive treatment among patients. Pill taking in front of camera. The program protocol requires taking pills in front of a camera in certain cases when there is suspicion that the treatment regime was violated. In most of the cases, patients did not feel concerned about this. There was a threat of incarceration associated with injection drug use; however, participants were confident that the recordings would not be disclosed to the police or the public. Those who were involved in the methadone substitution program felt more relaxed about this feature, as methadone dosing in Georgia is also conducted in front of a camera. Similarly, the service providers confirmed that the patients did not object to taking pills in front of camera. PWID talked about caring and responsive health professionals who were always ready to provide detailed answers to their questions. Doctors provided advice about taking care of themselves during the treatment process and warned about harmful behaviors. Respondents were confident that they were in the hands of qualified professionals and received appropriate care. At the same time, patients who had experience with interferon treatment wished that they had a qualified provider to deal with mental health symptoms e. HCV treatment service does not include consultations with mental health specialists qualified to provide such care. For many patients, family members and friends provide invaluable emotional and practical support during the treatment process. Family members encouraged patients, reminding them to take their prescribed drugs and accompanying them to medical appointments. When you have people who stand by your side you have hope. Not only in this regard. A family member, a spouse, may tell you something that will make you give up treatment, or the opposite, support you and make you think that it is worth to live. Among the barriers to seek and remain in treatment, participants reported financial challenges in covering costs for tests. Apart from the HCV screening test, which is free under the program, a number of additional tests are required for confirmation testing, inclusion in the program, and treatment monitoring. To overcome the financial barriers, some PWID were trying to find ways to be registered as Tbilisi residents. The co-payment was not affordable for some households. Several cases were identified where patients who did not seek HCV testing stated that they could not afford the costs associated with treatment. The problem was more profound for those living far from the cities where treatment sites are located, due to additional transportation costs. I basically mean people from provinces… I came across the cases when some patients could not afford tests and were not able to continue treatment. For some patients, extra expenses before treatment appeared to be much bigger than anticipated. This was mainly for cases when the three months duration of HCV treatment was not sufficient to achieve cure. As reported by key informants, due to financial difficulties, patients did not show up for this final test. This ultimately affected the treatment outcome data and the overall program performance statistics. This came into force at the beginning of the second phase of the elimination program, in mid This was partly due to a budget deficit and partly aimed to reduce inequality between Tbilisi and residents in other cities. One key informant viewed this as a positive, rather than a negative step towards creating motivation to adhere to treatment:. Moreover there was a significant difference between Tbilisi and other city residents which created a lot of complaints. Patients who were treated with interferon experienced the side effects associated with this drug, mainly with the first injections. Common side effects include fever, fatigue, depression, anxiety, panic attacks, and insomnia. Patients were informed in advance by service providers about possible side effects and how to reduce them. However, in some cases, the side effects were more severe than expected, and patients indicated that only receiving information about side effects was not sufficient. Patients expressed fear that they could not tolerate taking this drug again if needed. Some patients refused to initiate treatment with interferon, opting to wait for new drugs before resuming treatment. The MoLHSA representative mentioned that in the few months prior to the interview they encountered cases where patients interrupted treatment and resumed it later. To reduce the likelihood of such cases, the program added a policy to restrict re-enrolment into the program for one year for patients who stopped their treatment before completion of the regimen. Patients were well aware of HCV re-infection risks. They were advised by treatment service providers not to use drugs or to share injecting equipment. Some participants were firm in their decision not to engage in risk behaviors, to adopt a healthy lifestyle, and even to abandon drug injection following completion of treatment. As they continue to inject drugs, respondents admitted to being at risk for reinfection with HCV. They were well aware of the risks associated with non-sterile injecting equipment use; however, in certain circumstances they may still use unsafe injection practices. But generally, of course there is a risk. If it happens again it will be because of our carelessness. This is an unprecedented approach to implementing HCV treatment on such a large scale. Despite notable progress, challenges to achieving targets remain. A major challenge is that Georgia has a high a prevalence of injection drug use; according to a study about 52, adults or 1. To reach the Elimination Program goal, the national strategy outlines activities such as supporting access HCV treatment for PWID as well as promoting harm reduction to reduce disease incidence \\\\\\\\\[ 8 \\\\\\\\\]. Our study provides a better understanding of PWID in the context of seeking and adhering to HCV treatment, which is critical to improving treatment uptake and retention. Factors influencing treatment seeking and adherence include structural, social, and individual factors. In terms of structural factors, political commitment, co-financing of diagnostic and monitoring tests, and friendly clinic environments were key facilitators for the Hepatitis C Elimination Program in Georgia. The study identified some programmatic gaps; however, they were profound largely at the beginning of the program and mostly created operational challenges for service providers, rather than influenced treatment seeking and adherence among patients. The program received substantial political support starting from its launch and remains among the top health sector priorities in the country \\\\\\\\\[ 8 \\\\\\\\\]. The study findings support the suggestion that strong political commitment plays a key role in smooth implementation of the program and its success so far. Other structural factors positively influencing treatment uptake were the roles of TV and harm reduction networks in advertising the program and referring patients to the treatment sites. The success of the campaign at initial stages even created problems due to rapid influx of new patients seeking treatment; however, the program quickly adapted to manage the situation. Many participants described the relatively low cost for medical testing to monitor treatment response. However, the share to be paid by patients created a burden for some individuals, particularly in the provinces. At the time of data collection, local municipalities additionally co-financed monitoring tests for those seeking such financial support. As a result, municipality co-financing was suspended starting in January Further policy changes in and included covering costs for the confirmatory test along with the final testing and HCV genotyping from the program budget. Current patients who are not under the poverty line need to pay about — USD — GEL for pre-treatment, treatment monitoring and post-treatment tests. Whether this structural change has any influence on treatment seeking behavior or on treatment adherence is difficult to judge without further research. Additional financial barriers existed for those who were living in the regions where treatment services were not available. During and , the number sites providing HCV treatment services more than doubled thereby reducing some existing geographical and financial barriers to treatment entry. Individuals who fall under the poverty line and war veterans were totally exempted from co-payments from the beginning of the program. Few of our respondents who qualified for the financial exemptions confirmed that treatment was completely free for them. Our research identified social factors that affected access and adherence to treatment. Under this domain we included family and peer support, stigma, social norms, and other cultural factors. Social support was found to be essential in encouraging PWID to seek treatment and engaging them in treatment until completion, which is in line with the literature that examined the role of social context in treatment uptake and adherence \\\\\\\\\[ 17 \\\\\\\\\]. Family and peer support could help PWID overcome structural barriers and positively influence personal behavior. Peer-to-peer support has been shown to increase treatment adherence \\\\\\\\\[ 18 \\\\\\\\\]. Stigma associated with injection drug use and HCV as a barrier to seek treatment has been documented in the literature \\\\\\\\\[ 20 \\\\\\\\\]. Participants in our study did not mention experiencing stigmatized attitudes from health professionals at HCV treatment sites; however, more generalized stigma due to the association of HCV with injection drug use has been reported. This, along with lower prevalence of injecting drug use among females could be reasons for poor recruitment of female PWID in our study, as well as in other studies related to PWID in Georgia \\\\\\\\\[ 5 , 15 , 19 \\\\\\\\\]. The majority of PWID respondents, as well as key informants and service providers, highly valued the program and admit that the country has received an extraordinary opportunity to benefit from it. The program represents a point of national pride and respondents expressed concern that failure of the program will show the country in a negative light. In general, a wide range of individual, patient-related factors influence the decision to seek treatment and \\\\\\\\\[ 17 , 20 \\\\\\\\\]. At the same time, underscoring of the consequences of the disease, lack of knowledge that HCV can be asymptomatic, false perceptions that they are at low risk to contract the disease once they practice safe injection i. The study showed that HCV drugs side effects may hamper the decision to start and stay in treatment; fear of side effects were mentioned by a few respondents as barriers to seeking treatment and this finding is also corroborated by the bio-behavioral study indicating that about 5. Inadequate management of mental health symptoms associated with HCV treatment was mentioned in our study and may be an obstacle in treatment continuation \\\\\\\\\[ 21 \\\\\\\\\]. However, it is expected that the DAA, already in place in Georgia, will reduce this issue as fewer and less side effects are associated with these medications \\\\\\\\\[ 22 \\\\\\\\\]. The study did not look at other mental health issues. Once the patients are enrolled in treatment, they comply with the treatment regimen for the most part. This is largely supported by a friendly environment in the clinics as well as a responsive and caring staff that is critical to maintain the patients in treatment. The study is in line with the other research indicating that a friendly environment in the clinics, flexible service hours, and professionalism of the staff are important facilitators to treatment adherence \\\\\\\\\[ 18 \\\\\\\\\]. Reinfection after cure could be another threat to the Hepatitis C Elimination Program. A majority of the study participants admitted that they will continue injecting drugs; therefore, the risk to of reinfection is real. The literature suggests that risk of reinfection among PWID was considerably lower than estimates of the risk of primary HCV infection among the same group \\\\\\\\\[ 23 \\\\\\\\\]. Advice on reducing the risk of re-infection will be critical to minimize reinfection rates. This could be effectively delivered by harm reduction programs and peer educators \\\\\\\\\[ 19 \\\\\\\\\]; however, another drawback is the poor uptake of harm reduction services by PWID in Georgia. According to the latest research reports only Our study is subject to several limitations. Although the study attempted to recruit female PWID, we were only able to enroll one female participant. In general recruitment of female PWID is challenging in Georgia due to lower prevalence of drug injection among females compared to males and high levels of stigma towards women who inject drugs leading them to be one of the most hidden subgroups \\\\\\\\\[ 15 , 19 \\\\\\\\\]. The study also failed to enroll the PWID with a history of treatment interruption therefore our sample excludes views of this subset. The respondents in the study were a convenience sample recruited through harm reduction service centers, therefore the findings should not be generalized to the PWID community in the country and other geographic areas. The views of the participants who agreed to participate in the qualitative study might be different from those who were unwilling to participate. Finally, PWID interviews were conducted during a limited time period, while some policy changes took place afterwards and therefore their effects were not captured by the study. Despite these limitations, findings from this study are important for increasing the effectiveness of this unique program that is reaching a critical population at risk infected by HCV. This study provides important insights into the implementation of the Hepatitis C Elimination Program in Georgia and also highlights barriers and facilitators to HCV treatment initiation and completion. Co-financing for clinical diagnostics and laboratory tests is an essential element of the program, particularly for impoverished PWID. Ensuring that this program element is sustained at adequate levels across the country will be an important facilitator of treatment initiation and completion. Despite some challenges the Georgian program is an example for other countries wishing to initiate HCV elimination programs. We thank all the participants who agreed to participate in the study. Special thanks to the Public Union Bemoni for offering technical advice and making data collection from injection drug users possible. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Download: PPT. Table 1. HCV diagnostics, treatment monitoring and post-treatment tests cost sharing. Fig 1. Health service utilization conceptual framework modified Anderson and Newman, Sample and recruitment Prior to the recruitment of PWID we conducted key informant interviews with the individuals who had first-hand knowledge about the Hepatitis C Elimination Program implementation, successes, and challenges. Facilitators of the decision to seek HCV treatment Political support and media campaign structural. Hepatitis C elimination program as a national pride social. Knowledge about the HCV infection individual. Referral to the program and Public Financial support structural. Social support from family and friends social. Barriers for decision to seek HCV treatment Exemption from the program structural. Ability to pay individual. Geographical access structural. Knowledge about HCV, risk perception, and difficulty initiating treatment individual. Fear of test results and treatment individual. Stigma social. Skepticism about effectiveness of the program individual. Programmatic challenges structural. Facilitators of HCV treatment adherence Clinical environment structural. Quality of care structural. Barriers to HCV treatment adherence Ability to pay individual. Side effects individual. Prevention of re-infection Patients were well aware of HCV re-infection risks. Study limitations Our study is subject to several limitations. Conclusion This study provides important insights into the implementation of the Hepatitis C Elimination Program in Georgia and also highlights barriers and facilitators to HCV treatment initiation and completion. Acknowledgments We thank all the participants who agreed to participate in the study. References 1. Infect Agent Cancer. Infectious Agents and Cancer; ; 1—9. View Article Google Scholar 2. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Heal. The Author s. Published by Elsevier Ltd. Prevalence and genotype distribution of hepatitis C virus in Georgia: a nationwide population-based survey. J Hepatol. Elsevier B. View Article Google Scholar 5. Curatio International Foundation, Bemoni P. Sergeenko D. Hepatitis at a national level: government perspectives Dr Shin Young-Soo. Lazarus J V. A systematic review of Hepatitis C virus treatment uptake among people who inject drugs in the European Region. BMC Infect Dis. 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BMC Public Health; ; 1— View Article Google Scholar Harm reduction-based and peer-supported hepatitis C treatment for people who inject drugs in Georgia. Barriers and facilitators of hepatitis C screening among people who inject drugs: a multi-city, mixed-methods study. Harm Reduct J. Barriers to hepatitis C treatment. Liver Int. Medical and behavioral approaches to engage people who inject drugs into care for Hepatitis C Virus infection. Addict Disord their Treat. Aspinall E. Treatment of hepatitis C virus infection among people who inject drugs: uptake and outcome. In: Hepatitis C among drug users in Europe \\\\\\\\\[Internet\\\\\\\\\].