Although previous research has indicated that oral DAAs have a high cure rate over a short duration, have few side effects, and are free, many potential HCV patients still face barriers to viral detection and being referred for DAA treatment [5, 6, 17]. Therefore, the present study aimed to understand the implementation facilitators of and barriers to inviting potentially infected patients to accept transfer to a hospital for HCV RNA confirmation and free DAAs treatment in the western coastal Yunlin County . Three key findings emerged from this study. First, it was an efficient strategy to use the anti-HCV data from the collaborating hospital’s medical records for case-finding and to work with the collaborating hospital and clinics. Second, a nurse-led interdisciplinary collaboration involving five elements of referral and a telephone interview with four points for communication significantly facilitated the transfer of potential CHC patients to a hospital and increased their willingness to undergo DAAs treatment. Third, barriers to being referred to a hospital included a high percentage of patients who were unable to be contacted, the patients’ self-perception of being healthy, mistrust of treatment/healthcare, transportation issues, and work conflict.
Recently, in Australia, Pourmarzi et al.  demonstrated that a key to achieving the HCV elimination goal is the provision of its treatment in community settings, and that the integration and coordination of care and support provided for both patients and healthcare providers are important processes. The present study lends support to Pourmarzi et al. , who reported that successful elements of treatment in community settings include “training and support for healthcare providers, an open referral policy, linkage with or providing outreach services, a person-centered approach, and on-site screening and assessment.” Further, to increase access to treatment for HCV in Australia, White et al.  developed a community-based FibroScan and a nurse-led service to assess patients. All patients had treatment prescribed and monitored in primary care, and a telephone follow-up was conducted to confirm that sustained virologic response (SVR) was performed by a clinic nurse. They found that the community-based model facilitates access to HCV treatment in primary care with excellent SVR rates. In Taiwan, the confirmation of HCV and prescription of DAA still requires specialty physicians. The authors of this study strongly recommend that community nurses or primary healthcare providers initiate an integrative program to increase public awareness and promote the referral system for HCV screening and treatment. For instance, there are 368 district public health centers in Taiwan, each with a mastery of the local population’s annual health screening data. If these public institutions could duplicate the present study protocol—wherein once HCV RNA positivity was confirmed by the public health center, the patient would be persuaded to accept free DAAs treatment for 8 ~ 12 weeks depending on his or her genotype—mobilizing such efforts to actively promote DAAs treatment would be an effective integrative program to eliminate HCV in Taiwan.
Unfortunately, many residents with anti-HCV refused to be referred to a hospital for further confirmation because they perceived themselves to be healthy, and appear to have no uncomfortable symptoms. This finding is similar to that of Cheng et al. , who conducted a study in remote southern Taiwan. They stated that less than half of confirmed HCV-infected residents received adequate medical care. In addition, Treloar and her colleagues  described barriers to HCV care and stigmatization from a social perspective. Previous studies have emphasized the relationship between stigma and adverse health outcomes as well as health access measures. Stigma is a defining factor in HCV treatment, given the association of HCV with the socially demonized practice of injection drug use [16, 21]. Although the present study did not explore the effect of stigma on hospital transfers, it is necessary to comprehensively understand why some people refuse to be referred to a hospital. Nonetheless, when the present researchers approached the residents, some responded that they are worried about the phone scam gang, while others reported having transportation issues or not having enough time because of their need to keep working.
Regarding the barriers of hospital transfer, for rural residents, the hospital is 40–60 km away from the village, and it is particularly difficult for elders to get to without transportation assistance. In addition, it was hard for our research team to reach most patients to notify them because they do not have correct telephone numbers and many residents do not care about DAAs treatment because they feel healthy. Thus, the barriers to being referred to a hospital were clarified. The research team emphasized the communication of the following points to the anti-HCV positive villagers: (1) Since the Taiwanese government fully subsidizes DAAs treatment, patients should seize the opportunity to avail of the free treatment before the annual limit is reached; (2) health is priceless and is the most worthy investment; the sooner you complete your DAAs treatment, the sooner you can rid yourself of the threat of liver cancer; (3) with regard to the 552 patients concerned about adopting the treatment, appropriate health education was given as well as regular reminders to take their medicine; (4) weekly calls were made to remind the patients to return to the hospital for treatment completion; and (5) those who experienced excellent results after undergoing the DAAs treatment were encouraged to promote acceptance of treatment among other patients.
The findings from this study strongly suggest that to achieve the HCV elimination goal of eradicating HCV nationwide, there is a need to make vigorous efforts to enhance screening coverage, educate people about new information relating to liver disease, reduce the barrier of work conflict, and use the media to promote related policy and hospital referrals. The present findings showed a high percentage of invalid or disconnected home telephone numbers (n = 304). This may be due to wrong numbers being included in the medical records provided by the collaborating hospital and clinics. This could also be attributed to the fact that the patients’ health screenings were conducted many years ago, and they changed their telephone numbers in recent years. Therefore, to increase case findings, it is crucial to collect correct information through multiple sources (e.g., ask for help from the district government, or visit village leaders and make home visits).
This study has some limitations that should be noted. First, although the research team encouraged all healthcare providers in the outpatient clinics to survey medical records and refer each anti-HCV patient to the collaborating hospital for HCV confirmation, some medical personnel from the private sector had reservations regarding this approach (e.g., some of them felt that it was not so important). In addition, there were no incentives for primary healthcare providers from public health centers to make transfer referrals. Consequently, this may limit the case findings from rural areas. Second, the high percentage of invalid telephone numbers and failure to answer the telephone limits the referrals and the effectivity of the approach used in the study. Thus, it is necessary to reestablish valid telephone connections via the public and private sectors. Third, Taiwan has launched the NHI system and covers almost all of the Taiwanese population. However, since each item for the antibody test costs less than 7 USD, while each HCV RNA confirmation costs over 70 USD, the government uses two steps to confirm an active HCV infection. This procedure increases the barriers to hospital transfer for HCV RNA confirmation and DAAs treatment of CHC patients. Therefore, we strongly suggest that confirmatory testing (HCV RNA) should be done locally, with referrals for those that are HCV RNA positive.