Contributions to the literature

  • Applies an intersectionality lens to identify barriers and enablers to hepatitis C point-of-care testing among people who inject drugs and service providers.

  • Illuminates the impact of intersecting identities and structures of power on the experiences of individuals accessing hepatitis C testing and care.

  • Highlights the importance of tailored implementation strategies to address stigma, enhance communication skills, and foster inclusive environments for equitable hepatitis C care access.

  • Contributes to the evidence base for employing an intersectionality lens in implementation science to promote more equitable health services.

  • Advances the global health agenda towards the elimination of hepatitis C as a public health threat.

Background

Hepatitis C virus (HCV) infection poses a significant global health burden, particularly among people who inject drugs [1]. Globally, it is estimated that 14·8 million people inject drugs [2]. In high-income countries, up to 85% of new HCV infections occur in this population due to the shared use of contaminated needles and drug paraphernalia [1, 3]. The consequences of HCV infection include the development of liver disease, cirrhosis, cancer, and the potential need for transplantation [4,5,6]. Chronic HCV infection is also associated with significant physical and psychological burdens on affected individuals [7]. Physical health consequences can include chronic fatigue and increased susceptibility to opportunistic infections, impacting quality of life [8]. Psychologically, the stigma associated with HCV can lead to feelings of isolation and depression, further affecting mental health [9]. These burdens can strain relationships, hinder employment opportunities due to frequent medical appointments and reduced productivity, and ultimately diminish overall wellbeing [10].

Although no effective vaccine currently exists, the advent of highly-effective direct-acting antivirals with cure rates > 95% provide an opportunity to eliminate HCV globally [11,12,13]. In light of these therapeutic advances, the World Health Organization (WHO) has called for the elimination of HCV infection as a public health threat by 2030 [14, 15]. A major barrier to increasing uptake of HCV testing and treatment is that the current diagnostic pathway requires multiple visits (an HCV antibody test to confirm exposure, an HCV ribonucleic acid (RNA) test to confirm current infection, and one or more assessments to start treatment) leading to loss to follow-up and delays in treatment, which is exacerbated in higher risk groups [16]. Higher risk groups often face additional challenges such as unstable housing, substance use, and limited access to healthcare, making it difficult to comply with multiple visits [14]. Increasing access to testing and simplifying the diagnostic pathway will be critical steps towards achieving the WHO’s goal of eliminating HCV on a global scale [14].

The introduction of finger-stick tests capable of detecting HCV antibodies (results: 5–20 min) and HCV RNA (results: 60 min) at the point of care has revolutionized the clinical approach to HCV [17,18,19,20,21,22,23]. Point-of-care tests can be used by community workers and nurses, enable diagnosis and treatment in a single visit, increase testing acceptability, and reduce loss to follow-up [19,20,21,22,23]. Research has demonstrated reduced time to treatment initiation and high treatment uptake compared to standard diagnostic approaches [17, 18, 23,24,25,26], informing recommendations in the 2022 WHO guidelines on simplified service delivery and diagnostics for HCV infection [27]. The impact of point-of-care testing will be greatest in high HCV prevalence settings, such as needle and syringe programs who provide access to sterile injecting equipment [28, 29]. Harm reduction programs are critical intervention points because they provide services to people who inject drugs, a group that experiences higher rates of HCV due to practices such as needle sharing [28, 29]. However, there are numerous implementation challenges, including the revision of professional roles, training, quality assurance and integration of point-of-care tests into laboratory and public health surveillance frameworks [30,31,32]. A systematic, implementation science approach [33, 34] is essential to comprehensively identify factors that will limit or enable point-of-care HCV testing in community-based harm reduction organizations such as needle and syringe programs.

The traditional application of implementation science frameworks may overlook unique challenges faced by equity-denied groups, such as people who inject drugs, and the dynamics within settings serving these individuals [35,36,37,38]. People who inject drugs face stigma and discrimination which shape their interactions with healthcare systems, and access to care [2, 39, 40]. Recent shifts towards equity-focused implementation science underscore the importance of acknowledging and addressing these unique challenges to enhance health outcomes for all [35, 41,42,43]. The use of an equity-focused theoretical lens can complement determinant frameworks such as the Theoretical Domains Framework (TDF) by providing a deeper understanding of how intersecting social identities and structural inequities influence individuals' behaviors and attitudes, enriching the analysis of barriers and enablers to behavior change in healthcare settings [38, 42, 44, 45]. By considering the complex interplay of intersecting identities and structures of power within society (e.g., racism, classism, drug policy, stigmatization of HCV infection), an intersectionality lens has the potential to provide a more nuanced perspective on the factors influencing the implementation of point-of-care HCV testing within needle and syringe programs [46,47,48].

Objective and research questions

This study aimed to use an intersectionality lens to explore the theory-informed barriers and enablers to point-of-care HCV antibody and RNA testing in a needle and syringe program in Montreal, Canada. We sought to answer the following research questions:

  1. 1.

    What are the barriers and enablers to point-of-care HCV testing in needle and syringe programs from the perspective of people who inject drugs and service providers?

  2. 2.

    How does social identity and structures of power related to the healthcare system and society intersect with and influence these barriers and enablers?

Methods

Study design and guiding framework

A theory-informed qualitative study was conducted using semi-structured interviews. As presented in Fig. 1, we adapted methodological guidance from different sources [45, 49,50,51,52] to apply an intersectionality lens across the different phases of the study. Intersectionality is an analytical framework rooted in critical social theory developed by black feminist and critical race scholars in the 1980s [53]. It recognizes that individuals possess multiple, intersecting identities that are influenced by power structures and social hierarchies [54]. Our approach aimed to determine how barriers and enablers to implementation of point-of-care testing were shaped by social identity factors in people who inject drugs and service providers, as well as structures of power (e.g., racism, classism, transphobia) related to the healthcare system and society. The Research Ethics Boards of the Centre Hospitalier de l’Université de Montréal (#21.197) and the Ottawa Health Science Network (#20,210,655-01H) approved the study.

Fig. 1
figure 1

Using an intersectionality lens in implementation research

Full size image

We first identified research questions that were sensitive to intersectional perspectives. Next, we selected the intersectionality-enhanced TDF to guide data collection, including the development of an interview guide [55]. The TDF identifies 14 theoretical domains that influence behavior: (1) Knowledge; (2) Skills; (3) Social/professional role and identity; (4) Beliefs about capabilities; (5) Optimism; (6) Beliefs about consequences; (7) Reinforcement; (8) Intentions; (9) Goals; (10) Memory, attention and decision processes; (11) Environmental context and resources; (12) Social influences; (13) Emotions; and (14) Behavioral regulation [55]. Each theoretical domain may be an influencing factor (i.e., barrier or enabler) of the implementation of point-of-care HCV testing. These factors can then be targeted by implementation strategies and behavior change techniques suited to the influencing factor [56, 57]. The intersectionality-enhanced TDF [45] includes additional prompts that can be used to explore how social identity and structures of power intersect with the 14 domains. Our interview guide used some of these intersectionality prompts, which were modified to make them more naturalistic during the interviews. During interviews, in addition to TDF and intersectionality questions, we collected life-story narratives to better understand how individuals construct their identities based on various social categories [50]. Data analysis and interpretation were conducted using an intersectionality lens, recognizing the interconnected nature of various social structures and identities. Identity was seen as a narrative through which individuals both play the lead role and write the script, drawing upon different categories such as gender, class, and ethnicity.

Setting and context

The study was conducted at CACTUS Montréal, a large urban community organization focused on harm reduction and prevention of sexually transmitted and blood-borne infections (STBBIs) among people who use drugs, sex workers, and transgender communities (https://cactusmontreal.org/en/). Established in 1989, it pioneered North America’s first needle and syringe program and employed more than 80 individuals at the time of the study. It is co-located with the largest supervised consumption site in the province of Quebec. Over the course of 2020–21, 70,939 individuals visited the organization through different programs such as the needle and syringe programs at two different sites, the youth program, and the social involvement program.

Sample and recruitment

The sample for this study was composed of two groups: clients (people who inject drugs) and service providers. For clients, adult French- or English-speaking individuals with a recent visit (< 3 months) to the needle and syringe program and with a recent history (< 3 months) of injection drug use were eligible to participate. Individuals reporting a cognitive impairment or a health condition that might impede participation in this study were not eligible. For service providers, adult French- or English-speaking individuals working at CACTUS Montréal as peer workers, prevention officers, street workers or program coordinators. We used a modified version of the 10 + 3 decision rule to achieve an adequate sample for content validity, whereby we conducted 10 initial interviews followed by an additional two to three interviews until no new themes were identified [58]. We anticipated that 10 to 15 interviews per group (20 to 30 interviews total) would be sufficient. We used purposive sampling, aiming to include at least 30% of individuals identifying as women.

Identification of potential participants was conducted by CACTUS program coordinators and other staff members. A researcher (GF) was present onsite one to two days per week to describe the study, share posters containing a plain language explanation of the study and confirm the eligibility of individuals identified by CACTUS coordinators and staff. After confirming eligibility, we provided the informed consent form and obtained their signed consent.

To accommodate participant preferences, we scheduled individual in-person interviews at a suitable time in a dedicated private meeting room at the needle and syringe program, or via Zoom. The interviews were conducted by GF, a bilingual white male nurse who identifies as a member of the LGBTQ + community. At the time of the study, he was a postdoctoral researcher with expertise in qualitative research and was affiliated with the Ottawa Hospital Research Institute, but had no prior connections to the study setting. For people who inject drugs, this interview was the second of a series of two interviews focusing on HCV infection [59]. The first interview explored perceptions of HCV infection, while the second one explored barriers and enablers to testing. For service providers, no relationship had been established prior to the interviews. Each client and service provider received a compensation of $30 CAD upon the completion of the interview.

Data analysis

A comprehensive coding manual was developed, incorporating standard intersectionality-enhanced TDF definitions, related theoretical constructs and decision rules to ensure consistency in coding. Each interview transcript was independently double coded using directed content analysis to categorize statements into domains of the intersectionality-enhanced TDF in NVivo (https://lumivero.com/products/nvivo/, version 12) by two researchers (GF, CE, IT, AK, ZvA, or CJHH). Any discrepancies were resolved through a consensus-building process. Representative themes were inductively developed to contextualize barriers and enablers to point-of-care HCV testing. The significance of key domains was assessed based on the strength of participants' beliefs within each domain, as well as their frequency and consistency across the data. The frequency metric indicated the number of participants contributing to a specific belief statement within each intersectionality-enhanced TDF domain. The data were analyzed with careful attention to language that may reveal social identity factors, power relations or social dynamics. Overarching themes were developed using thematic analysis, and the intersections between barriers, enablers, and themes were also analyzed. We used OpenAI’s ChatGPT 4 (https://chat.openai.com/chat) to enhance the coherence and readability of specific sections of the manuscript, as well as for proofreading purposes.

Results

Sample characteristics

Between October 29, 2021, and March 10, 2022, a total of 27 individuals were interviewed, including 15 clients and 12 providers. The characteristics of participants are presented in Table 1. Most clients were 40 years or older, 10 self-identified as men, and 13 self-identified as white. Stable housing was reported in only three participants. Self-reported drugs injected in the past three months included opioids (9/15), stimulants (3/15), and both opioids and stimulants (3/15). Twelve participants self-reported one or more past HCV infection(s). Of those, seven were treated with direct-acting antivirals, four were spontaneously cleared, and three were treated with interferon-based therapies. Most service providers were aged between 18 and 39 years old. Seven self-identified as female, and all self-identified as white. They held various positions, with half being prevention officers, and the rest distributed as program coordinators and street workers. Providers had a median work experience of 61.5 months at the current organization. All interviews were conducted in French. Interviews with clients had a median duration of 33.25 min, whereas interviews with providers had a median duration of 71.5 min. While the interview guide was of a similar length for both clients and providers, providers offered more detailed and extensive responses, resulting in longer interview durations. This discrepancy could also be attributable to the fact that some clients collected needles and syringes and were keen to leave quickly to use them. Providers did not have protected time to participate in the interviews and participated when possible during their day.

Table 1 Sociodemographic characteristics of participants (N = 27)
Full size table

TDF domains and overarching themes in clients

In clients, our analysis identified that eight TDF domains (Knowledge; Social/professional role and identity; Beliefs about capabilities; Beliefs about consequences; Reinforcement; Environmental context and resources; Social influences; Emotion) were relevant for understanding barriers and enablers to implementing point-of-care HCV testing. These domains are highlighted in this paper in italics and parenthesis adjacent to relevant findings. Themes, subthemes, belief statements, sample quotes and key domains are presented in Table 2. Domain-specific barriers and enablers were synthesized into four overarching themes: (1) the understanding and perceptions of the HCV testing process, (2) the role of an accessible and inclusive environment in HCV testing, (3) the interplay of emotions and motivations in HCV testing decision-making, and (4) the impact of intersectional stigma related to drug use, identities, and HCV (see Fig. 2).

Table 2 TDF themes, belief statements and sample quotes linked to relevant TDF domains in clients
Full size table
Fig. 2
figure 2

Overarching themes in clients and service providers influencing the implementation of hepatitis C virus (HCV) testing. The themes in red represent the primary themes emerging from the intersectional analysis, and the arrows represent their interrelations with other themes

Full size image

Theme 1: Understanding and perceptions of the HCV testing process

Most participants had a good foundational understanding of the HCV testing procedure, but knowledge gaps persisted among many about what exactly the HCV test screens for, such as antibodies or RNA (Knowledge). Many had concerns about elements of the traditional testing process, such as the need for venepuncture and the lengthy wait times for results, which can discourage individuals from pursuing testing (Beliefs about capabilities, Beliefs about consequences). Finger stick point-of-care HCV tests were perceived as enablers due to their simplicity and quickness (Beliefs about capabilities), suggesting a shift towards these testing methods could enhance the uptake of HCV testing.

Theme 2: Role of an accessible and inclusive environment in HCV testing

Most expressed that they ‘feel at home’ at the needle and syringe program, which would serve as a strong enabler, facilitating the decision to undergo HCV testing (Environmental context and resources; Beliefs about capabilities). The convenience of integrating testing with their routine activities and daily life would simplify the decision to get tested (Beliefs about capabilities). Moreover, the trustworthiness and competence of service providers have a positive impact, instilling confidence (Social influences).

Theme 3: Interplay of emotions and motivations in HCV testing decision-making

Emotional barriers to HCV testing were prominent, with increased anxiety cited as a common response when individuals perceive themselves at risk due to past behaviors (Emotion). This emotional response can also be present when individuals face the prospect of testing for the first time, marked by significant stress and concern over the unfamiliar process (Emotion). The necessity of venipuncture for RNA testing introduces an additional layer of fear and can act as a barrier due to the discomfort and invasiveness associated with blood draws (Beliefs about consequences; Emotion). Motivating factors were the assurance and peace of mind that come from a negative test result (Beliefs about consequences) and the ability to take proactive steps towards health and treatment if positive (Beliefs about consequences). Monetary incentives for testing and obtaining results were highly valued, acting as a practical reinforcement that can sway the decision to get tested (Reinforcement). Not all clients of the needle and syringe program received monetary incentives for HCV testing. Monetary incentives of variable amounts ($10–20$) were not provided routinely but were given in the context of ongoing research projects for getting Ab/RNA tested, and sometimes when the client came back to get the results of the test(s). Lastly, the motive of preventing transmission to others reinforced the personal and social benefits of getting tested, contributing to a positive emotional outlook (Beliefs about consequences; Emotion).

Theme 4: Intersectional stigma related to HCV, behaviours, and identities

In examining the narratives of clients concerning HCV testing with an intersectionality lens, a recurring theme across all domains is the profound impact of stigma. This stigma is multifaceted, or intersectional, manifesting not only in relation to the health condition itself (i.e., HCV) but also intersecting with stigma related to behaviours such as drug use, and identities, such as ethnicity, gender identity and socioeconomic status. An HCV + diagnosis is associated with the fear of stigma; however, many recognize that knowing their HCV status is a necessary step to access treatment, which can ultimately reduce self-stigma and lead to greater acceptance in their social circles (Social influences; Social/professional role and identity). Stigma associated with drug use has led to judgment and discrimination from healthcare providers and society, affecting trust in and access to healthcare services. Some reported that the testing and treatment procedure itself is stigmatizing, given that it often requires extensive information about one’s lifestyle and substance use.

An environment free from identity-based discrimination is perceived as crucial for point-of-care HCV testing, as it communicates an ethos of inclusivity and respect, encouraging individuals to engage with HCV testing services without fear of judgment (Environmental context and resources; Social/professional role and identity). Women, particularly those with non-normative appearances or from queer or trans identities, discussed having experienced gender-based discrimination, affecting their social status and access to healthcare. While many expressed that the needle and syringe program is an inclusive environment with trustworthy providers, some women do not feel welcome due to male-dominated gender dynamics at play, further limiting their access to essential health services and support. Accessibility and inclusivity were more frequently discussed by individuals who were more visibly marginalized compared to those who identified as cisgender, male, and white.

Across all participants, the upbringing and life background reveal some similarities that further illuminate the theme of intersectional stigma. Many participants have experienced significant life challenges, including homelessness, legal issues, and mental health struggles. These challenges often stemmed from or were exacerbated by their early life experiences, such as family dynamics or traumatic events. A common theme is the use of drugs as a form of escape or coping mechanism for dealing with personal difficulties or trauma. Participants often emphasized the importance of community organizations for social interaction, support, and access to health services. These organizations provide a sense of belonging and acceptance that is crucial for their well-being. Despite their struggles, many express a desire for autonomy and take proactive steps to manage their health, including getting tested for HCV. They also demonstrate a sense of responsibility for their health and the well-being of others.

As presented in Fig. 2 and the interrelation of the themes demonstrated by the arrows, this intersectional stigma can compound various barriers related to accessing HCV care. The understanding and perceptions of HCV testing (Theme 1) are influenced by the stigma associated with HCV and drug use, which can exacerbate knowledge gaps and fears about the testing process. Individuals might be hesitant to seek testing due to the stigma of being labeled as a drug user or having HCV, and the traditional testing process, which involves questioning about drug use and lifestyle, can feel invasive and judgmental, further deterring individuals from getting tested. The perception of the accessibility and inclusiveness of the testing environment (Theme 2) is also impacted, as stigma can significantly impact how comfortable and welcome individuals feel in environments. For example, as described previously, women may feel unwelcome in male-dominated settings, affecting their willingness to access testing services. The interplay of emotions and motivations in HCV testing decision-making (Theme 3) is also intertwined with stigma. Emotional barriers to HCV testing, such as anxiety and fear, can be heightened by anticipating stigma related to an HCV + status, deterring individuals from getting tested. Addressing intersectional stigma is therefore crucial for improving the HCV testing experience and ensuring that individuals from diverse backgrounds feel supported and empowered to access testing and care.

TDF domains and overarching themes in service providers

In service providers, our analysis showed that 10 TDF domains (Knowledge; Skills; Social/professional role and identity; Beliefs about capabilities; Beliefs about consequences; Goals; Environmental context and resources; Social influences; Emotion; Behavioural regulation) were relevant for understanding and addressing barriers and enablers to implementing HCV point-of-care testing. Themes, subthemes, belief statements, sample quotes and key domains are presented in Table 3. Domain-specific barriers and enablers were synthesized into five overarching themes: (1) the knowledge, skills and confidence for effective HCV testing and counseling, (2) the definition of professional roles and their intersection with social identity and lived experience, (3) the availability of resources and integration of services in HCV care, (4) the social and emotional influences on HCV testing, and (5) behavioral regulation and incentives for HCV testing (see Fig. 2).

Table 3 TDF themes, belief statements and sample quotes linked to relevant TDF domains in service providers
Full size table

Theme 1: Knowledge, skills, and confidence for effective HCV testing and counseling

Most service providers believed that offering HCV testing and treatment would enhance the health and quality of life of individuals, and many highlighted broader benefits such as HCV elimination and economic benefits (Knowledge; Beliefs about Consequences). Providers recognized the importance of understanding antibody and RNA testing to accurately explain these tests to clients (Knowledge). The lack of skills to effectively provide HCV testing was identified as a major barrier (Beliefs about capabilities; Skills). Possessing good problem-solving skills, and effective pre- and post-test counseling skills were seen as enablers, contributing to the engagement of individuals in care and the empathetic delivery of test results. The importance of empathy, relational skills, motivational skills, and communication skills in developing trust and positively framing HCV testing was also emphasized (Skills). Consequently, many identified a need for practical training and training focused on ethnoculturally sensitive approaches and inclusive practices for effectively engaging transgender, intersex or queer individuals, and people with disabilities, in testing.

Theme 2: Definition of professional roles and intersection with social identity and lived experience

While some perceived that offering HCV testing is not a clear component of their job description, most agreed that the prevention and treatment of STBBIs, including HCV, was a priority and integral to their professional role (Social/Professional Role and Identity; Goals). However, most highlighted the need for redefinition of professional roles and task sharing to allow non-healthcare providers to play a bigger role in providing HCV testing. Importantly, most providers highlighted how crucial it is to leverage their social identity and lived experience in intervening with clients (Social/Professional Role and Identity). Providers often leveraged their own identities, for instance as members of the queer or transgender communities, and lived experiences, such as personal histories of drug use, homelessness, or HCV infection, to enhance communication and relate more authentically with clients, integrating their professional role with their social identity (Social/Professional Role and Identity).

Theme 3: Resource availability and service integration in HCV care

Many providers pointed out that, although nurses were available at a supervised injection site near the needle and syringe program to conduct HCV testing, the absence of dedicated or permanent healthcare providers directly on-site at the needle and syringe program was a significant barrier to testing (Environmental context and resources). Additionally, the shortage of staff and high turnover rates were identified as obstacles, leading to the need for continuous training and resulting in a loss of expertise in HCV care. Another major barrier was the absence of finger stick rapid antibody and RNA point-of-care HCV testing, which were described as crucial interventions to minimize loss to follow-up and ensure immediate linkage to care (Environmental context and resources). Many highlighted that without finger stick point-of-care tests, individuals may not receive timely results, increasing the likelihood of disengagement from care and reducing the chances of successful treatment and management of HCV. A key enabler was easy communication with and favorable influence of managers within the organization (Environmental context and resources; Social influences).

Theme 4: Social and emotional influences on HCV testing

Service providers emphasized the significant role of social and emotional factors in HCV testing. The trust and rapport built between providers and clients were identified as crucial enablers, fostering a conducive environment for discussing HCV testing (Social influences). However, concerns were raised about the potential negative impacts on these relationships if HCV testing is perceived as intrusive or judgmental (Social influences). Engaging clients in HCV testing discussions was highlighted as challenging, particularly due to the transient nature of some clients' lives, such as those experiencing homelessness or incarceration. Providers stressed the importance of peer support and positive influences within the client community to encourage testing uptake (Beliefs about capability; Social influences). The emotional and psychological impacts on providers themselves were also noted, particularly when delivering positive HCV diagnoses. Providers expressed a need for support and strategies to manage the emotional burden associated with this aspect of their work (Emotion).

Theme 5: Behavioral regulation and incentives for HCV testing

Service providers highlighted the importance of behavioral regulation strategies and incentives to promote HCV testing. Having a network of contacts for HCV testing and linkage to care was identified as an enabler, facilitating referrals and collaboration between different healthcare providers and services (Behavioural regulation). Financial incentives for clients to get screened, receive their results, and engage in care were seen as effective motivators. Providers noted that such incentives could increase testing uptake and ultimately be cost-effective for the healthcare system. Bundling HCV testing with other interventions addressing clients’ needs was recognized as a practical approach. Providers also mentioned using rewards or tangible items, such as hygiene kits or coffee vouchers, to promote screening. These small incentives were seen as helpful tools to initiate conversations about HCV testing and encourage participation (Behavioural regulation). Finally, providers emphasized the importance of seizing opportunities when clients present with healthcare needs, such as abscesses, to offer HCV testing. By linking testing to immediate health concerns, providers could frame HCV testing as a routine part of healthcare rather than an isolated or stigmatized procedure (Behavioural regulation).

As presented in Fig. 2, Theme 2 intersects with other themes, particularly Themes 1 and 4. The social identity and lived experience of service providers informs the knowledge and skills necessary for effective communication about HCV testing and counseling (Theme 1). Social identity and lived experience represent active components of their professional practice and enhance their skills and ability to deliver empathetic care and build trust. Their identity and lived experiences also provide them with unique insights into the social and emotional challenges faced by clients (Theme 4). This allows them to tailor their HCV testing interventions to account for the social and emotional dynamics at play. For instance, a provider who has experienced homelessness may better understand the challenges faced by a client without stable housing and can adjust their approach accordingly.

Discussion

In this qualitative study, we applied an intersectionality lens alongside the TDF to investigate barriers and enablers to the implementation of point-of-care HCV testing in needle and syringe programs from the perspectives of people who inject drugs and service providers. The intersectional approach allowed for a nuanced understanding of how intersecting social identities and structures of power influence the implementation process. This understanding helped to identify how these factors compound key barriers or enhance enablers. The findings revealed four overarching themes for people who inject drugs and five for service providers. These themes not only illuminate the intricate dynamics at play but also point to a substantial window of opportunity for enhancing HCV testing and care, provided that tailored implementation strategies are employed to address the identified barriers and leverage the enablers.

Our findings indicate that people who inject drugs perceive the traditional testing process as a significant barrier to HCV testing and treatment uptake due to the need for venipuncture and lengthy wait times, aligning with existing literature [19, 60,61,62,63]. In contrast, the simplicity and rapid results of finger stick point-of-care antibody and RNA HCV tests are viewed as enablers [19, 60,61,62,63]. Also aligning with previous research in Australia is the perception of the needle and syringe program as an ideal environment to access HCV testing, with most individuals feeling at home, trusting service providers, and highlighting that it would align with their activities of daily living [16, 62, 64, 65]. Our study expands current knowledge on the intersectional stigma faced by people who inject drugs in traditional healthcare settings, correctional settings and society [59, 66,67,68,69,70,71,72], and how this stigma can compound key barriers related to accessing HCV care. The application of an intersectionality lens offers a nuanced understanding of how multiple facets of stigma related to HCV, behaviors, and identities intersect in the lives of people who inject drugs, leading to cycles of internalization and reinforcement by healthcare teams and the public. As a result, several barriers to HCV testing are exacerbated, including emotional barriers (e.g., heightened anxiety and fear linked to testing), access barriers (e.g., avoidance of traditional healthcare settings) and informational barriers (e.g., misconceptions and lack of knowledge about HCV, testing and treatment). Addressing intersectional stigma is therefore crucial for improving the HCV testing experience and ensuring that individuals from diverse backgrounds feel supported and empowered to access testing and care.

Providers expressed a lack of knowledge about HCV testing, particularly regarding rapid point-of-care antibody and RNA tests, highlighting the need for thorough theoretical and practical training. This is consistent with the general practice of providing extensive training to providers for administering point-of-care antibody and RNA HCV tests [18, 24, 73]. Additionally, there was a notable emphasis on the importance of training in pre- and post-test counseling to ensure comprehensive care. As in previous research [74], the need for task-shifting and redefinition of professional roles was evident, as most service providers have little to no autonomy in administering HCV tests and rely on nurses or other healthcare professionals for this task. Intersectionality considerations were also important for providers, who described extensively how their social identity and lived experience intersects with their professional role. Many mentioned leveraging their lived experience of HCV, drug use or homelessness to relate more authentically with clients and enhance the effectiveness of HCV testing interventions.

The findings highlight several key areas for enhancing service delivery in needle and syringe programs, along with potential implementation strategies to support the uptake of point-of-care HCV testing. Notable strategies include enhancing education and awareness of HCV testing among people who inject drugs, potentially through educational meetings and materials that explain the testing process—including the distinctions between antibody and RNA testing—and that emphasize the benefits of point-of-care tests through stories and testimonials. Offering financial or material incentives to individuals who get tested, receive their results, and are linked to care appears to be critical. Equally essential is fostering inclusive and comfortable environments that cater to the diverse needs of people who inject drugs and providing comprehensive training for providers, including stigma reduction to create a non-judgmental and supportive environment and tailored approaches to engage women and transgender individuals in HCV care. Employing service providers with personal experience of HCV or drug use, with different social identities, and favoring peer-based approaches could enhance the trust and comfort levels of those considering testing. The integration of services is vital, creating pathways that seamlessly incorporate HCV testing with other services offered by the organization and establishing partnerships with other healthcare providers to facilitate referrals and comprehensive care [24, 73, 75].

Incorporating an intersectionality lens into implementation science is an emerging practice [36, 42, 45]. While the field has developed robust methodologies for addressing implementation challenges, there is an increasing consensus on the necessity of equity-focused approaches [35, 38, 41,42,43, 76, 77]. Our study contributes to this body of evidence by showcasing the application of an intersectionality lens throughout various phases of the implementation research process—from identifying relevant research questions to employing a multilayered approach to data analysis and interpretation. This approach demonstrates how to consider intersecting identities and experiences in the research process. The use of intersectionality should be complemented by community-based participatory research approaches [78] for the co-design of implementation strategies, enabling a deeper understanding of the nuanced realities of marginalized populations and the complex dynamics of real-world settings.

Our study has some limitations. First, the research was conducted within a single, relatively well-resourced urban community organization, which may affect the generalizability of the findings to other needle and syringe programs or harm reduction settings, both within urban areas and more broadly in rural or less-resourced settings. Second, as with any qualitative research, the themes and insights derived are interpretive, and the analysis is influenced by the researchers’ biases and perspectives, which may introduce confirmation bias or overlook other relevant themes. Third, while employing an intersectionality lens provides a comprehensive framework for analyzing the influence of overlapping social identities and systemic structures, it also adds complexity to data interpretation. There is a risk that some intersecting factors, particularly more subtle or less recognized forms of discrimination and privilege, may not have been fully captured or articulated by the participants, potentially leading to an incomplete analysis of how intersectionality influences point-of-care HCV testing. There is a need for future studies conducted with larger sample sizes, to ensure a more complete representation of different identity groups. Furthermore, the approach applied in this study should be refined and not considered a one-size-fits-all solution. It should be tailored to different contexts and populations to better address their unique needs and challenges.

Conclusions

In this study, applying an intersectionality lens provided detailed insights into the barriers and enablers influencing the uptake of point-of-care HCV testing within needle and syringe programs. The results demonstrate how various forms of stigma associated with HCV, substance use, and overlapping social factors such as gender, ethnicity, and socioeconomic status significantly affect access to care for people who inject drugs. These insights highlight the urgent need for tailored strategies that effectively address stigma, enhance communication skills among providers, and cultivate an inclusive environment that supports equitable access to HCV care. This study contributes to the growing recognition of intersectionality as a valuable tool in equity-focused implementation research.