Peer-led recruitment improves hepatitis C screening in people who use drugs

A peer-led recruitment strategy proved highly successful in engaging people who use drugs in testing and treatment for hepatitis C in the French city of Montpellier, researchers from the University of Montpellier report in the journal Open Forum Infectious Diseases.

They say their strategy has the potential to engage people who use drugs who are harder to reach and not in touch with drugs services or physicians. The peer recruitment strategy reached approximately one-third of people who use drugs in Montpellier within three months and identified 49 people eligible for hepatitis C treatment.

Hepatitis C treatment is just as effective in people who use drugs as in other people with hepatitis C, but lack of engagement with medical services has proved a barrier to hepatitis C elimination in people who use drugs.

The French study was designed to investigate the use of peer-led recruitment for testing and treatment. Peer-led recruitment may build trust in healthcare interventions and reach people who would otherwise be overlooked for the offer of testing.

The study was open to anyone who had used drugs apart from cannabis in the past three days and did so at least ten times a month. Recruitment was not restricted to opiate users.

Study recruitment began by identifying 15 people who use drugs with distinctive non-overlapping characteristics, including gender, age, sex work, drug-using and sexual behaviours and district of residence. To be recruited as a study ‘seed’, participants were required to have a network of at least five people who use drugs. Each ‘seed’ was given three tokens to distribute to other drug users and those who received the tokens were required to present them at the study site to receive free testing and counselling. After joining the study, the new participants were each given three tokens to distribute to their own contacts.

Study ‘seeds’ and participants received 20 euros for each token returned and also received 50 euros to cover travel costs and time spent at the study site.

Study participants attended for testing and counselling at a study site located near the university hospital. Study participants gave a urine sample to check for recent drug use and then gave blood samples for HIV, hepatitis B and hepatitis C rapid antibody tests. Anyone who tested positive for HCV antibodies underwent onsite HCV viral load testing and Fibroscan evaluation for liver fibrosis.

Those diagnosed with chronic hepatitis C were able to discuss treatment with an on-site physician, receive a prescription and be accompanied to a pharmacy by a peer volunteer to pick up their medication. It was not possible to deliver medication onsite under French law. People lacking health insurance received assistance from a social worker to obtain coverage before they could start treatment.

The study recruited 634 potential participants in a three-month period in late 2020, of which 554 were eligible to participate. Most participants were male (78%) with a median age of 39. Sixty-two per cent were living on social benefits. Thirty-two per cent tested positive for hepatitis C antibodies and 49 had detectable hepatitis RNA (8.8%) and were eligible for treatment.

Thirty-seven people started treatment, 30 completed treatment and 27 (73%) had a sustained virologic response 12 weeks after completing treatment. Of those who did not have a sustained virologic response, one was lost to follow-up. Sixty per cent of those who were treated did not start treatment during the survey period, but all except one were treated within six months of diagnosis.

Based on previous research into the size of Montpellier’s drug-using population, the study investigators estimate that the intervention reached one-third of the city’s drug users in three months. They say that the respondent-driven sampling method they used for recruitment is probably more effective than peer outreach because it has the potential to reach a wider range of networks.

Economic analysis showed that it cost 1816 euros to reach each person with chronic hepatitis C and 33,878 euros per cured patient.