Conditional cash transfers – giving money to encourage use
of services – may be needed to reach drug users for hepatitis C testing and
treatment if they are either unaware of hepatitis C or do not see it as a risk
or a priority, French researchers argue in the Harm Reduction Journal.
As a result of a respondent-driven sampling originally
designed to improve services for people who use drugs in the Strasbourg region
of France, the researchers concluded that efforts to achieve universal
screening and treatment of drug users for hepatitis C virus (HCV) are destined to fail without the
use of conditional cash transfers to encourage engagement with services that
provided testing and treatment for HCV.
Respondent-driven sampling has been used extensively as a
research tool. Respondents are incentivised to recruit others from their social
network and the technique enables researchers to reach people who might not be
engaged with existing services or who have become disengaged from health care.
Conditional cash transfers have been used extensively as
incentives to encourage health-seeking behaviours or educational attendance, as
well as poverty reduction. A
Cochrane Collaboration systematic review published in 2009 concluded that
studies of conditional transfers appeared to be an effective way to encourage
the uptake of preventive services. Subsequent studies have shown that cash
transfers were associated with a reduction in HIV risk behaviours in adolescents,
improved uptake of HIV prevention services such as medical circumcision, and
improved adherence to HIV treatment.
But in the field of viral hepatitis, there has been little
research to investigate the impact of cash transfers, except for studies investigating
the impact of conditional cash transfers on the uptake of hepatitis B
vaccination in people who inject drugs, and on adherence to child immunisation
schedules that include infant hepatitis B vaccination.
Although the French study was not an investigation of
conditional cash transfers, the investigators think that their findings reveal
the importance of using conditional cash transfers or other incentives to reach
drug users who may otherwise not consider themselves to be at risk of hepatitis
C or who may have little knowledge of hepatitis C or recent advances in its
The study set out to recruit 300 drug users by
respondent-driven sampling in the Strasbourg region of north-eastern France. The
study started with three 'seeds' recruited through a low threshold drugs
service, a drug treatment centre and a needle and syringe programme
respectively. The seeds were two men and one woman. Each received three tokens
to be given to three other drug users. If the recipient attended a drugs
service participating in the study within 14 days, the person received 20
euros. Each person who filled out a detailed questionnaire on their drug-using
behaviour, knowledge of HCV and social and economic situation received 30 euros.
People who filled out the questionnaire then received three tokens and the recruitment
process began again.
One seed’s chain of contacts eventually recruited 117 people
and in total, 327 people were recruited to the study. The mean age of
participants was 33 years, 74% were male and users had been injecting since an
average age of 21 years. Eighty-two per cent had been screened for hepatitis C.
However, the high screening rate proved to be less
comprehensive when analysed by sub-population. Less than half of those found to
have chronic HCV infection had been treated – the study took place in 2015 when
direct-acting antiviral treatment was available in France – and screening rates
were much lower in people who had either dropped out of drug treatment or never
attended a specialised drugs service. Even if optimal screening performance had
been achieved (testing of everyone attending services), one-third of drug users
would not have been tested.
Furthermore, 82% of those who had not been screened for
hepatitis C said that they were not concerned about the risk of acquiring
hepatitis C and only 30% said they knew of the efficacy of hepatitis C
treatment. Hepatitis C ranked far below obtaining paid work, stable housing and
dental care as a priority for all respondents and when asked to rank their
future priorities, it was almost at the bottom of the list for people who did
not know their HCV status.
The researchers say that their proposal should be tested in a
study to see whether conditional cash transfers and the respondent-driven
sampling method lead to improvements in screening and treatment among drug