Italy
2018

In 2015, a pilot hepatitis C screening program was offered within a hospital-based community dental clinic in Italy. The program was called EASY HCV-test. A point-of-care (POC) hepatitis C screening test was offered before routine dental procedures. More than three-quarters of the dental patients who were approached about the program agreed to be screened. Anyone who screened positive was immediately offered an appointment for confirmatory testing and care. This pilot suggests that a screening program using point-of-care testing at a dental clinic may be an effective strategy to increase screening within a community.

EASY HCV-test program description

Within a hospital-based community dental clinic, patients were asked by their dental hygienist if they would like to be screened for hepatitis C before beginning their routine dental work. If they consented, patients were screened using a saliva-based POC test that provided results within the same visit (see our Prevention in Focus article to find out more). Dental hygienists conducted the test and provided pre- and post-test counselling.

Patients who screened positive were referred to a specialist at the hospital within three working days. This free-of-charge appointment was for confirmatory testing and other diagnostic tests for liver disease. These referrals allowed patients who participated in the EASY HCV-test program to be fast-tracked into treatment once their viral load and genotype were identified.

As part of this program, brochures were distributed in the waiting room to provide patients with information about hepatitis C prevention. Dental hygienists were trained to provide pre-test counselling, to conduct the test and to help patients complete the consent forms. As part of the study, patients were asked to complete an anonymous questionnaire to collect information about their demographic profile, hepatitis C-related risk behaviours and previous testing experiences.

Results

This screening pilot was targeted to patients at a community dental clinic in Milan, Italy. The patients at this clinic were representative of the general public, many of whom would not normally seek out hepatitis C testing.

• Overall, 2377 dental patients were approached to receive testing and 2097 (78.4%) were screened.
• Of those screened, 22 cases returned positive results (approximately 1% of the total sample tested). Twenty-one of these patients were already aware of their hepatitis C status, and one individual had a newly diagnosed hepatitis C infection.
• Of those who completed the anonymous questionnaire, 65% reported never having been tested for hepatitis C.

These results suggest that point-of-care testing in dental clinics can be an effective strategy to increase hepatitis C screening. The dental clinic in the pilot serves a diverse population, many of whom had not previously been tested.  

What does this mean for service providers?

In this program, dental hygienists were trained to perform hepatitis C POC testing and provide pre- and post-test counselling. Dental care may be a common and trusted interaction with the health care system for many people. Thus, dental clinics may provide a good environment for hepatitis C screening.

Many public health dental clinics in Canada are targeted to marginalized populations, including low-income families, underhoused populations, seniors and others. Implementing similar programs in Canada may help to reach priority populations who may be more vulnerable to hepatitis C.

In addition, this program shows that training other health professionals or community-based workers to administer these tests could also enhance the capacity to do testing in the community. Partnerships such as this one or with others in the community may be an effective strategy to also increase screening among the general population.

The use of POC tests and rapid referrals to care within this program may have reduced loss to follow-up for patients. Losing patient contact while waiting for test results is often a barrier for hepatitis C diagnosis and treatment. POC testing can return results within the same visit. Additionally, this program partnered with a local hospital to ensure a follow-up appointment for positive screening tests within 24–72 hours.

Related resources

HIV Screening in Dental Clinics - Case Study

Hepatitis C point of care testing: What is its impact on testing and linkage to care? - Prevention in Focus article

References

1. Parisi MR, Tecco S, Gastaldi G et al. Point-of-care testing for hepatitis C virus infection at alternative and high-risk sites: an Italian pilot study in a dental clinic. New Microbiologica. 2017;40(4):242-45.
2. Shaw JL, Farmer JW. An environmental scan of publicly financed dental care in Canada: 2015 update. Canadian Association of Public Health Dentistry; 2015. Available from: http://www.caphd.ca/sites/default/files/FINAL%20-%202015%20Environmental%20Scan%20-%20ENGLISH%20-%2016%20Feb%2016.pdf

United States
2018

PositiveLinks is a mobile intervention for people with HIV, which includes use of a custom smartphone app that can be tailored to the needs and preferences of participants. The intervention was created to improve linkage and retention in care, as well as improve clinical outcomes, in a rural population of people with HIV living in the southern United States.

Pilot study participants were newly diagnosed with HIV (within 90 days of study enrolment), returning to care after a lapse, or at risk for falling out of care, and study results indicate significantly improved treatment retention and consistency of visits within a year, as well as significantly improved CD4 and viral load counts.

PositiveLinks program description^1,2

The pilot of the PositiveLinks intervention was affiliated with the Ryan White HIV Clinic at the University of Virginia and was informed by research suggesting that people with HIV prefer mobile health interventions and appreciate tailored bidirectional communication. The smartphone intervention provides the opportunity for participants to connect with peers for support through an app and accommodates for low literacy levels. New content was added to components of the app over the 12-month study period, and app content included:

• tailored educational resources (e.g., orientation to the clinic, HIV-related health information, stress reduction techniques);
• daily queries related to stress, mood, and medication adherence;
• weekly quizzes;
• contact information for the clinic-affiliated study team, which participants could use for individualized counselling and assistance;
• appointment reminders; and
• a community message board (CMB) where participants could leave or respond to messages. CMB content was monitored by the study team for misinformation and participants were advised not to use identifying information when participating.

Participants were provided with a smartphone when they enrolled in PositiveLinks with the app installed and an unlimited voice and data plan for 12 months. Participants received smartphone and app training, if required. Both the phone and app were password secured and consent addressed potential privacy risks.

Study results¹

Participants were mostly male (64%) (34% female; 3% transgender male to female); 49% were black non-Hispanic, 34% were white non-Hispanic, and 8% were Hispanic. Approximately 25% of participants had unstable housing and more than half of participants reported an income between 0 and 49% of the federal poverty level. Study results indicate that 40% of participants showed sustained use of the app.

The study looked at retention in HIV care, visit constancy, and clinical outcomes in 77 enrolled participants at baseline and at six and 12 months.

• The average response rates to the daily queries that assessed medication adherence, mood, and stress levels were 50%, 47%, and 47%, respectively, at six months and 41%, 39%, and 39%, respectively, at 12 months. The average response rates to weekly quizzes assessing general and HIV-specific knowledge were 43% at six months and 37% at 12 months.
• There were significant improvements in retention (i.e., keeping two appointments with an HIV provider separated by 90 days within a year) at six months (88%) and 12 months (81%) compared with baseline (51%).
• There were significant improvements in visit constancy (i.e., the proportion of four-month time internals in which one visit with an HIV provider was completed in one year) at six months (36%) and 12 months (51%) compared with baseline (22%).
• Mean CD4 counts significantly increased to 581 cells/mm³ at six months and 614 cells/mm³ at 12 months compared with baseline (522 cells/mm³).
• Mean viral load significantly decreased to 14,912 copies/mL at six months and 13,890 copies/mL at 12 months compared with 23,682 copies/mL at baseline. Additionally, the percentage of participants who were virally supressed (<200 copies/mL) significantly increased at six months (87%) and 12 months (79%) compared with baseline (47%).

What does this mean for service providers?

PositiveLinks provides an example of a mobile app that was effective at increasing engagement and improving treatment outcomes in participants in rural communities. A similar intervention could be adopted in other locations with similar population characteristics. This intervention used “warm technology,” which facilitates human contact and may have been an important component of its success and sustained usage.

Related resources

Text Message Reminder Tool – The Sex You Want

Adherence Apps – The Positive Side

References

1. Dillingham R, Ingersoll K, Flickinger TE, et al. PositiveLinks: a mobile health intervention for retention in HIV care and clinical outcomes with 12-month follow-up. AIDS Patient Care and STDs. 2018;32(6).
2. Flickinger TE, DeBolt C, Xie A, et al. Addressing stigma through a virtual community for people living with HIV: a mixed methods study of the PositiveLinks mobile healthiIntervention. AIDS and Behavior. 2018 Jun 7.

2018

Overview

On World AIDS Day 2017, the Gay Men’s Sexual Health Alliance (GMSH) launched a free text message reminder initiative as part of their The Sex You Want campaign for sexually active cisgender and transgender gay, bisexual, queer and other men who have sex with men. The text message reminder tool provides free text reminders to help individuals adhere to HIV treatment, as well as pre-exposure prophylaxis (PrEP) and testing. Text-based reminders can help people to stay on top of their medication and testing routines.

Why was the tool developed?

Research shows that the success of HIV treatment and PrEP are largely dependent on an individual’s adherence to their medications. However, there can be many barriers to medication adherence, such as substance use, mental health, age, and medication side effects. Text messages have been shown to be effective in promoting adherence to HIV treatment.

Testing and diagnosis for HIV and sexually transmitted infections (STIs) are important, to detect new infections and bring people into care and treatment. Diagnoses of infections can not only improve the health of people living with HIV or STIs through care and treatment but also help to prevent new infections, thus controlling infection in communities. Text messages may help to ensure that people are getting tested often, making it easier to detect HIV and STIs early.

How does it work?

Interested individuals can sign up by visiting this website: http://thesexyouwant.ca/reminder/ Users enter their Canadian cell phone number and select the type of reminder that they would like to receive – daily reminders for PrEP or HIV treatment, or 3-, 6-, or 12-month reminders for sexual health testing – as well as the time of day that they would like the reminder. Users can sign up for more than one type of reminder. Users must agree to the terms and conditions of the site. The information shared with the service remains private and the service can be stopped at any time.

How can I incorporate this tool into programming?

Agencies can integrate this tool into their programming to provide additional support for clients. For example, the use of this service has been taken up by some HIV care clinics; however, it could be used by any organization providing HIV and STI services.

For more information on the Sex You Want text-message reminder service please contact:

Dane Griffiths, Manager of Health Promotion
Gay Men’s Sexual Health Alliance
296 Jarvis Street, Unit 5
Toronto, ON  M5B 2C5
Phone: 416-364-4555
Email: Dgriffiths@gmsh.ca