Peer outreach point-of-care testing for hepatitis C
This program in Toronto, Ontario, used peer outreach workers to test people who inject drugs for hepatitis C and link them to care. The peer outreach workers were current or former program clients with lived experience of hepatitis C and drug use. They used point-of-care (POC) hepatitis C antibody testing to test marginalized community members who face barriers to accessing mainstream healthcare services and who, despite having a high risk for hepatitis C, are not aware of their status or engaged in care.
The study found that peer outreach testing and awareness of one’s antibody status did not improve linkage to hepatitis C care. However, it did show that testing delivered by people with lived experience is a feasible alternative to in-clinic testing by healthcare providers and can reach more marginalized groups. This approach helps to expand testing access to marginalized populations and make them aware of their hepatitis C antibody status.
The goal of this program was to use peer outreach workers to deliver POC hepatitis C antibody tests to marginalized populations and to evaluate if a POC test was a useful tool for engagement in hepatitis C care. The target populations include those with high rates of poverty, housing instability and injection drug use, who typically do not access traditional health and social services. The program was conducted as a research study by the Toronto Community Hepatitis C Program.
The program hired, trained and supported 11 outreach workers with lived or living experience of hepatitis C and drug use to deliver hepatitis C education and POC testing. All workers were former clients who had successfully completed treatment as part of the Toronto Community Hepatitis C Program. Peer outreach workers received training to administer POC tests (including pre- and post-test counselling) and provide hepatitis C education. Weekly meetings were held with outreach workers to provide support.
People who had a lifetime history of injection drug use and no prior knowledge of their hepatitis C status were approached for testing. These included people from each peer outreach worker’s personal networks and individuals they encountered in non-healthcare settings (i.e., community drop-ins, public places, private homes). In addition to testing, outreach workers provided hepatitis C education.
Outreach testing was done using a POC test, using blood from a finger prick. The entire process took about 30 minutes, including pre-and post-test counselling. Participants who tested positive were also given the program nurses’ drop-in hours and referred for follow-up testing.
The study used a randomized controlled trial design with half of those approached on outreach given a POC test and half referred to a program nurse for testing as usual. It measured whether participants visited the program’s treatment nurse within six months of receiving a POC test from a peer outreach worker and learning their antibody status. These results were compared with those of a “usual care” group, where outreach workers referred individuals to a program nurse.
The study took place from November 2018 to February 2019. To be eligible to participate, individuals had to be 18 years of age or older, have a history of injection drug use and have no prior knowledge of their hepatitis C status. Over a 14-week period, 920 individuals were approached to participate. A total of 380 individuals met the study’s eligibility criteria and were included in the study. Of these, 195 received POC testing and 185 were part of the “usual care” group.
Participants in both groups were primarily engaged in outreach in public spaces (66%) and the majority were previously unknown to the outreach workers (72%). Sixty-six percent of those tested reported recent injection drug use in the past 30 days. Despite this, 61% had no past history of hepatitis C testing.
In the POC testing group, there were high positivity rates, with 39% (77/195) testing positive for hepatitis C antibodies. However, only 3% (6/195) had at least 1 follow-up visit with a hepatitis C program treatment nurse. In the “usual care” group, 3% (5/185) had a visit with a hepatitis C program treatment nurse. Information on hepatitis C antibody status was not available for the “usual care” group.
Comparing the peer outreach testing group and the “usual care” group, there was no significant difference in the number of people who attended an appointment with a treatment nurse. The authors stated that in both groups, the number of people who followed up was too small for the researchers to meaningfully determine the impact of the program on engagement in hepatitis C care. Although they did not discuss this in their analysis, the authors indicated in a personal communication that it would be expected that those who tested negative with the POC test would be less inclined to follow up for an appointment with a nurse.
What does this mean for service providers?
This study demonstrates that testing by non-clinical, community workers, including pre-and post-test counselling, is feasible and efficient. This approach has the potential to expand the reach of hepatitis C screening, taking it out of the realm of healthcare settings and into the community. This can help service providers to reach marginalized populations that are at high risk of hepatitis C, as shown by the high antibody positivity rates from POC tests in this study.
However, this study found that outreach testing and knowing one’s antibody status did not increase linkage to care. This may point to other barriers to seeking care, including stigma, mistrust of healthcare providers and competing priorities from poverty and the overdose crisis. It may also suggest that additional supports, such as patient navigation or outreach nursing, are needed to better engage marginalized populations. Despite this, outreach testing was still able to help a large number of individuals learn about their hepatitis C status who otherwise would probably not have been tested.
Peer outreach testing also helps to better engage and employ people with lived experience in hepatitis C programs. Those who are embedded in drug user communities and have personal experience of hepatitis C are better able to engage people because of their specialized knowledge of the community and the perspective they share with potential clients.
Broad J, Mason K, Guyton M et al. Peer outreach point-of-care testing as a bridge to hepatitis C care for people who inject drugs in Toronto, Canada. International Journal of Drug Policy. 2020;80.