A community-based peer-driven program to reach people who inject drugs, monitor risk behaviours and 'test and treat' for infectious diseases in Athens, Greece: ARISTOTLE HCV-HIV

Background

The high prevalence of hepatitis C infection (HCV) among people who inject drugs (PWID) as well the occurrence of HIV outbreaks in several countries in the recent years stress the need to apply innovative approaches addressing PWID at high risk of infection and transmission. In Athens, Greece, 80% of PWID who seek opioid substitution treatment (OST) in Athens are anti-HCV(+) and an HIV outbreak in 2011 resulted in 1 out of 6 PWID becoming HIV-infected. In addition, linkage to HIV/HCV care and retention to treatment remains at low levels in this population. Since 2018, a community-based program is being implemented in Athens among PWID with the aim to monitor behaviours, screen for HCV/HIV and link to care.

Methods

ARISTOTLE HCV-HIV is a “seek-test-treat” community-based program where PWID are recruited using peer-driven chain-referral sampling with monetary incentives (respondent-driven sampling). Participation includes interviewing, blood testing for viral hepatitis and HIV, evaluation of liver fibrosis, counseling and linkage to care. A network of collaborating infectious diseases specialists and hepatologists is set up and a peer-navigator accompanies patients to their first appointment with them. The first phase of the program will be completed soon and a second phase will start with an emphasis in improving linkage to care.

Results

During April 2018-January 2019, 1,326 PWID have accessed the program. Of those, 1,043 (78.7%) are current users (injecting in the past 30 days). Based on the 2016 capture-recapture estimate of the population size of current PWID, the population coverage of ARISTOTLE HCV-HIV reached 78.6%. Heroin is the main substance of injecting drug use (60.8%), followed by cocaine (22.7%) and speedball (15.1%). A large proportion of participants (72.7%) are not on OST, 27.3% are currently homeless, 15.2% are migrants, 29.6% report at least daily injecting drug use and 23.6% shared syringes in the past 12 months. Anti-HCV and HIV prevalence is 77.2% and 16.0%, respectively, with 21% of HIV cases being diagnosed for the first time. The personnel arranges appointments with the clinicians and the peer-navigator has accompanied a large number of patients to their first appointment.

Conclusion

ARISTOTLE HCV-HIV succeeded in reaching a particularly vulnerable population of PWID in Athens: current injectors, homeless, not linked to OST, injecting frequently and with high prevalence of HCV and HIV infection. The high population coverage of the program suggests that peer-driven community-based programs with small incentives are acceptable by PWID and could assist in reaching the population of those most in need. In addition, the combination of testing and linkage to care with the help of peer-navigators can help reaching the goals for diagnosis and treatment for HIV and HCV, as set by WHO, in a population facing several barriers to treatment.