ALEXANDROS: Fast-tracked HCV screening for PWID
ALEXANDROS was a community-based programme offering fast-tracked HCV screening and linkage to care for people who inject drugs (PWID) in the Thessaloniki Metropolitan Area. It was designed in line with the ‘Seek, Test, Treat, Retain’ model of care. The programme ran from 2019-2021 and targeted the population of PWID who were at most risk: active injectors, homeless people, and those not linked to opioid substitution treatment (OST) programmes. It was implemented by the Hellenic Scientific Society for the Study of AIDS, STDs and Emerging Diseases and the Hellenic Liver Patient Organisation “Prometheus”.1
PWID who are not linked to harm reduction services constitute a high-risk population with ongoing transmission, limited opportunities for diagnosis and significant barriers to initiating treatment. Tailored community-based programmes have been used in Athens to target this group but there have been no similar interventions in Thessaloniki, the second largest city in Greece. Based on data from persons accessing drug treatment programmes in 2018, HCV prevalence in this population was estimated to be 57%. In addition, the coverage of needle and syringe programmes in Thessaloniki in 2016 was very low (1 syringe/PWID/year).
The programme was designed to address and overcome barriers to reaching the population, enhancing diagnosis, and improving linkage to care and retention:
- Peer-driven chain referral, through successive respondent-driven sampling (RDS) recruitment rounds, was used to provide community-based testing in the centre of Thessaloniki.
- Blood samples were collected during the first visit to the programme, as well as laboratory testing at no cost to the participants (test results are needed to request approval for free administration of direct acting antivirals (DAAs) in Greece).
- Personnel identified the social security number of participants and entered all necessary information in the national registry for chronic hepatitis C so that access to DAAs could be granted. The team also monitored whether treatment approval was granted, communicated with the patients, ordered DAAs from the designated pharmacy of the National Organization for the Provision of Health Services, and accompanied the patients to obtain their medication.
- Patients were asked to return to the ALEXANDROS site to receive their prescriptions, and monetary incentives were provided when they obtained DAAs from the pharmacy.
- There was dedicated staff for linkage to care and a peer navigator.
From September 2019 to July 2021, 1,101 unique PWID accessed the programme. Despite the disruptions caused by the COVID-19 pandemic, coverage was high (Thessaloniki has a population of approximately 1,200 high risk drug users). Of 1,101 participants, 17.2% were migrants and 15.0% were currently homeless. More than half (54.0%) were current PWID (past 30 days), 37.7% reported at least daily injecting, 79.7% were not currently on OST and 95.2% had not accessed needle and syringe programmes in the past 12 months.
Anti-HCV prevalence was 62.9%. Only 9.7% of anti-HCV(+) PWID reported previous treatment with DAAs. Chronic HCV prevalence in anti-HCV(+) PWID was 67.6%. Patients with HIV/HCV coinfection were linked to HIV specialists. Among PWID which chronic HCV monoinfection, it was possible to identify the social security number for 97.4% of them. 96.9% were entered into the national HCV treatment registry to apply for free treatment with DAAs, 61.8% were linked to HCV care and 53.6% had initiated treatment by September 2021.
The initiative reached the most vulnerable PWID, including current injectors, homeless people and those not linked to other services.
ALEXANDROS was successful for several reasons:
- Peer-driven chain referral made it possible to reach a highly vulnerable population and provide community-based testing. Successive sampling rounds were employed and PWID could participate in multiple rounds. This facilitated not only an increase in the number of participants but also improved linkage and retention to care.
- ALEXANDROS focused on the entire HCV care continuum, including prevention, diagnosis, linkage to care, and retention to treatment. There was dedicated staff for linkage to care and a peer navigator.
- The close collaboration of academia, clinicians, patients’ organisations, harm reduction and drug treatment providers made this programme possible.
Vana Sypsa, National and Kapodistrain University of Athens Greece