Conditional cash transfers may improve HCV screening and treatment in drug users

22 Jan 2019 Keith Alcorn
Originally published on

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 treatment.

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 users.