Will peer-based interventions improve hepatitis C virus treatment uptake among young people who inject drugs?

Abstract

People who inject drugs (PWID) are disproportionately affected by hepatitis C virus (HCV) and have low rates of direct-acting antiviral (DAA) treatment uptake, despite universal coverage of the medication in most Canadian settings. Investigation into peer-based interventions as a means of improving treatment uptake has yielded promising results in adult PWID populations. In this commentary, we discuss the benefits and considerations of integrating peer-based interventions into HCV care for adolescent and young adult PWID living with HCV. Given that young PWID experience high transmission rates and account for most new infections, improving strategies for youth engagement with DAA treatment is critical. We describe how peer-based interventions can feature the unique importance of peer relationships in this period of life and provide a low-barrier way of delivering health promotion messages. In particular, we discuss the ability of peer-based interventions to reshape the narrative of HCV care in young PWID peer networks by empowering youth to share experiences and knowledge with others. We conclude by addressing knowledge gaps in the literature which must be filled in order to strengthen the impact of peer-based interventions on treatment uptake rates among young PWID.

People who inject drugs (PWID) have been identified as a priority population for hepatitis C virus (HCV) care by The Canadian Network on Hepatitis C (2019). Despite the introduction of highly effective direct-acting antiviral (DAA) medication for no cost to most individuals, the rate of treatment uptake among PWID remains low. There has been extensive interest in social interventions (e.g., peer support programs) as one method of addressing this issue, yielding promising results (Henderson et al. 2017; Crawford and Bath 2013). However, the majority of studies focus on adult PWID, with less attention focusing on young PWID. Here, we discuss the implications of peer-based interventions on adolescents and young adults living with HCV who inject drugs.

Young PWID experience high transmission rates and account for the majority of new infections

Generally, the early life course is a period in which those who initiate injection drug use are among the highest at risk of acquiring HCV. For example, in Canada, while the HCV epidemic affects all ages, young PWID (under age 25) likely make up the majority of incident HCV infections compared with other age demographics (The Canadian Network on Hepatitis C 2019). Young PWID who inject with peers of a similar age are also at the highest risk for acquiring and transmitting HCV infection (Jacka et al. 2016). Improving strategies to engage youth with HCV care is therefore critically needed to reduce individual- and population-level health and social outcomes.

Peers as an underutilized resource in health promotion for HCV care

The influence of peers takes on particular significance from adolescence to young adulthood. There is an established body of evidence demonstrating the role of peer networks on youth behaviour patterns generally and substance use specifically (Small et al. 2009). The composition of youth networks differs from that of adult networks and frequently involves both in-person and online communication (Page et al. 2019). As such, young PWID are supported by specific community organizations tailored toward their age demographic. These offer health and social support, providing a centralized space for individuals to connect with other young people. These characteristic factors of young PWID networks could allow peer-based interventions to have a stronger impact than what has been observed among adults. Indeed, youth networks represent an underutilized resource which has the potential to introduce positive peer influences that can foster health-promoting behaviour, including DAA uptake among those living with HCV.

Peer-based interventions can also provide unique contributions to programs that traditionally support young PWID living with HCV. There are a variety of peer intervention models that exist at the service-provider level and community level (Crawford & Bath 2013), which are adaptable to local contexts. Often, peer support programs are not stand-alone entities. They are components of multi-faceted HCV care programs, which can be embedded into existing health infrastructure and services. One of their many strengths lies in their ability to facilitate health promotion and provide support to a population which otherwise faces many barriers. This is true of young PWID who experience distinct barriers to care, including stigmatization, unstable housing and/or transportation, experiences with violence, and the transition out of adolescent services (Phillips et al. 2014). Peer-based interventions can offer a low-barrier way in which to engage with young PWID. The capacity of peer-based interventions to effectively reach young people has already been demonstrated among youth living with HIV (Wolfe et al. 2013). If we want to get young people “in the door”, interested, and seeking DAA treatment, we cannot ignore the validity of peer-based interventions as an additional tool to reach this population, especially by integrating peer support into settings where young PWID frequently congregate (e.g., treatment centres, youth shelters, OAT [opioid agonist treatment] clinics) (Roose et al. 2014). Indeed, while we focus here on DAA uptake, the promise for peer-based interventions within and across other health services should also be considered, including sexual health, harm reduction, and substance use-related needs of youth.

At the same time, there are limitations to peer-based interventions which need to be considered. First, while there are screening methods to select peers and variable training programs, challenges in ensuring the quality of peer-buddy relationships remain (Bonnington and Harris 2017). For example, tensions can exist between the intent of peer ‘buddy’ systems and the structural constraints of larger organizations which manage these programs. Guidelines and policies suggesting how and when peer-buddy interactions can occur could be limiting to legitimate relationship development (Bonnington and Harris 2017). Furthermore, peer support workers desire a sense of legitimacy within the healthcare system and validation of their roles (Bonnington and Harris 2017). It follows that our existing programs for young PWID living with HCV need to carve out an appropriate space for this work and ensure sustainable funding for long-term investments. The literature commonly refers to peer support programs as “low-cost” interventions (Roose et al. 2014); however, in real-world conditions, securing ongoing public funding can be a challenge given the limited resources available. Further research into the impact, cost-effectiveness, and acceptability of peer-based interventions is needed. Ideally, the establishment of best practice guidelines can guide future interventions for success.

Reshaping the narrative of HCV care among young PWID networks

We know that peers in PWID networks share their experiences with one another, acting as sources of knowledge on health-related matters (Falade-Nwulia et al. 2020). In the advent of new guidelines easing DAA treatment criteria for many PWID in most Canadian settings, updating local knowledge of HCV and treatment eligibility is vitally important to increasing treatment uptake. Outdated information about the interferon medication and its associated side effects is still prevalent and can negatively impact treatment uptake (Jost et al. 2019). Thus, sharing the latest information among peers can be an avenue through which treatment uptake can be improved (Falade-Nwulia et al. 2020), given that those sharing the knowledge have lived experience with the process, access to new information, and opportunities to navigate the health care system (Richmond et al. 2018; Falade-Nwulia et al. 2020).

As such, peer-based interventions may have an important role to play in addressing some of the major barriers to care for young PWID, including those that centre around misinformation and knowledge gaps within young PWID networks (Jost et al. 2019). Creating robust education and knowledge-building opportunities within peer networks may better enable public health to share up-to-date and accurate HCV treatment information. As youth move through the HCV care cascade, peer champions who have large networks can be identified. The role of the peer champion is multi-faceted and dynamic, which can be tailored to suit the needs of the community. Some initiatives have even successfully incorporated motivational interviewing into the skillset of youth peer support workers (Wolfe et al. 2013). The adaptable design allows peer supporters to operate in the group setting, one-on-one, or in combination with substance use support programs (Crawford and Bath 2013). Peer-based interventions offer the opportunity to engage with young PWID in a way that health care workers may not be able to, given the constraints of the health care system (e.g., wait times, specialist-led care model, etc.). The goal is to empower peers to communicate their first-hand experience with DAA treatment to spread health promotion messages.

Ultimately, we know that young people are motivated by factors beyond the availability and efficacy of DAAs (Skeer et al. 2018). Educational interventions that focus only on the biomedical aspects of DAA medications will likely not be sufficient for many young PWID. Sharing lived experiences is the backbone of peer-based interventions, as well as providing emotional, social, and physical support when needed and able.

Conclusion

There is a need for greater investment in youth-focused, low-threshold HCV programs that can adequately reach young people living with HCV who inject drugs (The Canadian Network on Hepatitis C 2019). As health services scale up DAA treatment, the inclusion of peer-based interventions in these programs may help us encourage treatment uptake, share current messages about DAA treatments, and mitigate some of the unique barriers to care facing young PWID. However, given the drawbacks of peer-based interventions and the uncertainty of how these might play out among youth networks, we want to underscore the importance of gathering youth’s experiences and perspectives on this topic. Peer-based interventions are one component of a larger initiative to strengthen interventions aimed at improving treatment uptake of DAAs. We remain hopeful that further investigation into peer-based interventions for youth will reveal insights into how best to utilize social connections to promote treatment-seeking behaviour.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.