Innovative peer-to-peer educational intervention to reduce HIV and other blood-borne infection risks in difficult–to-reach people who inject drugs: results from the ANRS AERLI study Patrizia Carrieri, Jean-Marie Le Gall, Marie Debrus, Baptiste Demoulin, Caroline Lions, Aurélie Haas, Marion Mora, Perrine Roux, Marie Suzan-Monti, Bruno Spire

French harm reduction policies have contributed to vastly reduce HIV incidence among people who inject drugs (PWID) –~1% of new HIV diagnoses in 2012 However, complications related to injecting practices remain –High prevalence of Hepatitis C Virus (HepC) infections Needle/syringe and paraphernalia sharing – Other intravenous drug use related complications Local lesions : venous damage, abscesses, cellulitis, other skin infections Cardiovascular and pulmonary complications Background (1)

Existence of persisting at-risk behaviors suggests that current Harm Reduction Programs are insufficient for PWID –Opiate substitution treatments –Needle/syringe programs –Support services Need to experiment with, evaluate and implement alternative and innovative strategies that effectively improve the health of this population Background (2)

The objective was to assess the effectiveness and feasibility of a community-based training and education intervention on reducing injection- associated risks Viral infections (HIV, HepC) Other injection-related damages AIDES and Médecins du Monde staff members or volunteers were involved in study design, training of peers, performing the intervention, collecting and analyzing the data Objective

National multi-site community-based study comparing the evolution of injection- related risks over one year in low-threshold services, hold by AIDES and MDM, between: –An intervention group, comprising people benefitting from educational sessions in 8 participating services –A control group, comprising people recruited in 9 services, working in accordance with current guidelines Study design (1)

InclusionM6M12 Study design (2) Phone interviews with an independent trained interviewer not involved in the ES Educational sessions (ES) with PWID = educational tailored intervention by NGO staff member/volunteer after observation of participants’ self-injection practices Intervention group Control group At least 1 ES over 5 months

Eligibility criteria –≥18 years old; injected drug at least once during the previous week; willing to be contacted for a phone interview; able to provide written informed consent Data collection –Phone interviews at M0, M6 and M12 collecting : socio-demographic characteristics behaviors related to HepC transmission risk (BBV-TRAQ) experience with drug use; history of incarceration access to care; HIV, Hep C and B testing and diagnosis motivational factors for willing to participate in the intervention –Data from the intervention sessions were collected by community-based association members Methods (1)

Analyses –Outcomes Having at least one at-risk practice for HepC transmission in the previous month Having at least one local complication at the injection site –2-step Heckman model to avoid possible selection bias arising from the clustering of intervention (n=113) and control groups (n=127) 1 st step: probit model to identify baseline factors associated with exposure to the ES to compute the inverse Mills ratio (IMR) 2 nd step: probit mixed model to identify factors associated with each outcome after introducing the IMR to control for the clustering bias Methods (2)

Participants recruited n=144 Intervention group M0 n=113 Intervention group M6 n=75 Intervention group M12 n=44 Participants recruited n=127 Control group M0 n=127 Control group M6 n=92 Control group M12 n=71 Study sample diagram Participants who did not receive ES N=31 Intervention sites n=8 Control sites n=9 288 ES

Results (1) – Participants’ characteristics † Chi-squared test or Wilcoxon test § in years ⱡ AUDIT score ≥3 for women; ≥4 for men *during the previous 4 weeks 1 more than 1 HCV at-risk practice during the previous month 2 more than 1 problem at the injection site Baseline characteristics (n (%) or median [IQR]), ANRS-AERLI study (n=240) Control group n=127Intervention group n=113p-value† Gender Male 99 (78)88 (78)0.99 Age § 31 [26-37]30 [25-37]0.38 High School Certificate 23 (18)36 (32)0.01 Precarious housing 17 (13)32 (28)0.01 Age at first drug injection § 19 [17-23] 0.73 Harmful alcohol consumption ⱡ69 (54)63 (56) 0.77 Heroin use* 32 (25)46 (41)0.01 Cocaine/crack use* 50 (39)55 (49)0.19 Morphine sulphate use* 36 (72)60 (53)<0.001 Buprenorphine use* 67 (53)30 (27)<0.001 Frequent daily injection 58 (46)61 (54)0.20 HCV screening 108 (85)84 (74)0.04 HCV risk practices 1 34 (27)49 (44)0.01 Problems at the injection site 2 71 (56)75 (66)0.10 HCV seropositivity 29 (23)37 (33)0.05 HIV seropositivity 5 (4)2 (2)0.35

Results (2) – Evolution of the outcomes Percentage of participants who reported at least one complication at the injection site Percentage of participants who reported at least one HCV at- risk practice p<0.05 : significant difference between M0 and M12 in the intervention group p<0.05 : significant difference between M0 and M6 in the intervention group

Results (3) - Impact of education intervention on HCV risk practices Multivariate model (n = 238, visits = 497)

Results (4) - Impact of education intervention on local complications at the injection site Multivariate model (n=240, visits=520)

Limitations –Difficult to have a comparable control group because of clustering –High diversity of PWID population –Lost to follow-up –Self-reports Positive impact of this innovative education intervention on injecting practices in terms of -A decrease in HCV at-risk practices -A reduction in local complications at the injection site Discussion

Innovative aspects of this intervention -Peer-based intervention -Short intervention -Low-cost intervention Intervention that may be used in several contexts –Needle/syringe programs, safer injecting facilities, outreach intervention in settings where prevalence of PWID is high Conclusion

People who agreed to participate in the study The ANRS-AERLI study group : M. Beaumont ; G. Boyault ; P.M. Carrrieri ; M. Debrus ; A. Haas ;J.M. Legall; G. Maradan ; M. Mora ; M. Préau ; P. Roux : B. Spire ; M. Suzan-Monti All participating centers and their staff: M. Debrus (Paris); G. Boyault (Nevers); G. Penavayre (Pau); C. Labbé (Lille); C. Urdiales (Nîmes /Alès); J. Murat (Toulouse); C. Saramago (Grenoble); F. Tempez (Rennes); N. Perrin (Clermont Ferrand); G. Dubosc (Avignon); N. Rodier (Limoges); M. Louanges (La Roche sur Yon); F. Rigaud (Béziers); M. Alvès Da Costa (Nancy) Funding Acknowledgements

Thank you for your attention