Addressing digital exclusion to improve access to HIV and viral hepatitis care for people who experience criminalization: a mixed methods evaluation of a quality improvement project

People who experience criminalization, such as those who use drugs, are incarcerated, and are affected by homelessness, have a high prevalence of HIV and/or hepatitis C virus (HCV) infection and low treatment uptake in British Columbia. Barriers to care include unreliable means of maintaining contact with healthcare providers. To reduce these barriers, the Test, Link, Call (TLC) Project provides cell phones and peer health mentors to support access to HIV and/or HCV care. This study aims to determine the outcomes and acceptability of TLC and its impact on care engagement. A mixed-methods evaluation was conducted over the first 29 months (October 2021–March 2024) of the TLC Project. Data were collected concurrently in two rounds: the first after one year and the second two years after launch. Qualitative data were collected using semi-structured interviews conducted with healthcare providers (n = 8), peer health mentors (n = 6), and program participants (n = 20). Quantitative data, including demographic and clinical information, were gathered through program records and cross-sectional clinical chart reviews. Factors associated with HCV treatment uptake were assessed among HCV RNA positive participants (n = 245) using multivariate logistic regression. Data from both rounds were integrated for comprehensive analysis. 273 participants were enrolled in HCV care, and 26 in HIV care. Interviewees found TLC highly acceptable and effective. Positive outcomes included increased access to health and social services, connection to loved ones, independence, and safety. Challenges included phone theft and digital literacy issues. Overall, 57% of TLC participants enrolled for HCV care initiated curative treatment, compared to 40% among people who currently inject drugs in the provincial administrative database in 2020. The multivariate logistic regression analysis suggested that gender, housing stability, safer supply prescriptions, and length of involvement in the TLC program are predictive factors influencing treatment initiation. The provision of cell phones and peer health mentors effectively increased engagement in HIV and HCV care, demonstrating substantial benefits despite some challenges. This cost-effective intervention could be expanded to support people who experience criminalization in other geographic locations and addressing other health conditions, such as syphilis and substance use disorder.