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Community-Based HCV Self-Testing Widens Testing Access in Big Vietnam Study
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AIDS 2024, July 22-26, 2024, Munich
Mark Mascolini
Community-based HCV self-testing (HCVST) could broaden access to testing by reaching previously untested people, according to results of a large multigroup analysis in Vietnam [1]. At the same time, HCVST could boost new HCV diagnoses and expand linkage to HCV care.
Diagnosis and treatment of people with HCV infection remain low across the globe. In Vietnam, where this study took place, fewer than 10% of an estimated 1 million people with HCV have been diagnosed and treated. HCV experts recognize HCVST as a potentially ground-breaking way to widen HCV testing and treatment among people at risk. Bao Vu Ngoc (PATH, Hanoi) and colleagues at CCIHP, PHD/CDC, and HCMC set out to find the best ways to deliver HCVST with an eye to expanding HCV testing and treatment.
The September 2023 to April 2024 study aimed to compare HCVST delivery models to provider-led HCV testing (PL-HCVT, that is, standard-of-care facility-based HCV testing, SOC-HCVT) and HCV testing by community-based organizations (CBO-HCVT). The analysis targeted people living with HIV (PLHIV), people who inject drugs (PWID), men who have sex with men (MSM), female sex workers (FSW), and sexual and injecting partners of people in these cohorts. The study group of 2882 people included 1834 who used HCVST and 1048 who relied on PL-HCVT at 20 sites. Researchers collected data from participant surveys and E-logbooks and analyzed cost data on Excel worksheets.
Among 1047 eligible clinic-based clients who consented to the study, 524 chose to use HCVST, while 523 opted for SOC-HCVT. In the clinic-based HCVST group, 88 had a reactive HCV test, 87 had confirmatory testing, 65 got diagnosed with HCV, and 65 began treatment. Among the 523 clients who used SOC-HCVT, 109 were reactive, 108 had confirmatory testing, 68 got an HCV diagnosis, and 63 began treatment.
Of the 1049 eligible and consenting CBO participants, 524 chose HCVST and 525 picked CBO-HCVT. In the HCVST group, 95 were reactive, 86 had confirmatory testing, 55 got diagnosed with HCV, and 53 began treatment. Among the 525 CBO participants who chose CBO-HCVT, 84 were reactive, 72 had confirmatory testing, 44 got an HCV diagnosis, and 42 began therapy.
Person-to-person secondary distribution of HCV test kits and online distribution also contributed to the study cohort. Among 524 primary HCVST clients, 288 (55%) agreed to distribute up to 3 test kits to sex or injecting partners, and 524 secondary clients got test kits and completed a self-test. All 524 had a phone interview after 1 to 2 weeks, and 20 of them had a reactive result. Sixteen of those 20 had confirmatory testing, and 11 of them received a follow-up call for diagnosis and treatment.
The secondary study population also included 370 people who saw HCVST recruitment outreach online, 276 (75%) of whom agreed to HCV risk screening. Of those 276 people, 274 completed part 1 of an online survey and 271 ordered delivery of a kit. Among 269 participants who got kits, 262 completed the self-test, 4 reported a reactive result in a follow-up call after 1 week, 4 had confirmatory testing, and 3 got a follow-up call for diagnosis and treatment.
The investigators measured the effectiveness of HCVST distribution models by how well they reached previously unreached people (percent of first-time testers), how often they found new people with HCV infection (HCV positivity rate), and how successfully HCV-positive people got linked to care (percent uptake of HCV confirmatory testing).
First-time testing proved more frequent in the secondary distribution group (91.4% of 524 people), in people who used community-based HCVST (83.8% of 524 participants) and in individuals who used community-based PL-HCVT (81.1% of 525 participants) than in clients who got kits through online distribution (48.9% of 262), people who relied on clinic-based PL-HCVT (36.9% of 523), and participants who used facility-based HCVST (36.8% of 524). Populations with the highest first-time tester rates were female sex workers (90.3% of 185), PWID (87.7% of 782), and sex partners of primary clients (82.3% of 299).
Logistic regression analysis adjusted for age, marital status, education, occupation, income, key population group, and testing model determined that PWID had 2-fold higher odds of first-time testing than MSM (adjusted odds ratio [aOR] 1.98, 95% confidence interval [CI] 1.31 to 2.97, P = 0.001), and female sex workers had more than 2-fold higher odds than MSM (aOR 2.37, 95% CI 1.31 to 4.27, P = 0.004). Compared with MSM, sex partners had about two-thirds higher odds of first-time testing (aOR 1.69, 95% CI 1.11 to 2.57, P = 0.015).
Three community-based HCV testing models had independently higher odds of reaching first-time testers than facility-based HCV testing models: CBO-HCVT (aOR 3.97, 95% CI 2.82 to 5.57, P = 0.000), community-based distribution (aOR 5.44, 95% CI 3.86 to 7.68, P = 0.000), and secondary distribution (aOR 10.19, 95% CI 6.82 to 15.21, P = 0.000).
SOC-HCVT yielded the highest HCV positivity rate (20.8%), followed closely by community-based HCVST (18.1%), then facility-based HCVST (16.8%), and CBO-HCVT (16.0%). The least productive testing models were secondary distribution (3.8% positivity) and online distribution (1.5% positivity). Three risk groups led in HCV positivity rate: methadone maintenance treatment users (31.1%), PLHIV (23.7%), and PWID (16.8%). HCV positivity rates lay below 4% in sex partners, female sex workers, and MSM.
Logistic regression determined that older age independently boosted odds of HCV positivity. Compared with people 18- to 29-years-olds, 30- to 49-year-olds had 26-fold higher odds of a positive HCV test (aOR 25.98, 95% CI 8.13 to 82.02, P = 0.000), and people 50 and older had almost 20-fold higher odds (aOR 19.58, 95% CI 5.94 to 64.54, P = 0.000). Compared with sex partners, three populations had independently higher odds of testing positive for HCV: PWID (aOR 2.58, 95% CI 1.34 to 4.98, P = 0.005), methadone maintenance users (aOR 4.18, 95% CI 2.07 to 8.46, P = 0.000), and PLHIV (aOR 5.06, 95% CI 2.56 to 9.98, P = 0.000).
Cost per HCV diagnosis ran much higher with online distribution ($3638) than secondary distribution ($983). Both facility-based HCVST ($633 per HCV diagnosis) and community-based HCVST ($604) cost more per diagnosis than SOC HCVT ($404) or CBO-HCVT ($217). But if the analysis overlooked test kit cost, community-based HCVST and SOC HCVT proved similar in cost per diagnosis ($350 and $333) and facility-based HCVST cost even less ($263).
Summary analysis of four HCVST service delivery models-community-based HCVST, facility-based HCVST, secondary distribution, and online distribution-considered reaching unreached populations, new HCV detection, linkage to care, and cost. Community-based HCVST came in first overall (second in reaching unreached populations, first in new HCV detection, second in linkage to care, and first in cost). Facility-based HCVST took second place (fourth in reaching unreached populations, second in new HCV detection, first in linkage to care, and second in cost). Secondary distribution came in third in this analysis, and online distribution fourth.
Pulling these results together, the researchers concluded that HCVST can substantially expand access to HCV testing and treatment in at-risk populations. The strategy ranked well in detecting new HCV cases and reaching previously untested populations. Community-based HCVST cost more per diagnosis than SOC HCVT, but costs were comparable when researchers subtracted outlays for self-test kits.
Reference
1. Vu B, Green K, Tran M, et al. Integrating hepatitis C virus self-testing into HIV and harm reduction services as an approach towards HCV micro-elimination among key populations and people living with HIV in Vietnam. AIDS 2024, July 22-26, 2024, Munich. Abstract OAE2005.
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