A team in Australia implemented an alternative hepatitis C testing model, where hepatitis C antibody and RNA point-of-care testing (POCT) was provided in three priority settings: a prison, an inpatient mental health service (MHS) and an inpatient alcohol and other drug (AOD) unit. The model used a nurse trained in viral hepatitis care and experienced hepatitis C peer educators to administer hepatitis C POCT in each setting. There were 1,549 people who received a hepatitis C antibody POCT, of whom 264 (17%) received a positive result. Of those who tested positive for hepatitis C antibodies, 55 (21%) tested positive for chronic hepatitis C (using a confirmatory RNA test). Of those who tested positive for chronic hepatitis C, 50 (91%) were linked to care and 47 (86%) started treatment.
Program description
To overcome barriers associated with the multi-stage hepatitis C testing process, a mobile POCT approach was developed and implemented at three priority settings in Adelaide, Australia: a reception prison (i.e., a maximum-security facility for people awaiting sentencing), an inpatient MHS and an inpatient AOD unit. Program participants were aged 18 years and older and were not currently engaged in hepatitis C care. To increase awareness, testing was advertised through posters and pamphlets in each setting and staff were encouraged to discuss testing with potential participants.
Hepatitis C POCT was performed using small blood samples taken from a finger prick. The test was administered by a nurse trained in viral hepatitis care and experienced hepatitis C peer educators. Every participant received a hepatitis C antibody POCT, and participants who tested positive for hepatitis C antibodies were offered confirmatory RNA testing using the novel GeneXpert HCV Viral Load Fingerstick assay. In addition to administering the POCT, the nurse and peer educators were trained to report results to participants and provide pre- and post-test counselling and harm reduction education.
Participants received their results on the same day they had their test. A positive hepatitis C antibody result could be read within five minutes, and negative results were available after 20 minutes; confirmatory RNA testing results were available after 60 minutes. If participants received a positive RNA result, they were linked to care. The program nurse or peer educators notified the clinical service staff in each setting about positive RNA results; the clinical service staff then shared information on the participants with positive results with the local viral hepatitis nurse for case management and treatment.
Results
The program took place between October 2020 and December 2021. During this time, 1,549 people enrolled in the study and received hepatitis C POC antibody testing. The mean age was 37 years, 1,290 participants (83%) were male and 379 (25%) identified as “Aboriginal/Torres Straight Islander.” Overall, 830 (54%) had previously received some form of hepatitis C testing (i.e., antibody and/or RNA).
Of those who were enrolled in the study, 264 (17%) tested positive for hepatitis C antibodies, and 100% of these individuals received RNA testing. Among those with a positive antibody test, 55 (20.8%) received a positive confirmatory RNA test (i.e., 4% of all participants in the study received a positive RNA test). Among the participants who were RNA positive, 29 (53%) reported experiencing homelessness in the previous 90 days.
To generate a historical control group, hepatitis C testing and treatment data from all three settings were analyzed from a 12-month period before program implementation. Comparison of the testing rates between the historical control and POCT groups revealed the following:
- The rate of antibody testing increased significantly, by approximately three-fold, across all three settings during the POCT program (rates approximately doubled in the prison and inpatient MHS and increased approximately nine-fold in the inpatient AOD unit).
- The rate of RNA testing increased significantly, by approximately two-fold, across all three settings, largely driven by a significant increase of approximately six-fold in testing in the inpatient AOD unit (the increases were not significant in the inpatient MHS and prison settings).
The rate of hepatitis C antibody positivity was similar between the historical control and POCT groups (22% and 17%, respectively). However, the rate of hepatitis C RNA positivity was higher in the historical control group (33%) than in the POCT group (21%).
Among the 55 participants who received a positive RNA result, 50 (91%) were linked to care and 47 (86%) commenced treatment. Of the participants who were not linked to care, all reported a history of homelessness. The proportions of participants who were linked to care and commenced treatment varied across the three settings:
- 37 of 39 (95%) prison participants were linked to care and started treatment
- 7 of 10 (70%) inpatient AOD unit participants were linked to care and 6 (60%) started treatment
- 6 of 6 (100%) inpatient MHS participants were linked to care and 4 (67%) started treatment
In comparison with the historical control group, the POCT group had a significantly higher rate of treatment uptake (61% vs. 86%).
Overall, 1,517 (98%) of participants indicated that they would prefer to have their blood taken from a from a finger prick and have their results available the same day versus having conventional hepatitis C testing (i.e., blood taken from their vein and results available in a week), and 1,297 (84%) of participants indicated that it was important for them to receive their results on the same day they had their test.
What does this mean for service providers?
This approach demonstrated that implementing hepatitis C antibody and RNA POCT in three priority settings was associated with an increase in testing rates and treatment uptake. Considering that the conventional multi-step testing process is a key barrier to linking individuals to hepatitis C care, these results illustrate the feasibility and effectiveness of implementing a scalable hepatitis C POCT model in priority settings and demonstrate that this model is highly acceptable in populations at high risk for hepatitis C.
In Canada, one point-of-care hepatitis C antibody test (i.e., the OraQuick HCV Rapid Antibody Test) has been licensed for use and one point-of-care hepatitis C RNA test (i.e., the Xpert HCV Viral Load Fingerstick) is currently under Health Canada review for potential approval in Canada. If approved, the approach used in this study could be replicated in Canada. The study findings suggest that the training required to perform hepatitis C POCT is not complex. Additionally, the authors indicated that utilizing peer educators to perform POCT contributed significantly to participant engagement in the study. As such, these findings support the integration of people with lived and living experience into programs to engage key populations more effectively in hepatitis C testing and linkage to care. Given that half of the RNA positive participants reported experiencing homelessness, and all participants who were not linked to care also reported experiencing homelessness, streamlined hepatitis C testing may improve engagement and retention rates for hepatitis C care among vulnerable populations. Opportunities should be explored to expand more streamlined, accessible hepatitis C testing models.
Related resources
Hepatitis C point-of-care testing – CATIE Prevention in Focus article
Single-visit hepatitis C testing and linkage to care through a mobile unit – CATIE Programming Connection evidence brief
Peer outreach point-of-care testing for hepatitis C – CATIE Programming Connection evidence brief
National Australian Hepatitis C Point-of-Care Testing Program
Reference
McCartney E, Ralton L, Dawe J et al. Point of care testing for hepatitis C in the priority settings of mental health, prisons and drug & alcohol facilities–the PROMPt Study. Clinical Infectious Diseases. 2024; ciae155