Background:
Hepatitis C (HCV) remains a challenge in sub-Saharan Africa given limited testing and treatment. South Africa (RSA) and Cameroon illustrate differing epidemic profiles: RSA has a concentrated epidemic among people who inject drugs (PWID), with low background prevalence (29-73% vs. 0.1-0.7%). Cameroon has a generalized epidemic, (3.6% general population, 12.2% high-risk groups). We compare the effectiveness of HIV self-testing (HCVST) to link PWID into HCV care.
Description of model of care:
Under Unitaid-funded STAR research (Jun2023–Mar2024), HCVST was integrated into harm reduction services: a mobile outreach clinic in Yeoville, RSA, and PWID drop-in center in Yaoundé, Cameroon. Reactive tests were confirmed by RNA-tests (on-site in RSA, off-site in Cameroon). RNA-positive participants were offered Direct-Acting Antivirals (DAAs), with PCR-cure confirmation week-12. Primary outcomes were (1) proportion of RNA-positive PWID accessing DAAs and (2) proportion completing treatment. Chi-square tests compared outcomes.
Effectiveness:
Among 1208 PWID tested in RSA and 698 in Cameroon, test positivity was higher in RSA (80.9% vs. 1.4%, p<0.001).
Table 1. Linkage outcomes
South Africa
(n, %, 95%CI)Cameroon
(n, %, 95%CI)P-value
Reactive977(80.9%, 78.5%-83.1%)10(1.4%, 0.6%-3.6%) <0.001
RNA tests 948(97.0%, 95.8%-98.0%)3(30%, 6.7%-65.2%)1
Confirmed positive 837(88.3%, 86.1%-90.2%)3(100%)1
DAAs-initiations33(3.9%, 2.7%-5.5%)3(100%)1
DAAs-completion13(39.4%, 22.9%-57.9%)3(100%)1
Week12 cure 2(50%)†13(100%)1
† 4 tests
1 Insufficient sample-size for tests.
More PWID in RSA underwent RNA testing (97.0% vs. 30%, p<0.001), but treatment initiation and completion were higher in Cameroon (100% vs. 3.9% and 39.4%).
Conclusion and next steps:
On-site blood draws in RSA increased RNA testing, but loss-to-follow up of viremic PWID and supply chain challenges with DAAs limited treatment uptake. Programmes must consider epidemic burden, prior testing levels and flexible models of care when implementing HCVST in concentrated settings. Further evaluation is needed to assess whether high linkage rates in Cameroon persist at HCVST-scale |