Disengagement from care and disease severity among people self-testing positive for hepatitis C in Nigeria, Cameroon, and South Africa: a multi-country cohort analysis of implementation studies.

IntroductionAccess to Hepatitis C virus (HCV) testing and treatment remains low globally. HCV self-testing (HCVST) may facilitate diagnosis and cure. We analysed treatment uptake and outcomes following a positive HCVST result in three distinct African epidemic contexts. MethodsA multi-country cohort study nested within HCVST implementation programmes in Cameroon, Nigeria, and South Africa (May 2023-May 2024). Adults ([≥]18 years) with positive HCVST results were followed through confirmatory testing and care outcomes until last event. Co-primary outcomes were: (i) cascade progression, (treatment initiation and sustained virological response [SVR]); estimated using country-cascades; and (ii) cumulative incidence of disengagement from care, estimated using Bayesian competing-risks survival models. Analyses were conducted separately for South Africa and jointly for Cameroon-Nigeria due to structural differences in service organisation. Covariate associations were estimated as hazard ratios. Disease severity was assessed through fibrosis staging derived from AST-to-platelet ratio index (APRI). Results1,341 participants had positive HCVST results (117 in Cameroon, 226 in Nigeria, 998 in South Africa). Among laboratory confirmed HCV cases, treatment initiation and SVR were highest in Cameroon (Tx 98.6%, 71/72; SVR 96.4%, 53/55), followed by Nigeria (Tx 90.8%, 168/185; SVR 91.8%, 56/62), and low in South Africa (Tx 4.3%, 37/854; SVR 60.6%, 3/5). Crude disengagement was lowest in Nigeria (24.4%; 95% CrI 19.1%-30.3%), followed by Cameroon (52.4%; 95% CrI 44.4%-61.2%), and South Africa (77.9%; 95% CrI 76.2%-79.8%). By 24-weeks, disengagement was lower in specialist hospitals than community sites in Cameroon and Nigeria. In South Africa, the greatest predictor of disengagement was HIV positive status (HR 1.96; 95% CrI 1.71 to 2.23). Viraemia exceeded regional estimates (82.2%, 1102/1341), with liver scarring highest in Cameroon (fibrosis: 8.3%, cirrhosis: 6.9%) and lowest in South Africa (2.9% and 1.6%, respectively). ConclusionHCV self-testing enabled detection of HCV cases, including severe disease, but poorer progression in community settings suggests decentralised treatment pathways require strengthening to realise cure.