Reach and uptake of facility- and home-based hepatitis C self-testing in urban slums in Haridwar, India; A Comparative Implementation Study

Routine facility-based testing for hepatitis C virus (HCV) remains underutilised in India despite national screening policy. WHO has recommended HCV self-testing (HCVST) since 2021 to increase access to testing services. This study evaluated the HCVST by assessing its reach and uptake in urban-slum communities within Haridwar, Uttarakhand, India. The implementation study (CTRI/2023/07/054590) took place between 12th July 2023 and 31st August 2024. Three Primary Healthcare Centre (PHC) catchment areas were assigned to deliver either (1) facility-based HCVST, (2) home-based HCVST, or (3) standard of care (SoC). Facility-based delivery involved trained users offering kits to patients visiting the PHC (Site 1: Jwalapur 1), whereas home-based delivery (Site 2: Jwalapur 2) involved trained users and ASHAs approaching community households selected via a KISH grid. Primary outcomes were OPD-footfall standardized operational reach; the proportion offered testing out of the PHC catchement areas footfall, and uptake (acceptance among those offered). Secondary analysis explored demographic and behavioural predictors of those that refused to test. Of 7,091 outpatient department (OPD) footfall, 724 (10.2%) individuals were offered HCVST at intervention sites, of which 465 (64.2%) agreed to self-test. Operational reach was 17.8% (393/2,212; 95% CI: 16.2 to 19.5%) through the facility-based intervention and 14.4% (331/2,296; 95% CI: 13.0 to 15.9%) in the home-based intervention.HCVST uptake was higher through the home-based model (71.9%, 238/331, 95% CI: 66.7 to 76.7%) than in the facility (57.8%, 227/393, 95% CI: 52.7 to 62.7%). At the SoC site, only 11 individuals received standard of care HCV testing. The study HCV positivity was 1.1% (5/465; 95% CI: 0.35% to 2.49%): with four testing positive at the facility site (4/227), one at the community site (1/238), and none at the SoC site (0/11). Men were more likely to refuse HCVST than women (OR 0.54, 95% CI 0.37 to 0.78, p=0.001).Participants in the facility-based model had 1.87 times higher odds of refusal compared to those in the home-based delivery model. There is minimal routine HCV testing in the OPD setting of Urban PHCs despite national screening policy. HCVST improved testing coverage and uptake in urban slums compared to SoC. However, HCV positivity was low overall, suggesting that untargeted screening - whether facility-based or home-based - may identify few infections without additional strategies to reach higher-risk populations.