This study is one of the first to assess the acceptability of combining HCV screening with COVID-19 vaccination in marginalised communities, globally. We found that the combined intervention had an acceptability rate of 62.8% at the CAS and 100% at the MTU and was safe, as no adverse events, to either HCV screening or COVID-19 vaccination, were identified. It also optimised time use, as HCV screening was carried out during the post-vaccination observation period, thus maximising the use of participants’ time during the intervention and preventing the need for multiple visits. Furthermore, the average intervention took only 23 minutes and the longest one 25 minutes at the CAS. As for the MTU, the average intervention was 33 minutes and the longest one 75 minutes, but the extra time allowed for participants to know by the end of the encounter whether they had an active infection or not and be linked to care if they did.
The lower HCV screening acceptance at the CAS could be explained by the methods used to test. HCV Ab testing was done via venepuncture at the CAS and PoCT at the MTU. A study of people who inject drugs found that 82.9% of participants preferred HCV Ab screening via PoCT versus venepuncture.27 PoCT has other benefits, with a study in marginalised populations finding that participants screened via PoCT were significantly more likely to be linked to care.28 Similarly for HIV, a systematic review found a higher likelihood of participants being linked to care via PoCT screening methods.29 Our own findings show that screening via PoCT enables linkage to care, with 88.9% of HCV-RNA + participants having started treatment at the time of writing and 60% of those HIV + who had abandoned ART having re-started it, to date.
PoCT is encouraged by WHO to facilitate integrated, people-centred health approaches. Using a single, co-localised, healthcare encounter to provide multiple interventions, e.g., testing for multiple diseases, and, as we did, providing vaccination and linkage to care, can increase testing and treatment uptake and save costs relating to outreach, infrastructure, and human resources.7 A programme in Lombardy, Italy, used an integrated approach similar to ours whereby they offered HCV screening to 1969–1989 birth-cohort subjects undergoing COVID-19 vaccination using PoCT and found that four (0.06%) of 7219 participants were HCV-RNA + .30 Another programme in Salerno, Italy, offered HCV screening via PoCT to anyone (17 years or older) undergoing COVID-19 vaccination at a vaccination centre, and found that one (0.05%) of 1952 participants were HCV-RNA + .31 In our study, we found that nine (4.8%) of 187 participants were HCV-RNA+, by focusing on marginalised groups; all positive cases were found in one of the two sites (MTU). A Canadian study that also screened for HCV post COVID-19 vaccination in a centre for addiction and mental health found that six (3.1%) of 192 marginalised individuals were HCV-RNA + .32
In terms of the low prevalence found in the Salerno study,31 according to WHO, HCV screening in the general population is not considered cost-effective outside of specific settings with a high population prevalence. They thus recommend tailoring HCV screening efforts according to the epidemiology of each country. An example of this would be considering birth-cohort screening for identified birth cohorts with a higher HCV prevalence.6 The Lombardy study used birth-cohort screening and unexpectedly found that the prevalence of HCV in the 1969–1989 birth-cohort was lower than previously estimated.30 Regardless of the HCV prevalence found, the aforementioned studies demonstrate that co-locating COVID-19 vaccination and HCV testing and linkage to care efforts is possible.
Even screening programmes aimed at individuals considered at risk for HCV, such as people with SUDs,1,7, 17–20 may yield low HCV-RNA prevalence results, as was the case in our own study, where we found no HCV-RNA + participants at the CAS. This finding may be explained by the fact that only 62.8% of participants accepted HCV screening and so HCV infected participants may have gone unidentified. This result could also be considered an indication of a well-functioning CAS, whereby 16 (94.1%) of 17 HCV Ab + participants had been previously treated for HCV and cured (one participant had spontaneous HCV clearance), as none were HCV-RNA+, even though they continue to engage in high-risk behaviours like injecting drug use. An ongoing study in the Balearic Islands, Spain, is aiming to improve CAS functioning in this regard by, for the first time in this part of the country, screening and treating individuals with SUDs for HCV. Of 1050 recruited patients, 12.3% have been found to be HCV-RNA+, of whom 86% have initiated treatment, of whom 82.9% have finished it. Of the sustained virological response tests at 4 and 12 weeks performed so far, 95.7% and 94.8% showed undetectable HCV-RNA, respectively.33 However, this new model of care does not include COVID-19 vaccination, and the findings from our study (≥ 62.8% acceptance) along with those in Canada (50.1% acceptance)32 and Italy (≥ 63.3% acceptance)30 demonstrate that there is a high degree of acceptability of combining COVID-19 vaccination with HCV screening. The interventions of our programme and that of the Canadian study32 also enabled 88.9 and 66.7% of HCV-RNA participants to be linked to care, respectively.
Improving access to and retention in care for marginalised communities must continue to be a priority as they are more likely to require healthcare interventions.7 To this end, the Nobody Left Outside initiative designed a checklist, in alignment with the goals of universal health coverage and the WHO frameworks on integrated, people-centred healthcare, to promote a collaborative, evidence-based approach to service design and monitoring based on equity, non-discrimination, and community engagement. This checklist can be used when designing or redesigning healthcare interventions, to help overcome inequalities in and improve access to healthcare for marginalised populations.34 As demonstrated by our findings, marginalised groups are less likely to engage with traditional healthcare models, with no MTU participants having been vaccinated for COVID-19 despite extensive efforts in Madrid35 and no CAS participants having received a COVID-19 vaccine booster prior to the study despite it being recommended. During the continued roll-out of COVID-19 vaccine boosters, there is an opportunity to use the Nobody Left Outside checklist to guide outreach approaches like the one in Madrid, focusing on marginalised communities. Such efforts should combine COVID-19 vaccination with the detection of other diseases like HCV36,37 and HIV,38 as well as the hepatitis B virus, and linkage to care, if needed, to maximise the use of each healthcare encounter. With regards to simplifying HCV testing, resources could be further maximised by omitting HCV Ab screening and only testing for HCV-RNA in individuals with a known history of HCV, as those with a previous infection will continue to test HCV Ab+,2 which was evident in this study´s results.
Only by ensuring that healthcare is inclusive of everyone, will we achieve the WHO goal of eliminating the viral hepatitis and AIDS epidemics as public health threats by 2030.7 As shown by our results, CAS participants with a history of HCV infection were more likely to be experiencing homelessness or have a precarious living situation, less educated, unemployed, have an incarceration history, have mental health disorders, have had an STI other than HCV or HIV, have had a previous COVID-19 diagnosis, and be HIV+. Furthermore, at the MTU, participants who were positive for HCV and/or HIV were more likely to be experiencing homelessness or have a precarious living situation, have a SUD, have mental health disorders, be a sex worker, be less educated, be unemployed, have an incarceration history, have had an STI other than HCV or HIV, and have had a previous HCV infection; they were also less likely to have been treated for a previous HCV infection. Healthcare approaches need to be adapted to accommodate the needs of these groups.
Strengths and limitations
To our knowledge, this study is one of the first of its kind to assess the acceptability of combining HCV screening with COVID-19 vaccination in marginalised populations. Even though our pilot study’s sample size was small, at 187, future studies can build on this pilot study within Spain and beyond. As demonstrated by this and the aforementioned Canadian32 and Italian30,31 studies, approaches that co-locate multiple interventions into a single encounter can be used to not only offset the effects of the COVID-19 pandemic on HCV and HIV testing and treatment5,10,22,23 but also increase the reach of healthcare interventions within marginalised populations.