Online risk assessment for hepatitis C and home-based
sampling for HCV-RNA testing proved acceptable, easy to use and resulted in a
high rate of diagnosis of chronic hepatitis C infections among gay and bisexual men in the Netherlands,
researchers from the University of Amsterdam report in the Journal of Viral
Ordering a test online to carry out at home has become
routine in many countries since the onset of the COVID-19 pandemic. But home
testing or sampling for other infectious diseases is limited.
In the United Kingdom, gay and bisexual men and other people
at higher risk of HIV have been able to order self-sampling kits to take blood
or saliva samples for HIV antibody testing in a laboratory through a national service
since 2015. The scheme has expanded access to HIV antibody testing and has been
an important element of a national strategy to increase the proportion of
people who test for HIV and the frequency of testing. Similar schemes for HIV testing and self-sampling for sexually transmitted infections have also been developed in other European countries.
Improving the rate of diagnosis of hepatitis C is critical
for elimination of hepatitis C. Identifying ways of improving the uptake of
testing is critical.
In the Netherlands, the NoMoreC project is designed to
reduce hepatitis C transmission among gay and bisexual men. Although HCV
incidence has declined among gay and bisexual men with HIV since access to
direct-acting antivirals was expanded in 2015, HIV-negative men continue to
To increase the uptake of testing among gay and bisexual
men, the NoMoreC project designed an online tool to help men assess their past
risk of acquiring hepatitis C. Men were asked about condomless receptive anal
sex or fisting without gloves in the previous 6 months, injecting drugs or
sharing straw in the past 12 months and self-reported ulcerative sexually
transmitted infections in the past 12 months.
Men who had a high score on the risk assessment tool
received online advice to test for HCV. They were offered the opportunity to
purchase a self-sampling kit online at a price of 25 euros for one test or 80
euros for four tests. Promotional flyers offered discount codes of 50% or 100%
for test kit purchases.
The self-sampling kit enabled men to prick their finger with
a supplied lancet and place five blood samples on a card. The sample card was
subsequently sealed in a plastic bag and returned in a postage-paid envelope to
the University of Amsterdam Medical Centers, where it was tested for HCV-RNA.
The project offered HCV-RNA testing rather than antibody
testing because HCV-RNA is detectable within 1-3 weeks of infection and can be
used to diagnose recent infection or reinfection. HCV antibodies, on the other
hand, do not enable differentiation between a past infection that has been
cleared or cured and current chronic infection.
Men who tested positive received a referral letter for
The C-Test service was available online between March 2018
and November 2020, promoted through gay dating apps, volunteers at community
events and an Amsterdam pharmacy that specialised in dispensing prescriptions for
HIV pre-exposure prophylaxis (PrEP). During that period 43,075 people visited
the site, 3401 viewed the webpage on testing and 2250 did the online survey
to get personalised test advice.
Of those who did the online risk assessment, 992 (44%) were
advised to get tested for hepatitis C and 105 (10%) ordered one or more tests.
A total of 141 tests were ordered, half (71) were returned for testing and seven
(just under 10%) tested positive. An additional forty-seven men who were advised
they did not need to test ordered one or more tests, 33 tests were returned and
four tested positive.
Men who had ordered tests were asked about their experience of
using the service and their reasons for choosing to test. Fifty-four users responded.
Their median age was 46 years, 15 were HIV-positive, 19 were using PrEP and
two-thirds of all service users reported a previous test for hepatitis C,
mainly at an STI clinic or hospital.
Half of respondents reported that self-sampling was easy but
31% had encountered difficulties during the process, most commonly collecting enough
blood after pricking their finger to fill five circles on the sampling card.
The majority of respondents said that they were testing to confirm
that they were HCV-negative (61%) or because they were worried that they had
acquired hepatitis C (37%). Twenty-five per cent had ordered the test because self-sampling
saved time and 14% wanted to have a test kit in case they needed to test for hepatitis
C in the future.
The study investigators say that the uptake of testing compared
favourably with other self-sampling programmes for HIV and sexually transmitted
infections. The positivity rate was remarkably high, they say, especially
compared to the rate seen at Amsterdam’s STI clinic (1.2%) or in self-sampling schemes
for HIV (0.3% - 6%), suggesting that the TestC scheme reached men at high risk
of having hepatitis C. Integrating the service into a platform offering testing
for other sexually transmitted infections could enhance uptake, say the investigators.