Community-based versus facility-based services to improve hepatitis C screening in Cambodia: a cluster randomized controlled trial (ANRS 12384 Cam-C study).

Background: The estimated prevalence of hepatitis C virus (HCV) infection among adults aged over 45 years in Cambodia is approximately 5%. The present study aimed assessing the effectiveness of a novel community-based strategy comprising HCV rapid testing (RDT) and dried blood spot (DBS) collection performed by community health workers (CHWs) in outreach contexts. Methods: ANRS 12384 Cam-C is a parallel arm cluster randomized controlled trial conducted in the Siem Reap and Kampong Cham provinces of Cambodia between April 2022 and September 2023. Four geographical areas in each province were randomized into two arms to compare HCV RDT and DBS collection provided in homes by community health workers (i.e., community-based strategy) with facility-based HCV RDT and whole blood collection provided by healthcare workers in health centers (i.e., facility-based strategy). The primary outcome was combined testing uptake, defined as the proportion of participants who were actually tested for HCV using RDT or RDT/RNA if positive out of all those who participated in the study. Mixed effects logistic models were used to estimate the effect of the community-based strategy. The study is registered on ClinicalTrials.gov (NCT03992313). Findings: Among the 7692 participants who initially enrolled in the study, 5590 (72.7%) actually went on to have HCV RDT or HCV RDT/RNA screening (i.e., combined testing uptake). Combined testing uptake in the community-based (2990 participants) and facility-based (2600 participants) arms was 78.1% and 67.3%, respectively (p < 0.001). Positive HCV RDT was found for 57 (2.2%) including 39 (1.5%) with detectable HCV RNA among participants in the facility-based arm. In the community-based arm, 37 (1.2%) had positive HCV RDT including 32 (1.1%) with detectable HCV RNA. Treatment uptake concerned 36 participants (out of 39 with positive HCV RDT) and 30 (out of 32) in the facility-based and community-based arms, respectively. The odds of combined testing uptake in the community-based strategy were 2.18 (95% CI [1.28-3.73], p = 0.004) times higher than in the facility-based strategy. Interpretation: Combined testing uptake (HCV RDT or HCV RDT/RNA) was higher for the community-based strategy than for the facility-based strategy. The involvement of community health workers improved first contact with HCV services and uptake. Integrating this trial's community-based screening strategy into the national Cambodian HCV program could improve its effectiveness as part of the country's broader goal of eliminating HCV by 2030. Funding: This study was supported by the ANRS MIE (ANRS 12384).