Balance of benefits and harms

Strategies for the delivery of general population or focused testing approaches include door-to-door/home-based testing and mobile outreach campaigns, and testing in workplaces, parks, bars, places of worship and educational establishments.

Benefits of community-based testing

1. There is some evidence that the offer of HBsAg testing in community settings may increase the acceptance and uptake of testing, and rates of early diagnosis (193).
2. The benefits of community-based testing to access the general population are that it can also reach first-time testers and people who seldom use clinical services or are unlikely to go to a facility. This particularly includes those from key and vulnerable populations in all settings (11, 194), but also those who are asymptomatic.
3. Community-based focused testing of high-risk groups. Innovative models of care have been developed and effectively implemented in many settings to provide integrated HIV (194) and hepatitis testing, and opioid substitution therapy (OST) services for PWID in community drug treatment services. Many of these programmes provide additional interventions, including education, harm reduction, mental health services, other general medical services, and referrals to care and treatment (195). These models can provide a framework for lower-income countries to expand viral hepatitis testing and treatment for at-risk populations.

Risks of community-based testing. Key challenges encountered in delivering community-based HIV testing include ensuring the availability and accessibility of prevention, care and treatment services; and risks associated with potential lack of confidentiality in these settings, and associated stigmatization and discrimination. These will need to be addressed while delivering community-based hepatitis testing.

Costs and cost–effectiveness

Community-level screening with outreach components is one of the most active types of case-finding; and therefore also one of the most labour- and resource intensive (152). A US-based study reported that costs per person tested ranged from $40 up to $280 for programmes with more active outreach strategies (149). The only cost–effectiveness analysis of a community-based test-and-treat strategy from an LMIC setting in west Africa showed that a community-based test and treat approach (compared to the status quo) can be regarded as cost–effective (144).

Feasibility

The feasibility in sub-Saharan Africa of large-scale community-level outreach testing, clinical assessment and antiviral treatment if meeting eligibility criteria, has been demonstrated by the PROLIFICA study in west Africa (152).

Balance of benefits and harms

Testing for viral hepatitis in the populations most affected in health-care facilities or clinical settings provides a major opportunity to scale up hepatitis testing.

Benefits of facility-based testing

1. Facility-based testing for hepatitis B and C can be successfully integrated with other health services such as HIV testing and treatment, which can in turn provide an entry point for other treatment services.
2. Facility-based focused testing can increase the uptake of viral hepatitis testing, case detection rate, and referrals to specialist-level care and other important services. This approach will generally be associated with higher rates of case identification and be more cost–effective.

Risks of facility-based testing. In low-prevalence settings, routine health facility -based testing will most likely be cost–effective only if delivered to high-risk populations.

Feasibility

Multiple studies have shown that HIV testing is feasible both in health-care and other clinical facilities such as harm reduction and drug treatment services for PWID (196), in TB and STI clinics (and other services), with a high uptake of testing, and has been widely implemented in developed countries. In a similar way to HIV testing, hepatitis testing can be integrated with other health services and offered as part of the package of care, either routinely to all those attending services or offered in particular clinical settings.

Costs and cost–effectiveness

Integrating screening into existing clinical services was shown to be the least costly method of testing, but also reached the least people, whereas extending screening outside the clinical setting was more costly as it included costs of organizing events and volunteer time, but reached more people (149).

Acceptability

Facility-based provider-initiated testing for HIV has been widely accepted in the context of testing in antenatal and TB clinic settings, as well as in drug treatment programmes (196). These clinics can in addition provide an entry point to services for viral hepatitis testing, prevention and care, which is likely to be acceptable to patients attending these clinics. It also can help normalize testing and remove the potential embarrassment of clients asking for a test, and saves time for clients attending clinical services for other reasons.

Research gaps in HBV and HCV testing approaches

Further evaluation and comparisons of different HBV and HCV testing approaches are needed (i.e. routine general population, focused risk-based, ANC, birth cohort testing) using different service delivery models (community- or health-facility -based). This can take the form of comparative trials, or large-scale implementation studies in a range of epidemic settings and populations in LMICs. Key outcome measures should include impact (uptake, case detection and linkage to care and treatment); cost and cost–effectiveness (and key drivers of cost–effectiveness), and proportion of HBV- or HCV-infected individuals missed by a specific testing approach. Further research into the simplification of testing and care, and integration of hepatitis services with other health services (e.g HIV, TB services) is needed to guide how impact and cost–effectiveness can be improved.