Journal of Community Health https://doi.org/10.1007/s10900-019-00780-0 ORIGINAL PAPER Hepatitis C Screening in Community‑Based Voluntary Counselling and Testing Services in Europe: An Observational Study from the COBATEST Network 2014–2018 Anna Conway1,2 · Laura Fernàndez‑López1,2,3 · Juliana Reyes‑Urueña1,2 · Jordi Casabona1,2,3,4 · COBATEST Study Group1,5 © Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract The COBATEST Network links community-based voluntary counselling and testing (CBVCT) services in the European region and collects testing data using standardised data collection tools. This study aims to describe the population being screened for anti-HCV antibodies in the COBATEST Network and identify risk factors associated with a reactive HCV screening test result in the period 2014–2018. Clients aged > 16 screened for HCV in the period 2014–2018 at one of the Network’s CBVCT services were included in the study. In the 5 year period, 7426 clients were screened for HCV in 22 centres in 10 countries and anti-HCV antibodies were detected in 113 (1.5%). The majority of people screened were aged 25–44, men who have sex with men (MSM), not HIV+ , not reporting a history of injecting drug use or sex work. Detection of anti-HCV antibodies was associated with being HIV + MSM (aOR 9.1, 95% CI 3.8; 21.8 compared to HIV-clients) and being a person who injects drugs (PWID, aOR 28.1, 95% CI 17.6; 45.0, compared to people with no history of injecting drug use). This study demonstrates that HIV-MSM with no history of injection drug use are using CBVCT services for HCV screening, but reactive screening test is associated with being HIV+ or PWID. The integration of HCV screening into the CBVCT service model may widen access to testing for populations that may otherwise not be tested. Keywords Hepatitis C · Screening · Community networks · Europe The COBATEST Study Group members are listed in Introduction Acknowledgement section. Electronic supplementary material The online version of this In 2017, 31,273 cases of hepatitis C virus (HCV) were article (https​://doi.org/10.1007/s1090​0-019-00780​-0) contains reported to the ECDC in 29 EU/EEA Member States, cor- supplementary material, which is available to authorized users. responding to a crude rate of 7.3 cases per 100,000 popula- tion [1]. These figures are likely to be an underestimate as * Anna Conway aconway@igtp.cat hepatitis infection often shows no symptoms. Only 26.0% of the cases in 2017 included data on the mode of transmis- 1 Generalitat de Catalunya Departament de Salut, Centre sion, the most common of which was injecting drug use Estudis Epidemiologics sobre les Infeccions de Transmissio accounting for 44.0% of those cases with complete informa- Sexual i Sida de Catalunya (CEEISCAT), Barcelona, Catalunya, Spain tion on transmission status [1]. WHO in 2016 recommended 2 a dramatic scale-up of HCV testing and linkage to care to L’Institut de Recerca en Ciències de la Salut Germans Trias i Pujol, Badalona, Catalonia, Spain achieve elimination of HCV by 2030 [2]. HCV screening 3 and treatment interventions carry a double public health CIBERESP, CIBER Epidemiologia y Salud Publica, Barcelona, Catalunya, Spain benefit: reducing both morbidity and incidence through a 4 treatment-as-prevention effect [3]. Department of Paediatrics, Obstetrics and Gynecology and Preventive Medicine, Universitat Autonoma de A recent scoping review of studies investigating bar- Barcelona, Barcelona, Catalunya, Spain riers to HCV testing, found that low self-perceived risk 5 AIDS Action Europe, c/o Deutsche AIDS-Hilfe, Wilhelmstr of acquiring HCV, perceived stigma and fear of a posi- 138, 10963 Berlin, Germany tive result were reported as barriers to HCV screening 13 Vol.:(0123456789) Journal of Community Health and testing. There are also barriers to providers wishing data collection tools to investigate screening for HCV in a to offer HCV screening, including time constraints, lack range of populations. Using COBATEST data, this study of specific knowledge about HCV and discomfort in ask- aims to understand who is using CBVCT services for HCV ing about risk behaviours [4]. Peer counselling offered screening and what factors determine a reactive test. This in community-based voluntary counselling and testing study describes HCV screening activity in CBVCT ser- (CBVCT) services can help men who have sex with men vices, describes the populations being screened, describes (MSM) overcome additional barriers to testing such as the proportion of reactive HCV screening tests and identi- homophobia and internalised homonegativity [5]. The fies risk factors associated with a reactive HCV screen- WHO recommends that CBVCT services form part of a ing test result in the COBATEST Network in the years country’s national testing strategy, including testing by 2014–2018. trained non-medical professionals. Many CBVCT ser- vices, recognising the needs of their clients, have moved beyond HIV screening and now offer screening for HCV Methods and syphilis [6]. WHO guidelines state that rapid diagnostic tests have This study is based on disaggregated data collected from acceptable sensitivity and specificity compared to labora- members of the COBATEST Network which offered HCV tory-based testing and can be successful at increasing test- screening for a minimum of 6 months during the period of ing uptake and reducing loss to follow-up (World Health study (January 1st 2014–December 31st 2018). Counsellors Organization (WHO) [7]). Once the rapid diagnostic test complete pre-test counselling and collect information on the performed in CBVCT services detects anti-HCV, a HCV client using the COBATEST standardised data collection RNA nucleic acid test has to be performed to establish tools. COBATEST network members can submit their data active HCV infection and ensure linkage to care. in one of three ways: using the online COBATEST tool; in The COBATEST Network links organisations across disaggregated format according to data file specifications; in Europe who offer CBVCT services and promotes testing, aggregated format with the COBATEST indicators already early diagnosis and linkage to care in at-risk populations. calculated. For this study, all disaggregated data submitted Services are heterogenous, variously targeting the gen- before the censuring date of 28 February 2019 was included. eral population or mix of key populations; (MSM), people CBVCT services use a unique Client Identification Code who inject drugs (PWID), migrants or sex workers (SW). to anonymise the client data and allow the identification Clients enter CBVCT services seeking an anonymous and of repeat testers. In the case that one person was screened confidential HIV, hepatitis C or syphilis screening. Not all multiple times for HCV over the study period, only the most services offer testing for all diseases. The HCV screening recent HCV screening test was included in the study. Those tests detect antibodies to HCV in human serum, plasma or with no reported HCV screening test result or aged under whole blood (giving result: reactive/unreactive). Clients 16 were removed from the analysis. The flowchart of inclu- with a reactive specimen then require referral for an RNA sion criteria is presented in Fig. 1. The same inclusion cri- test to identify current HCV infection (giving result: active teria were applied to people tested for HIV, not HCV, in the HCV infection/no active HCV infection). RNA testing is COBATEST Network and a comparison between the two not part of the standard offer for CBVCT services but they groups is presented in Online Annex 1. can report to the COBATEST data collection tool if they Firstly, we described characteristics and activity in have the result of the RNA test performed at another site. CBVCT services which offer HCV screening. To do this The COBATEST Network began in 2013 with the goal we used an existing database created as part of a 2017 study of homogenizing the monitoring and evaluation of HIV into the quality of the COBATEST Network’s data [10]. In testing activities at the community level [8, 9] and later the scope of that study, all the CBVCT services that were expanded to syphilis and HCV screening. The standardised partners of the COBATEST Network in 2017 were invited to data collection tools collect information on sociodemo- complete the online survey which was a piloted, structured graphic characteristics, reasons for testing, previous HIV/ ad hoc instrument hosted by the Survey Monkey website. HCV/syphilis screening testing, risk behaviours, HIV/ CBVCT services that did not send the information in 2017 HCV/syphilis screening test results, linkage to care. Since were contacted for this study via email to report their ser- 2014 this data has been collected and centralised in a sin- vices’ characteristics. We refer to each CBVCT service by gle database. In 2018, 45 organisations in 20 countries in its number which is randomly assigned when a service joins the WHO European region submitted data on their testing the COBATEST Network. According to CBVCT service, we activity. report testing setting, target population, which HCV screen- This study is the first pan-European observational study ing tests were offered (rapid oral test, rapid blood test, con- using data from CBVCT services which share common ventional test) and number of people screened for HCV. 13 Journal of Community Health Fig. 1  Flowchart of inclusion criteria for participation in study All entries COBATEST online tool of HCV testing in the COBAT- n= 52,711 EST network 2014–2018 + All entries COBATEST offline tools n=41,529 All entries COBATEST n=94,240 Remove duplicates n=806 All unique entries n=93,435 Remove cases with no HCV test n=84,449 HCV screening performed n=8,986 Remove cases with no data on HCV test result n=855 Entries with HCV screening result n=8,131 Remove prior tests by repeat testers n=646 Most recent test by each client n=7,485 Remove clients aged <16 n=59 Study population n=7,426 Secondly, the clients screened for HCV and clients with (see below for sensitivity analysis). The multivariate a reactive screening test were described by socio-demo- logistic regression model was decided using a forward- graphic characteristics (gender [men, women, transgen- stepwise method, using the significant variables from the der], age group [16–24, 25–44, 45–64, > 65], migrants univariate analysis. In the case that two variables that were [defined as been born in a country different to the country both significant in the univariate analysis showed colin- where the CBVCT service is placed], region of origin), key earity, the one likely to be a bigger contributor to HCV populations (MSM, PWID, SW) and epidemiological vari- incidence according to the literature was selected for the ables (HIV status, HCV screening test results and RNA forward-stepwise method. For example, if the variables test results). Differences between groups were assessed HIV + MSM and MSM were both significantly associated using the Pearson’s C ­ hi2 test with a p value of < 0.05 con- with reactive HCV test, MSM was discarded when select- sidered statistically significant. ing variables for the multivariate model. Finally, the univariate logistic regression analysis was There were high proportions of missing data in some vari- performed and the odds ratios for a reactive HCV screen- ables included in the logistic regression model. A sensitivity ing test were presented with their 95% confidence inter- analysis was performed to understand the impact of recoding vals and p values. Clients with missing information on missing data to the non-risk category in the logistic regression key populations were considered in the non-risk category model. The results from the analysis of two different logistic 13 Journal of Community Health regression models were compared; the first (the model used for proportion of missing data. The final multivariate model this study) considered all missing and “don’t know” responses included HIV + MSM, PWID and migrant status, finding in the non-risk category and the second eliminated all missing each to be independently associated with a reactive HCV and “don’t know” answers from the analysis. screening test. Data analysis was performed using StataSE 14.1. The results of the sensitivity analysis are presented in Online Annex 1. The factors associated with a reactive HCV screening test remained the same in both models Results and the strength of the association differed only slightly indicating that considering the missing responses in the The description of COBATEST members in Table 1 shows non-risk category did not greatly impact the results of the the heterogeneity of their services; testing is variously study. offered on-site, in outreach or in venues using rapid oral test, rapid blood test or conventional laboratory tests. The majority of centres target the general population or MSM. Discussion The services are not representative, neither at the national nor European level, of CBVCT services offering HCV This study demonstrates that HIV- MSM with no history screening. of injection drug use are using CBVCT services for HCV In the 5 year period, 7426 clients were screened for screening, but a reactive screening test is associated with HCV in 21 centres in 10 countries and 113 had a reactive being HIV+ or PWID. CBVCT services in the European result (1.5%, range 0.0–15.5%). In the first year of the region are increasingly integrating HCV screening into their study (2014), the number of centres submitting data on service model to ensure testing is more widely available for HCV screening was 6 and the number of tests was 81. In populations that may otherwise not be tested. The use of the last year of the study (2018) this rose to 18 centres and standardised data collection tools in the COBATEST net- 3917 tests. The proportion of reactive HCV screening tests work allows for HCV screening data to be pooled and ana- was 4.9% in the first year of the study, dropping to 1.2% in lysed in a timely and robust manner. The study identifies cli- the last year. During the period of study, seven COBAT- ent characteristics associated with a reactive HCV screening EST members had no reactive results. The CBVCT service test which could assist CBVCT services in targeting testing. with the highest proportion of reactive test results is the The number of CBVCT services in the COBATEST only one which has a target population of PWID. Of the Network offering HCV testing and the number of tests per- 113 clients with reactive screening test, 95 (84.1%) had formed has increased every year since 2014 but the large no information on RNA test result, 16 (14.2%) reported numbers of HIV tests carried out over the study period active infection (2 of those were HIV + MSM) and 2 shows that this is still services’ main testing activity (see (1.8%) reported no current HCV infection (Not displayed). Fig. 1). Although this sample is not representative of all Table 2 describes the testers; the majority aged ≥ 25 and CBVCT services in Europe or CBVCT services in each < 45, MSM, not HIV+ , not reporting a history of inject- country, it may reflect the increasing number of CBVCT ing drug use or sex work. Of the 75 persons reporting to services offering HCV screening. The rising number of tests be HIV+ , 68 were MSM (not displayed). The proportion performed in the network comes with a decrease in propor- of reactive HCV screening test was higher in transgender tion of reactive HCV tests, reflecting services increasingly people compared to men and women (not statistically sig- offering screening to populations at low risk of HCV. This nificant), higher in people living with HIV (PLHIV) than could have implications for the cost-effectiveness of CBVCT others, higher in sex workers (SW) than non-sex work- services and requires more investigation to understand how ers and higher in PWID than those not reporting history services fund their HCV screening programme and to under- of injecting drug use. Missing data is displayed as a per- stand if CBVCT services have the knowledge to identify centage of each variable. More than 80% of information people at higher risk of HCV. was complete for each of the following variables: gender, Services offered by COBATEST members are heteroge- migrant, MSM. Other variables were less complete: age neous but the majority of clients being screened for HCV group (77.6% complete), sex worker (64.2% complete) are MSM, as has been seen in previous studies on HIV result of last HIV test (51.9% complete) (Table 2). screening [8]. We found a high proportion of reactive HCV Table 3 presents the results of the univariate and mul- tests in PWID, in line with the lower end of the estimated tivariate logistic regression analysis. A reactive HCV range from the ECDC (7–95.4%) [11]. The low number of screening test result was associated with being aged ≥ 25 PWID tested reflects the fact that PWID are not the target and < 45, MSW, PWID; a migrant or a PLHIV. For the population for the majority of the CBVCT services in this multivariate model, age was excluded given the large study. PWID could benefit from improved access to services 13 Table 1  HCV screening and reactive tests by centre type, centre location and by year: COBATEST network 2014–2018 Centre no Country Testing setting Target population Test used Total Total reac- Number of clients tested (% reactive) clients tive tests, n tested, N (%) 2014 2015 2016 2017 2018 Journal of Community Health 4 Spain On-site Rapid (oral or blood) 28 0 (0.0%) – (–) – (–) – (–) – (–) 28 (0.0%) 6 Denmark On-site, outreach, venue MSM, male sex worker Rapid (oral or blood) 959 9 (0.9%) 1 (0.0%) 70 (4.3%) 151 (1.3%) 434 (0.9%) 303 (0.0%) setting 10 Spain On-site MSM, female sex Rapid (oral or blood) 29 2 (6.9%) – (–) – (–) 1 (100.0%) 2 (0.0%) 26 (3.8%) worker, Male sex worker, PWID 11 Spain On-site, venue setting General population Rapid (oral or blood) 79 4 (5.1%) – (–) – (–) 2 (0.0%) 33 (0.0%) 44 (9.1%) 12 Spain On-site, outreach General population Rapid (blood) 23 0 (0.0%) – (–) – (–) – (–) – (–) 23 (0.0%) 16 Spain On-site General population Rapid (blood) 6 0 (0.0%) – (–) 6 (0.0%) – (–) – (–) – (–) 17 Spain On-site MSM, LGBT Rapid (oral or blood) 62 0 (0.0%) – (–) – (–) 18 (0.0%) 34 (0.0%) 10 (0.0%) 20 Latvia On-site, venue setting MSM Rapid (blood) 1425 17 (1.2%) – (–) 426 (1.4%) 507 (1.4%) 34 (0.0%) 458 (0.9%) 22 Spain Health centre PWID Conventional 84 13 (15.5%) 28 (3.6%) 11 (27.3%) 12 (25.0%) 10 (20.0%) 23 (17.4%) 23 Spain On-site, outreach, health General population Rapid (oral or blood) 181 1 (0.6%) – (–) – (–) 5 (0.0%) 73 (1.4%) 103 (0.0%) centre 24 Romania On-site, venue setting General population, Rapid (blood) 1047 24 (2.3%) – (–) – (–) – (–) 89 (6.7%) 958 (1.9%) MSM 29 Lithuania On-site General population Rapid (blood) 185 2 (1.1%) – (–) – (–) 74 (0.0%) 51 (0.0%) 60 (3.3%) 30 Italy On-site, outreach, venue General population Rapid (oral or blood) 643 15 (2.3%) 13 (15.4%) 171 (3.5%) 88 (0.0%) 59 (8.5%) 312 (0.6%) setting 31 Spain On-site General population Rapid (oral or blood) 96 1 (1.0%) 36 (2.8%) 3 (0.0%) 3 (0.0%) 31 (0.0%) 23 (0.0%) & conventional 32 Ukraine On-site MSM Rapid (blood) 53 0 (0.0%) – (–) – (–) 53 (0.0%) – (–) – (–) 34 Slovenia On-site, venue setting MSM Conventional 7 0 (0.0%) – (–) 3 (0.0%) 2 (0.0%) 2 (0.0%) – (–) 36 Spain On-site General population Rapid (oral or blood) 225 2 (0.9%) – (–) – (–) – (–) 93 (1.1%) 132 (0.8%) 43 Spain On-site, outreach Female sex worker, Rapid (oral or blood) 155 2 (1.3%) 3 (0.0%) 11 (0.0%) 102 (0.0%) 6 (0.0%) 33 (6.1%) Male sex worker 44 Austria On-site General population Rapid (anti-HCV) 1441 16 (1.1%) – (–) – (–) – (–) 758 (1.5%) 683 (0.7%) 49 Belgium On-site, outreach MSM Rapid 18 0 (0.0%) – (–) – (–) – (–) – (–) 18 (0.0%) 60 Ukraine 680 5 (0.7%) – (–) – (–) – (–) – (–) 680 (0.7%) Total 7426 113 (1.5%) 81 (4.9%) 701 (2.6%) 1018 (1.2%) 1709 (1.7%) 3917 (1.2%) 13 Journal of Community Health Table 2  Description of Non-reactive Reactive p ­valuea HCV screening tests by sociodemographic variables and N % non-reactive in n % reactive in each risk behaviours: COBATEST each category category Network 2014–2018 Total 7313 98.5 113 1.5 Gender Male 5642 98.6 82 1.4 Female 1563 98.2 29 1.8 Transgender 103 98.1 2 1.9 Missing 5 100.0 0 0.0 0.7 Age group ≥ 16 and < 25 1695 99.2 13 0.8 ≥ 25 and < 45 3188 97.9 69 2.1 ≥ 45 and < 65 730 98.3 13 1.7 ≥ 65 56 98.2 1 1.8 Missing 1644 99.0 17 1.0 0.002 Migrant Yes 1403 97.5 36 2.5 Sub-saharan Africa 116 99.1 1 0.9 North Africa 43 93.5 3 6.5 North America 29 100.0 0 0.0 Latin America & Caribbean 207 98.1 4 1.9 Asia 158 95.8 7 4.2 Australasia 10 100.0 0 0.0 Europe 487 96.2 19 3.8 Migrants missing region of origin 353 99.4 2 0.6 No 4855 98.7 66 1.3 Missing migrant status 1055 99.0 11 1.0 0.007* MSM Yes 62 99.0 42 1.0 No 5287 97.8 62 2.2 Missing 1964 98.1 9 1.9 0.001 Sex worker Yes 320 97.0 10 3.0 Male 153 98.7 2 1.3 Female 107 94.7 6 5.3 Transgender 60 96.8 2 3.2 No 4360 98.3 76 1.7 Missing 2633 99.0 27 1.0 0.001* PWID Yes 96 75.6 31 24.4 No 4774 98.7 61 1.3 Missing 2443 99.1 15 0.9 < 0.001 HIV+ Yes 68 90.7 7 9.3 No 3717 98.3 64 1.7 Missing 3528 98.8 42 1.2 < 0.001 MSM HIV+ Yes 62 91.2 6 8.8 No 5287 98.4 87 1.6 Missing 1964 99.0 20 1.0 < 0.001 MSM men who have sex with men, FSW female sex worker, MSW male sex worker, TSW transgender sex worker, PWID people who inject drugs *Comparing categories: yes, no, missing a Pearson ­Chi2 test 13 Journal of Community Health Table 3  Odds of a reactive cOR 95% CI p aOR 95% CI p HCV screening test by sociodemographic variables and Gender risk behaviours: COBATEST Male Network 2014–2018 Female 1.3 (0.8; 2.0) 0.26 Transgender 1.3 (0.3; 5.5) 0.69 Age group ≥ 16 and < 25 ≥ 25 and < 45 2.8 (1.6; 5.1) < 0.001 ≥ 45 and < 65 2.3 (1.1; 5.0) 0.03 ≥ 65 2.3 (0.3; 18.1) 0.42 Migrant No Yes 2.0 (1.3; 2.9) 0.001 1.6 (1.0; 2.4) 0.04 MSM No Yes 0.5 (0.3; 0.7) < 0.001 Sex worker No FSW 0.9 (0.2; 3.6) 0.87 MSW 3.8 (1.6; 8.9) < 0.001 TSW 2.3 (0.5; 9.4) 0.26 PWID No Yes 28.4 (17.9; 45.0) < 0.001 28.1 (17.6; 45.0) < 0.001 HIV+ No Yes 7.0 (3.2; 15.7) < 0.001 MSM HIV+ No Yes 6.6 (2.8; 15.5) < 0.001 9.1 (3.8; 21.8) < 0.001 MSM men who have sex with men, FSW female sex worker, MSW male sex worker, TSW transgender sex worker, PWID people who inject drugs, cOR crude odds ratio, aOR adjusted odds ratio, CI confidence inter- val offering HCV screening which are tailored to their needs. and SW be tested for HCV every 6–12 months depending Peer counselling for this group has been suggested as a way on ongoing risk (sexualised drug use, PrEP or PEP use, to destigmatise testing [12]. HIV infection, history of rectal bacterial STI), that PWID In this study, being MSM was not associated with a be tested up to every 6 months and migrants be tested reactive HCV screening test but being HIV + MSM was. once with re-testing based on individual risk assessment HIV + MSM account for a small fraction of all people [15]. To assess clients’ ongoing risk, from the beginning tested but show a high proportion of reactive tests, reflect- of 2019 the COBATEST data collection tool will collect ing studies that find the HCV burden in MSM is concen- information on PrEP use and chemsex. trated in HIV + MSM [13]. The COBATEST questionnaire There are several limitations to this study. The study does not collect enough information to identify other sub- includes services in 10 countries but the results are not populations of MSM at higher risk of HCV such as pre- representative of all CBVCT activity in these countries, exposure prophylaxis (PrEP) users. A study in France in nor in the European region, and therefore cannot be gen- 2016-early 2017 found the incidence of primary HCV in eralised to the region. We do not have complete informa- HIV + MSM similar to that of HIV-MSM who use PrEP tion on how centres select who to screen for HCV, and and recommends both groups should be targeted for HCV why over 84,000 clients were screened for HIV and not screening (Cotte et al. [14]. ECDC public health guid- HCV. There was a high proportion of missing data for ance for HCV testing recommends that MSM, trans people some variables but, according to the sensitivity analysis, 13 Journal of Community Health the estimated effect of this was minimal. There are issues Iskorak (Croatia), LaSky (Russia), Legebitra (Slovenia)*, Mujer Gades with the data quality and documentation at service level (Spain), National AIDS Centre (Poland), OMSIDA (Spain)*, StopSida (Spain), Swiss Checkpoints (Switzerland). which have been identified in a recent study [10] and have not all yet been resolved. CBVCT services offer anony- Funding The COBATEST Network received grants from Gilead Sci- mous and confidential screening services, and no on-site ences Europe Ltd (2017) and the Health Programme of the European RNA test, thus it is unsurprising that there is a high per- Union (2018–2019) during the study. centage of missing information on RNA tests. In order to understand if CBVCT services are diagnosing active HCV Compliance with Ethical Standards infections, the reporting of RNA tests and results should be improved. This could be achieved by collaborating with Conflict of interest There are no conflict of interest for any author. local infectious disease clinics or laboratories to share RNA test results with the consent of the client. Further investigation is needed to understand if CBVCT services References have functional linkage to care pathways for clients with a reactive HCV screening test. 1. European Centre for Disease Prevention and Control. (2019). This study shows that the CBVCT service model can Annual epidemiological report for 2017—Hepatitis C. be used to screen for HCV and that services are detect- 2. World Health Organisation. (2016). Combating hepatitis B and C to reach elimination by 2030. ing possible active HCV infection. CBVCT services that 3. Heffernan, A., Cooke, G. S., Nayagam, S., Thursz, M., & Hal- historically focussed on HIV testing are now expanding lett, T. B. (2019). Scaling up prevention and treatment towards to offer screening for HCV and other diseases. This could the elimination of hepatitis C: A global mathematical model. boost testing coverage, especially for key populations, The Lancet, 6736(18), 1–12. https​: //doi.org/10.1016/S0140​ -6736(18)32277​-3. which is an essential element of any European country’s 4. Shehata, N., Austin, T., Ha, S., & Timmerman, K. (2018). Barri- strategy to eliminate HCV. Countries should incorporate ers to and facilitators of hepatitis C virus screening and testing: the CBVCT service model as part of a national strategy A scoping review. Can Commun Dis Rep, 44(6), 166–172. to increase HCV diagnosis and linkage to care in order to 5. Ross, M. W., Berg, R. C., Schmidt, A. J., Hospers, H. J., Breveg- lieri, M., Furegato, M., et al. (2013). Internalised homonegativity reduce the burden of disease. Governments can support predicts HIV-associated risk behavior in European men who have CBVCT services by facilitating circuits that allow fast sex with men in a 38-country cross-sectional study: Some pub- referral to an RNA test for clients who have had a reactive lic health implications of homophobia. British Medical Journal HCV screening and ensure linkage to care for those with Open, 3(2), 1–11. https:​ //doi.org/10.1136/bmjope​ n-2012-001928​ . 6. Conway, A., & Fernàndez López, L. (2018). COBATEST network: an active infection. Community-based voluntary counselling and testing in Europe 2017 Report. Acknowledgements We thank the following for taking the time to 7. World Health Organization (WHO). (2017). WHO guidelines on review the manuscript: Cristina Agusti Benito (CEEISCAT), Julia hepatitis B and C testing. Becerril Gascón (CASDA—Asociació Ciutadana Contra la SIDA), 8. Fernàndez-López, L., Reyes-Urueña, J., Agustí, C., Kustec, T., Valentin Blaison (ExAequo), Patricia Colomera (CAS/ARDS Lluís Klavs, I., & Casabona, C. (2016). The COBATEST network: A Companys), Lella Cosmaro (LILA Milano), Sabrina Penon (LILA platform to perform monitoring and evaluation of HIV commu- Milano), Heidi Slavin (AIDS Fondet). We thank all organisations nity-based testing practices in Europe and conduct operational who form part of the COBATEST Network and carry out testing research. AIDS Care, 0121, 1–5. https​://doi.org/10.1080/09540​ activities throughout the year (organisations whose data is included 121.2016.11462​18. in this study are marked with an asterix): Associació Antisida Lleida 9. Klavs, I., Kustec, T., Fernàndez López, L., Casabona, J., Meul- (Spain), Abraco (Portugal), Asociación Comunitaria Anti Sida de broek, M., Rios, L., & Al, E. (2014). Guidelines for data collec- Girona (Spain), Associació Ciutadana Antisida de Catalunya (Spain), tion for monitoring and evaluation of community based volun- Associació Ciutadana Alacant i província de persones afectades VIH tary counselling and testing (CBVCT) for HIV in the COBATEST (Spain)*, Asociación Ciudadana Cántabra Anti Sida (Spain), Actu- network. avallès (Spain)*, Adhara (Spain), AIDES (France), AIDS Fondet 10. Reyes-Urueña, J., Fernàndez-Lopez, L., Montoliu, A., Conway, (Denmark)*, AIDS Hilfe Wien (Austria)*, Alliance Global (Ukraine)*, A., Tavosch, L., Klavs, I., … Network, T. C. (2019). Assessing Àmbit Prevenció (Spain)*, ARAS (Romania)*, AIDS Solidarity Move- the quality of routine HIV testing data in the community setting ment Cyprus (Cyprus), Asociación Somos LGT (Spain)*, Asocijacija ‘COBATEST Network.’ International Journal of STD and AIDS. Duga (Serbia), Assexora’Tgn (Spain)*, Associació Lambda (Spain)*, https​://doi.org/10.1177/09564​62419​85757​2 AVACOS-H (Spain)*, Baltic HIV Associati (Latvia)*, CAS/ARDS 11. European Centre for Disease Prevention and Control. (2018a). Lluís Companys (Spain)*, Asociación Ciudadana Contra el SIDA Hepatitis B and C epidemiology in selected population groups in Castellón—CASDA (Spain)*, Comité Ciudadano Antisida de Asturias the EU/EEA. (Spain), Centre Jove d’Antico (Spain), Checkpoint Milano (Italy), Creu 12. Schatz, E., Schiffer, K., Maher, M., Harris, M., Roca, X. M., Mat- Roja Tarragona (Spain), Czech AIDS Help (Czech Republic), Demetra icic, M., et al. (2016). The Berlin Hepatitis C Manifesto: access (Lithuania)*, Deutsche AIDS Hilfe (Germany), Ex Aequo (Belgium)*, to prevention, testing, treatment and care for people who use Fondazione LILA Milano (Italy)*, Fulcrum (Ukraine)*, Gais Positius drugs. Hepatology, Medicine and Policy, 1(1), 1–9. https​://doi. (Spain)*, GAT Portugal (Portugal), GenderdocM (Moldova), Health org/10.1186/s4112​4-016-0021-9. Without Borders (Bulgaria), HERA (Macedonia), HUHIV (Croatia), 13 Journal of Community Health 13. MacGregor, L., Martin, N. K., Mukandavire, C., Hickson, F., 15. European Centre for Disease Prevention and Control. (2018). Pub- Weatherburn, P., Hickman, M., et al. (2017). Behavioural, not lic health guidance on HIV, hepatitis B and C testing in the EU/ biological, factors drive the HCV epidemic among HIV-positive EEA—An integrated approach. MSM: HCV and HIV modelling analysis including HCV treat- ment-as-prevention impact. International Journal of Epidemiol- Publisher’s Note Springer Nature remains neutral with regard to ogy, 46(5), 1582–1592. https​://doi.org/10.1093/ije/dyx07​5. jurisdictional claims in published maps and institutional affiliations. 14. Cotte, L., Cua, E., Reynes, J., Raffi, F., Rey, D., Delobel, P., … Dat’AIDS study Group. (2018). Hepatitis C virus incidence in HIV-infected and in preexposure prophylaxis (PrEP)-using men having sex with men. Liver International. https:​ //doi.org/10.1111/ liv.13922​ 13