Engagement in hepatitis C virus cascade of care and factors associated with testing among people who inject drugs in Iran

Background: Understanding the hepatitis C virus (HCV) cascade of care (CoC) and factors associated with engagement is crucial for designing interventions for achieving HCV elimination. However, data on engagement in the HCV CoC among people who inject drugs (PWID) in the Middle East and North Africa remains limited. We examined the HCV CoC and factors associated with testing among Iranian PWID. Methods: We recruited PWID in 14 cities using respondent-driven sampling. PWID completed structured interviews capturing measures on socio-demographics, behaviors, and HCV CoC. We examined the self-reported numbers and proportions of individuals who ever tested for HCV, tested positive for HCV antibody, were diagnosed with HCV, initiated HCV treatment, and achieved sustained virologic response (SVR). Multivariable logistic regression models were built to assess factors associated with HCV antibody testing. Results: Of 2308 PWID, 23.1% had ever received an HCV antibody test, 13.9% received the HCV antibody test in the last year, 3.4% had tested positive for HCV antibodies, and 2.5% had received an HCV diagnosis. Of those diagnosed, 54.4% reported initiating treatment, and 31.6% had achieved SVR. HCV antibody testing was significantly associated with having knowledge about HCV transmission through sharing needle/syringe (adjusted odds ratio [aOR] 8.09; 95% confidence intervals [CI] 5.25, 12.48), living with HIV (aOR 4.15; 1.58, 10.92), no previous history of homelessness (aOR 1.89; 1.31, 2.72), history of arrest/incarceration (aOR 1.83; 1.26, 2.64), history of being diagnosed with any mental health problems (aOR 2.88; 1.79, 4.61), history of non-fatal overdose (aOR 1.51; 1.08, 2.10), receiving needle exchange programs in the last 12 months (aOR 6.20; 3.86, 9.93), opioid agonist treatment in the last six months (aOR 2.10; 1.39, 3.18), and having ever received HBV vaccine (aOR 2.31; 1.59, 3.35). Conclusions: We found a considerably low engagement in HCV CoC among PWID in Iran. Enhancing access to testing services for PWID, especially those with limited awareness of HCV transmission and those encountering structural challenges, is essential as the initial step in the HCV CoC. This improvement is vital for strengthening HCV elimination efforts in Iran.