Title: Women in the 2019 hepatitis C cascade of care: Findings from the British Columbia
Hepatitis Testers Cohort Study
Version: 2 Date: 15 May 2021
Reviewer's report:
Pearce and colleagues have described the cascade of hepatitis C care for women in British
Columbia, Canada in the BC Hepatitis Testers Cohort. They have specifically described the
cascade of care for women compared to men who a) received RNA testing and b) who did
not undergo RNA testing, to identify gendered differences in linkage to hepatitis C care and
associated risks for attrition from the cascade of care.
This is a very well written paper that fills an important literature gap in the experiences and
outcomes of women with hepatitis C infection and provides insights that could potentially
change practice through targetted interventions to improve outcomes for women living with
hepatitis C and ultimately facilitate timely achievement of hepatitis C elimination goals in BC.
The dataset is well described and the limitations of the dataset and methodology carefully
considered. The involvement of affected communities through consultation in the design process
is noted and appreciated.
My major comment is that this work  would benefit from statistical analysis to determine whether
the differences in cascade linkage described between men and women are actually significant
differences. Otherwise, it is difficult to justify investment in targetted campaigns to improve
hepatitis C cascade linkage for women. This is a great paper and it would be a missed opportunity
to not capitalise on these data with appropriate analyses, which would markedly strengthen the
paper and should be feasible to perform.
Other minor comments are:
-Suggest change Figure 1 graph to 2D to make it easier to read, and I would suggest adding in
a colour legend to show men and women are dark and light  blue for clarity (especially when
the graph may be shrunk to fit size in journal format).
-The discussion is very long and includes reiteration of a lot of numerical data. It could easily
be shortened through removal of much of the specific numerical data and just explaining the
results in summarised sentence form.
-It would be worth mentioning that genotype was needed in BC for DAA prescribing- or at least
it would appear so from your data, as not all countries still require genotype testing.
-One of the most convincing difference between men and women appeared to be for PWID
using opiates and treatment rates, with women 68% not receiving Rx and men 28% (if I have
interpreted the data correctly). Do the authors have any specific explanations for this difference,
given women had progressed to that point through blood tests etc?
-It would also be good to have a brief understanding (perhaps in supp methods) of how the
cascade works in BC- for example is there onsite testing, do people have all their blood tests
done at once at visit one or across multiple visits as test positive results come back to their
doctor etc? There is unlikely to be a one-size-fits all approach but good to understand whether
the testing process usually involves, one, two or ten appointments with health services.
-Did you have access to TORCH screening data for your cohort at all as part of the BBV test
results? would be interesting to see what proportion of women were not being treated because
they were pregnant among those born after 1975. The authors may consider this additional data,
or pregnancy related admissions data to expand their cascade details. There are some papers
internationally suggesting women may have higher ab testing due to pregnancy screening among
those born after 1975, for example, which did not appear to be borne out in the BC dataset.