Background <p>Globally, hepatitis C virus (HCV) elimination is a priority for marginalised communities, including Aboriginal and Torres Strait Islander peoples in Australia. Innovative and equity focused models of care are required to achieve elimination. The aim of this analysis was to evaluate prevalence of, and factors associated with, HCV infection among Aboriginal peoples engaged during implementation of a point-of-care testing and treatment intervention at Aboriginal primary health care services.</p> Methods <p>The SCALE-C prospective cohort study implemented a decentralised, on-site community-based “test and treat” intervention through four regional Aboriginal Community Controlled Health Organisations (primary care services) in New South Wales and South Australia between May 2019 and July 2022. Following a screening questionnaire (history of HCV infection, injecting drug use, incarceration, opioid agonist therapy use), participants underwent fingerstick point-of-care HCV testing (antibody [no risk] and/or RNA [history of HCV, ever at risk]); those at risk or with current HCV infection were also offered point-of-care HIV and HBV testing, education, and longitudinal follow-up. Participants with current HCV infection were offered DAA treatment. The primary endpoint was current HCV infection, with secondary endpoints including DAA uptake and outcome. Factors associated with current HCV infection were assessed using logistic regression analysis.</p> Results <p>Of 536 individuals enrolled (median age 39 years, 49% women, 37% injecting drug use ever, 32% incarceration ever), 79% identified as Aboriginal and/or Torres Strait Islander. The proportion with current HCV infection was 9%, ranging from 0.5% among people reporting no lifetime risk to 20% among those reporting risk within the past 12 months. Current HCV infection was associated with recent injecting drug use (adjusted OR: 10.43; 95% CI: 1.34–81.01). Among participants with HCV infection, 62% (28/45) received DAA treatment (median time from enrolment to treatment initiation, nine days [range 2, 22]) and 57% (16/28) of those treated had confirmed sustained virological response (SVR); SVR was 100% (16/16) among those retained in follow up.</p> Conclusion <p>A community-based decentralised on-site “test and treat” intervention integrated within existing Aboriginal community-controlled health organisations was feasible and effective in HCV case detection. While it holds potential for future elimination efforts, health system enhancement will be required (including dedicated staffing and infrastructure) to support broader implementation and improve linkage to care and treatment.</p> Clinical trial <p>This study was registered with clinicaltrials.gov (NCT03776760) on December 12, 2018.</p>