Offering Testing for Hepatitis B and C in Primary Care Presentation 3 October 2017 0
Learning Outcomes Participants will be able to: ‐ Undertake a pre ‐ test discussion for Hepatitis C and • Hepatitis B testing to ensure informed consent is obtained Implement strategies in practice to maximise uptake • amongst those at risk Interpret Hepatitis C and Hepatitis B serology results • NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 1 1
Raising the issue of Hepatitis B and C testing Normalise the request • Avoid stigmatising and blaming language • Emphasise the benefits of testing for the individual • NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 2 Testing for these viruses needs to be part of routine clinical practice if we are to reduce the number of people with undiagnosed infection. The request should be normalised. Be aware that the people who are at risk are in groups who are often stigmatised and excluded ‐ injecting drug users, MSM, immigrants and we need to make sure that we are not seeming to blame them for their risk of infection. The benefits of having a test clearly outweigh any perceived risks and we need to be very clear what the benefits of knowing your diagnosis are when obtaining informed consent to test. 2
Testing ‐ normalising testing – suggested approaches “Your tests have shown some damage to your liver and it is important that we work out why this is happening. There are many causes of this damage, including viral infections called Hepatitis B and Hepatitis C. These are treatable infections and I recommend we test for them in these circumstances’’ NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 3 You need to find your own language and phrases that suit you. 3
Testing ‐ avoiding stigmatising and blaming language “People who have used drugs, even if it was a long time ago, are at higher risk of certain viral infections including Hepatitis C, Hepatitis B and HIV. All of these are now treatable infections and we recommend routine testing for them. Would you agree to us taking these tests?” NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 4 NOT ‐ drug users can catch all sorts of infections so I am going to test you for Hepatitis C and HIV. NOT ‐ your country has lots of Hepatitis C infection so we had better test you for it. 4
Testing ‐ benefits of Testing Emphasise the following: Allows access to treatment which can control or cure • infection Helps you to avoid future risk to yourself or others close • to you Can allay anxiety if you are worried you June be infected • Allows you to take measures to help protect liver if • infected with Hepatitis B or C NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 5 You are much more likely to do harm by not testing someone for a blood borne virus. You do need to get informed consent to taking the test. 5
Testing ‐ pre ‐ test discussion Remember – informed consent – not ‘counselling’! Three essentials : 1. Explain what you are testing for and the benefits of testing to that individual 2. Allow opportunity to ask questions (and be able to answer them) 3. Explain how and when they will get the results NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 6 These essentials are based on the UK National Guidelines for HIV Testing 2008 published by BHIVA 6
Testing ‐ other issues Window period – length of time after infection that it • takes for a test to show a positive result – Hepatitis C – 3 months – Hepatitis B – 3 ‐ 6 months – (HIV – 4 weeks ‐ 3 months) Test and repeat test after window period rather than • delay testing NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 7 People need to know whether the test will give them a definitive result ‐ or it they will require a repeat test to ensure that they are not infected if the first test comes back negative. This situation arises if they test within the ‘window period’ that is the time during which antibody levels may not high enough in the blood stream for the current tests to detect. The length of time varies between the different BBV infection. 7
Testing ‐ other issues (cont.) • What to test for? As the risks overlap it is sensible to test for Hepatitis C, Hepatitis B and HIV at the same time • Use published material at pre ‐ test discussion Available from Hepatitis C Trust http://www.hepctrust.org.uk/resources/leaflets ‐ and ‐ print ‐ publications Hepatitis Scotland http://www.hepatitisscotland.org.uk/publications ‐ and ‐ resources/resources/living ‐ hepatitis ‐ c ‐ patient ‐ booklet The British Liver Trust (http://www.britishlivertrust.org.uk ) NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 8 Risk of one BBV infection means that you have some risk for the others and it is often sensible to test for Hepatitis B, Hepatitis C and HIV on the same test, consenting the patient for all three tests. Good written materials are available to to back up the oral information that you are giving. 8
Testing ‐ other issues (cont.) Patient anxiety whilst awaiting result Offer support and signpost to organisations such as the • Hepatitis C Trust and Hepatitis Scotland Informing others Discuss who they should tell about having the test – and • who they do not have to tell at this stage NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 9 Waiting for the result is often the most anxious time for people, a test may take a week to come back in primary care. Offer support yourself and from other organisations during this time. Find out who your local voluntary organisation offering support to patients with BBV infections are. People often start to worry about who they need to tell that they are having a test. If they tell someone they are testing they are likely to have to tell them the result so they need to consider that. 9
Testing ‐ how often to test for Hepatitis B and C? If a one ‐ off exposure to infection, check about window • period and if tested after that then no more testing is required If recent exposure, test after the window period (6 • months) Immunise against Hepatitis B – no further testing • required for Hepatitis B All active drug users – offer 6 ‐ 12 monthly testing for • Hepatitis C (and HIV) ‐ consider even if not disclosing injecting/sharing NES and HPS accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind made to the training resources by a NHS board/third party to reflect local policy and information Page 10 This is particularly an issue for Hepatitis C as there is no immunity from previous exposure and no vaccine to protect them. So all injecting drug users who continue to inject should be offered regular repeat testing ‐ even if they are not disclosing sharing of equipment. Some people would recommend repeat testing of all drug users as they may not disclose injecting at all and there is a risk from snorting drugs. 10
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