Offering Testing for Hepatitis B and C in Primary Care Presentation 3 - - PDF document

Offering Testing for Hepatitis B and C in Primary Care Presentation 3 October 2017

Learning Outcomes Participants will be able to:‐

• Undertake a pre‐test discussion for Hepatitis C and

Hepatitis B testing to ensure informed consent is

• btained
• Implement strategies in practice to maximise uptake

amongst those at risk

• Interpret Hepatitis C and Hepatitis B serology results

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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

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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.

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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’’

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You need to find your own language and phrases that suit you.

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Testing ‐ avoiding stigmatising and blaming language

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“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?”

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.

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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

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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.

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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

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These essentials are based on the UK National Guidelines for HIV Testing 2008 published by BHIVA

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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

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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.

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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)

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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.

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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

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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.

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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

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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.

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Testing ‐ getting the result

• Arrange appointment at pre‐test discussion stage.
• Ideally done by the person who undertook pre‐test

discussion (and took blood samples)

• Invite patient to have someone with them when they

get the result.

• Use as a harm reduction opportunity

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As increasing amounts of hepatitis tests are performed it may not be practical to give all results face to face. It is acceptable to give negative results on the telephone although a harm reduction/prevention opportunity may be missed Positive results should be given in person, ideally by the person who did initial discussion, but should be done by any appropriately qualified professional at next contact, rather than risk missed opportunity. Harm reduction regardless of result is of prime importance.

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Testing ‐ maximising uptake

• Perform test your self‐ don’t expect someone to come

back for another appointment

• Offer the test again even if previously declined –

emphasise the benefits.

• Consider offering testing to all new registrants from

areas of high prevalence

• Offer to all drug users – even if no history of injecting
• Use Dried Blood Spot (DBS) testing if venous access

hard

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In view of the population that we are targeting it is best to take the opportunity to offer and carry out testing whilst they are with you. Bringing people back to appointments just for testing results in high non‐attendance rates due to the other priorities in peoples

• lives. Non‐attendance should not be takenas a refusal to test. Emphasise the benefits of

testing.

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Testing ‐ taking the test

• Single venous blood test can be used to test for

Hepatitis B, Hepatitis C and HIV

• Clearly state clinical history and risk factors on request

from including estimated date of last possible exposure

• DBS testing available in Scotland for diagnosis of all BBV

using finger prick capillary blood

• If using DBS all five target circles must be completely

covered in blood

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Brown tube, single virology form.

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Dried Blood Spot (DBS) testing

• Dry blood spot testing
• Hepatitis C antibody testing
• Hepatitis C RNA detection OR Antigen detection
• HIV antibody testing
• Hepatitis B surface antigen detection
• Hepatitis B core antibody

testing

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Measuring the incidence, prevalence and genetic relatedness of Hepatitis C infections among a community recruited sample of injecting drug users, using dried blood spots. Hope VD, Hickman M, Ngui SL, Jones S, Telfer M, Bizzarri M, Ncube F, Parry JV. J Viral

• Hepat. 2011 Apr;18(4):262‐70. doi: 10.1111/j.1365‐2893.2010.01297.x.

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Interpreting the results

Make sure you give the person the correct result! Test your previous knowledge gained from eLearning module now! Write down answers to the questions on the following 3 slides and check your knowledge at end of this section.

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Ask them to look at examples of results in their pack and write down what they think the result mean ‐ we will come back to these at the end of the talk.

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Test your previous knowledge

Working it out in practice – what does it mean if?

• Hepatitis C antibody test positive
• Hepatitis C PCR test negative
• Hepatitis B surface antigen positive
• Hepatitis B core antibody negative

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Please see slide 30 for the answer.

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Test your previous knowledge

Working it out in practice – what does it mean if?

• Hepatitis C antibody test negative
• Hepatitis B surface antigen negative
• Hepatitis B core antibody positive

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Please see slide 30 for answer.

17

Test your previous knowledge

Working it out in practice – what does it mean if?

• Hepatitis C antibody test positive
• Hepatitis C PCR test positive
• Hepatitis B surface antigen negative
• Hepatitis B core antibody negative

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Please see slide 30 for answer.

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Interpreting the results ‐ Hepatitis C

• Initial test is serology for antibodies to Hepatitis C

‘Hepatitis C antibody positive’ – it shows exposure to the virus but not whether infection is ongoing

• A positive result will automatically be sent for PCR (or in

some areas an ANTIGEN) test

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Antigen testing in Lothian and starting in Glasgow and other areas.

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Interpreting the results – Hepatitis C ‐ PCR is the key!

• PCR test ‐ viral load test
• Detects viral RNA by amplification and a positive PCR

test indicates chronic infection

• Only Hepatitis C PCR +ve patients are chronically

infected

• Also used to determine efficacy of treatment and ‘cure’

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People are still telling patient who are Hepatitis C antibody positive but PCR negative that they have Hepatitis C infection. PLEASE DO NOT DO THIS ‐ ONLY PATIENTS WHO ARE PCR OR ANTIGEN POSITIVE HAVE ONGOING INFECTION.

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Interpreting the results – Hepatitis C antigen test

• In some areas an ANTIGEN test is carried out to

diagnose Hepatitis C

• In some areas it replaces the PCR test to confirm
• ngoing infection‐ If the antigen test is positive it shows

chronic infection with Hepatitis C

• If the antigen test is negative the patient needs a PCR

test to double check result (another sample)

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In many areas the patient has an initial antibody test and if this is positive an ANTIGEN test is performed instead of the PCR test, if the antigen test is positive the patient has

• ngoing Hepatitis C infection. If the antigen test is negative the lab requests that another

blood sample is taken in a red EDTA tube on which PCR test is performed to confirm no active infection. This second test is required because the lab is concerned about false negative antigen tests. The antigen test is cheaper and quicker than the PCR test. It may show an active infection earlier than the antibody test but has a higher false negative rate than the PCR test.

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Interpreting the results – Hepatitis C – negative tests

• If the test comes back Hepatitis C antibody

negative the patient has not been infected with Hepatitis C (however remember the window period!)

• Should be advised that they have not been

infected but if they put themselves at risk again they could become infected

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These are the people who do NOT have evidence of Hepatitis C infection.

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Interpreting the results – Hepatitis C – negative tests (cont.)

If the test shows Hepatitis C antibody positive but the PCR test is negative:

• They have been infected with Hepatitis C, but have

cleared the virus

• They are not immune to Hepatitis C and could become

infected again – and it may become a chronic infection next time If the test shows Hepatitis C antibody positive but the antigen test is negative:

• Lab may request EDTA (red) tube for PCR testing to

confirm the negative result

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Antigen tests are not so straight forward in this situation and a negative antigen test associated with a positive Hepatitis C antibody test requires confirmation with a PCR test.

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Interpreting the results – Hepatitis B

Must establish two key factors:

• Is the person infected currently?
• If not currently infected, is the person

immune? Three tests can answer these questions:

• Hepatitis B surface antigen (HBsAg)
• Antibody to HBSsAg (anti‐HBsAg)
• Antibody to HB core antigen (anti‐HBcAg)

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Two questions ‐ three tests to answer them. Hepatitis B surface antigen is a viral particle, the other two tests are for antibodies (i.e. the immune response) to viral elements.

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Diagram of Hepatitis B virus

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Surface antigen on the outside of the virus is released into the blood stream during an infection and also evokes an immune response. Artificial surface antigen is uses in the Hepatitis B immunisation. Core antigen in the middle of the virus also evokes an immune response.

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Interpreting the results – Hepatitis B surface antigen: a viral component

• Hepatitis B surface antigen (HBsAg) is detected in

current infection. (>6 months = chronic infection)

• If this is positive the patient has an ongoing Hepatitis B

infection

• If this is negative the patient does not have an ongoing

Hepatitis B infection

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Surface antigen is a bit of the virus so if it is detected in the blood stream there must be an active infection. If it is not present there is no active or ongoing infection.

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Interpreting the results – antibody to Hepatitis B surface: an immune response

• Hepatitis B surface antibody (anti‐HBs)
• If this is positive it means that the patient has had a

past infection or been immunised and is now immune to Hepatitis B

• If this is negative it means that they have not had a past

infection, and if the antigen test is also negative, they need immunised

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An immune response from a past infection or after immunisation. If it is not present the patient should not be considered immune.

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Interpreting the results – antibody to Hepatitis B core: an immune response

• Hepatitis B core antibody (anti‐HBc)
• If this is positive it means that the patient has had a

past infection and may now be immune to Hepatitis B

• If this is negative it means that they have not had a past

infection, if the antigen and surface antibody tests are also negative, they need immunised

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An immune reaction to the middle of the virus, only occurs after an infection NOT after immunisation.

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Test your previous knowledge

Working it out in practice – what does it mean if?

• Now please check your answers

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Slide 17

• Hepatitis C antibody test positive
• Hepatitis C PCR test negative
• Hepatitis B surface antigen positive
• Hepatitis B core antibody negative

This shows previous exposure to Hepatitis C but no evidence of active infection, the patient is not immune to Hepatitis C. The patient has active Hepatitis B infection and requires urgent referral to Infectious Diseases or a Liver Unit. Slide 18

• Hepatitis C antibody test negative
• Hepatitis B surface antigen negative
• Hepatitis B core antibody positive

The patient does not have active Hepatitis B infection but has had previous infection and is immune to Hepatitis B infection now. They are not immune to Hepatitis C infection. Slide 19

• Hepatitis C antibody test positive
• Hepatitis C PCR test positive
• Hepatitis B surface antigen negative
• Hepatitis B core antibody negative

This shows no evidence of exposure to Hepatitis C infection. This shows active infection with Hepatitis C as the PCR is positive. There is no evidence of exposure to Hepatitis B infection and they are not immune, they require immunisation.

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Interpreting Hepatitis B antibody results – summary

If the Hepatitis B surface antigen test is negative then:

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Anti‐HBc Anti‐HBs Interpretation and action ‐ ‐ Never had Hepatitis B and no immunity ‐ immunise + + Past infection ‐ no action as now immune + ‐ Past infection ‐ no action as now immune ‐ + Past immunisation – complete the course or re‐ immunise unless certain fully immunised

Emphasise that these results are for patients who are known to be Hepatitis B surface antigen negative, that is they do not have a current Hepatitis B infection.

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Group work ‐ testing

• The group facilitator will present you with three case

studies on ‘Testing’

• Each case study has a number of questions to be

addressed

• For each case – please discuss and capture main points
• f responses on flip chart for feedback at end of this

session

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