Offering Testing for Hepatitis B and C in Primary Care Presentation - PowerPoint PPT Presentation

Offering Testing for Hepatitis B and C in Primary Care Presentation 3 January 2016 Quality Education for a Healthier Scotland Quality Education for a Healthier Scotland 1 1

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 Quality Education for a Healthier Scotland 2

Raising the issue of Hepatitis B and C testing • Normalise the request • Avoid stigmatising and blaming language • Emphasise the benefjts of testing for the individual Quality Education for a Healthier Scotland 3

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’’ Quality Education for a Healthier Scotland 4

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?” Quality Education for a Healthier Scotland 5

Testing - benefjts 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 Quality Education for a Healthier Scotland 6

Testing - pre-test discussion Remember – informed consent – not ‘counselling’! Three essentials: • Explain what you are testing for and the benefjts of testing to that individual • Allow opportunity to ask questions (and be able to answer them) • Explain how and when they will get the results Quality Education for a Healthier Scotland 7

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 Quality Education for a Healthier Scotland 8

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 Health Scotland (Take Control leafmet for Hepatitis C at http://www.healthscotland.com) or the British Liver Trust (http://www.britishlivertrust.org.uk) Quality Education for a Healthier Scotland 9

Testing - other issues (cont.) • Patient anxiety whilst awaiting result Ofger 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 Quality Education for a Healthier Scotland 10

Testing - how often to test for Hepatitis B and C? • If a one-ofg 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 – ofger 6-12 monthly testing for Hepatitis C (and HIV) - consider even if not disclosing injecting/sharing Quality Education for a Healthier Scotland 11

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 Quality Education for a Healthier Scotland 12

Testing - maximising uptake • Perform test your self- don’t expect someone to come back for another appointment • Ofger the test again even if previously declined – emphasise the benefjts. • Consider ofgering testing to all new registrants from areas of high prevalence • Ofger to all drug users – even if no history of injecting • Use Dried Blood Spot (DBS) testing if venous access hard Quality Education for a Healthier Scotland 13

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 fjnger prick capillary blood • If using DBS all fjve target circles must be completely covered in blood Quality Education for a Healthier Scotland 14

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 Quality Education for a Healthier Scotland 15

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 Quality Education for a Healthier Scotland 16

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 Quality Education for a Healthier Scotland 17

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 Quality Education for a Healthier Scotland 18

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 Quality Education for a Healthier Scotland 19

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 Quality Education for a Healthier Scotland 20

Interpreting the results – Hepatitis C - PCR is the key! • PCR test - viral load test • Detects viral RNA by amplifjcation and a positive PCR test indicates chronic infection • Only Hepatitis C PCR +ve patients are chronically infected • Also used to determine effjcacy of treatment and ‘cure’ Quality Education for a Healthier Scotland 21

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 confjrm ongoing 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) Quality Education for a Healthier Scotland 22

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 Quality Education for a Healthier Scotland 23

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 confjrm the negative result Quality Education for a Healthier Scotland 24

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) Quality Education for a Healthier Scotland 25

Diagram of Hepatitis B virus Core Protein HBc DNA DNA polymerase Surface Protein HBs Quality Education for a Healthier Scotland 26