offering testing for hepatitis b and c in primary care · if the test shows hepatitis c antibody...

Quality Education for a Healthier Scotland 1Quality Education for a Healthier Scotland 1

Offering Testing for Hepatitis B and C in Primary CarePresentation 3

January 2016

Quality Education for a Healthier Scotland 2

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


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


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’’


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?”


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


Testing - pre-test discussion

Remember – informed consent – not ‘counselling’!

Three essentials:

• Explain what you are testing for and the benefits 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


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


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 leaflet for Hepatitis C at http://www.healthscotland.com) or the British Liver Trust (http://www.britishlivertrust.org.uk)

http://www.healthscotland.com

http://www.britishlivertrust.org.uk


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


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


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


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


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


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


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


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




• Hepatitis C antibody test negative

• Hepatitis B surface antigen negative

• Hepatitis B core antibody positive




• Hepatitis C antibody test positive

• Hepatitis C PCR test positive

• Hepatitis B surface antigen negative

• Hepatitis B core antibody negative


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


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’


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 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)


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


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


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)


Diagram of Hepatitis B virus

DNA polymerase

DNA

Surface Protein HBs

Core Protein HBc


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


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


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




• Now please check your answers


Interpreting Hepatitis B antibody results - summary

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


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 of responses on flip chart for feedback at end of this session

offering testing for hepatitis b and c in primary care · if the test shows hepatitis c antibody...

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