Voluntary testing for hepatitis C is available for all inmates in accordance with the National Hepatitis C Testing Policy which provides the framework for testing for hepatitis C in Australia, including within custodial services.
4.1 The national hepatitis C testing policyThe National Hepatitis C Testing Policy provides guiding principles, including that testing is confidential, voluntary and only performed with informed consent. It also endorses the use of pre and post test discussion and where a positive result is confirmed, further information, support and referral is recommended as necessary.
The seven key principles that guide hepatitis C testing in Australia are:
confidential, voluntary testing with informed consent is fundamental to Australia’s response to hepatitis C;
- testing is of the highest possible standard;
- testing is of benefit to the person being tested;
- testing is accessible to all those at risk of hepatitis C infection;
- testing is fundamental to understanding the epidemiology of hepatitis C infection in the community;
- testing is critical to interruption of transmission; and
- testing to assist in the monitoring of patients during the course of their Hepatitis C management is an integral part of their care.
The policy emphasises that the decision to have a hepatitis C test requires careful consideration. There are clear advantages and disadvantages to determining one’s hepatitis C status.
Top of Page
4.2 Risk assessment and testing for hepatitis CRecommendations to inmates for hepatitis C testing are appropriate and based on a thorough risk assessment.
Voluntary testing is available to inmates in all jurisdictions, with the exception of the Northern Territory, where testing is mandatory at reception.
Custodial facilities should undertake a risk assessment of all inmates to determine their past testing history, previous results, hepatitis C status and the risk of hepatitis C infection, and on the basis of this offer testing. Since reception into a custodial facility is quite stressful, there is more benefit in deferring clinical assessment and testing until a more settled time when the inmate is better able to understand the meaning of the test and remember health information provided. There are many reports of adverse health consequences to individuals who were unaware they had been tested and unprepared for the diagnosis (NSW Anti-Discrimination Board 2001).
Testing is the primary tool for diagnosing and assessing the prognosis for people with chronic hepatitis C. Inmates found to be hepatitis C antibody positive and inmates who report having previously been diagnosed as hepatitis C positive are offered Polymerase Chain Reaction (PCR) testing (which detects the presence of viral nucleic acids) to determine whether they have chronic infection or have cleared the virus. This diagnostic event shapes how people with hepatitis C understand their infection. It is essential that the diagnosis is handled with sensitivity and that everyone tested receives information about hepatitis C, the management of hepatitis C and the services, including treatment services, available to them.
The benefits of testing are maximised if the inmate is provided with pre and post test discussion and appropriate follow-up if the test is positive. For inmates infected with hepatitis C, the usefulness of testing will be maximised if their health status is regularly monitored. Repeat testing is indicated for inmates who are hepatitis C antibody negative on reception, based on exposure to risk factors while incarcerated or development of clinical conditions.
Top of Page
4.3 Pre and post test discussionAll information about hepatitis C, the test, prevention and management is provided appropriately, using understandable language and resources that are suitable to the inmates’ socio-cultural background. Privacy and confidentiality are beneficial to this process. Training, including regular updates, is essential for health staff who provide testing and follow-up.
The provision of accurate, suitably presented information before testing and when giving test results is essential to allow individuals to make informed decisions about the benefits and risks of hepatitis C testing and understand the immediate and long term health implications of a positive result. Staff providing pre and post test discussions for both hepatitis C antibody and PCR testing need to be trained and supported to do this.
Respect for the inmate’s privacy is important following the decision to test and at the time of the delivery of the test result. A confidential consultation will facilitate a more open exchange of thoughts and information. It is similarly important that information relating to testing and the test result be restricted to health service staff and custodial staff where it is relevant to the inmate’s accommodation, movement or treatment.
Along with discussion and counselling, written information should be made available for inmates including in low literacy formats and languages other than English. Other formats for the provision of information should also be available such as video or computer based resources. Community based organisations can provide these resources, some of which have been developed specifically for custodial settings.
It is very important that inmates from Aboriginal and Torres Strait Islander communities and inmates from culturally and linguistically diverse backgrounds participate in the test discussion, so it is essential that it is performed in an appropriate language and is easily understood. Likewise, the discussion also needs to be appropriate for other individuals with low health literacy. For confidentiality reasons, inmates from Aboriginal and Torres Strait Islander communities and culturally and linguistically diverse backgrounds may not want to participate in a pre or post test discussion with a health care provider from their community.
Health professionals in custodial settings require training to develop clinical expertise in the difficult and complex area of hepatitis C risk assessment, prevention and management. Many of the related concepts of alcohol and drug use, social and mental health issues and harm reduction need to be considered and responded to in the management of inmates. Staff (and consequently their patients and the organisation) benefit from appropriate training and support in this complicated field.
Top of Page
4.3.1 Pre-test discussionWhen offering a test, the practitioner provides appropriate information to the inmate in an understandable way about risk, points of referral (if necessary), assurances about confidentiality and privacy and assessment of the person’s preparedness to be tested. This pre-test discussion prepares individuals for hepatitis C testing and the results of testing.
The health care provider and inmate thoroughly discuss testing before the test is performed. This is called ‘pre-test discussion’ rather than ‘counselling’ because the health care provider may also be required to assess risk, obtain consent, arrange follow up and identify referral needs. Counselling does not encompass this broader role. Use of the term discussion is not intended to diminish in any way the importance of the process. The need for pre test discussion is not reduced when testing is mandatory.
The hepatitis C test discussion is to provide accurate information about safe practices that are appropriate to the inmates injecting drug use, gender, culture and language. The complexity of the discussion will vary from person to person, depending on their risk assessment and other variables. The principles outlined in the National Hepatitis C Testing Policy are applicable to the discussion (DoHA 2006a).
Health staff of custodial facilities require training in the provision of test discussions and to ensure that appropriate test discussion precedes testing. The test discussion needs to be delivered in a format which is culturally and linguistically appropriate to the inmate.
4.3.2 Post-test discussionTest results are given in clear and understandable way that is appropriate to the inmate’s cultural, educational and social background. Delivering negative results provides an opportunity to reinforce preventive behaviours. Positive results are conveyed personally and privately. Components of this consultation include discussions of relevant health issues, the opportunities for referral and treatment, and prevention issues.
A negative result provides an opportunity to reinforce information and education messages about risk reduction strategies and to examine any difficulties or concerns the inmate may have. It is important to determine how recently the inmate has participated in risk behaviours so that a follow-up test can be arranged if necessary.
If the result is positive, post-test discussion with additional information, support and referral are given, as required. Information must be easily understood and provided in accessible formats, especially if giving a positive test result.
Staff of custodial facilities also require training in delivering test results and conducting the ensuing discussion. It is their responsibility to provide additional information, support and referral if the result is positive.
4.4 Hepatitis A and B vaccinationCo-infection with hepatitis C and hepatitis A and/or B can lead to worse health outcomes. Longer term imprisonment is an opportunity to protect inmates against vaccine preventable conditions such as hepatitis A and B.
Inmate health surveys indicate suboptimal hepatitis B immunisation of inmates, particularly those who are injecting drug users. Inmates are at increased risk of hepatitis B (Holly 2001). In settings such as prisons, outbreaks of some infections like hepatitis A are spread by faecal-oral contact. Inmates are at a higher risk of this infection than the general community (Whiteman 1998, Daly 2000). In Australia, outbreaks of hepatitis A have also been reported in men who have sex with men and injecting drug users (Ferson 1998).
The National Health and Medical Research Council (NHMRC 2003) recommends that inmates of long term custodial facilities be screened upon incarceration and, if susceptible, vaccinated using the combined hepatitis A and B vaccination. The Australian Immunisation Handbook (Australian Technical Advisory Group 2003) supports this recommendation. It also recommends that custodial staff, adolescent detainees (10-13 years), injecting drug users and individuals with hepatitis C are screened and immunised as appropriate. Hepatitis A and hepatitis B vaccination is standard care for people with hepatitis C, as outlined in the Model of Care for the Management of Hepatitis C Infection in Adults (DoHA 2003). Note the NHMRC Immunisation Handbook recommends inmates as a priority population for hep A and B vaccination (www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home).
The period of incarceration provides an opportunity to offer preventive health initiatives such as immunisation to inmates and juvenile detainees. Vaccination against both hepatitis A and hepatitis B should be offered to all inmates who have hepatitis C, who have not previously been immunised. Immunising custodial staff against hepatitis B is also strongly encouraged.
4.5 SurveillanceParticipation by custodial services in sentinel site surveillance programs for hepatitis C provides useful data to understand patterns of infection and to develop and evaluate prevention programs at an institutional and jurisdictional level.
Under public health legislation, hepatitis C is a notifiable disease in all jurisdictions. Infectious disease notifications form the basis of disease surveillance mechanisms that are crucial for monitoring the prevalence and incidence of hepatitis C. Surveillance also provides data to assist in the evaluation of prevention interventions and increases knowledge of the long-term consequences of hepatitis C infection. There is wide support for the collection of quality data across the country.
The National Hepatitis C Strategy 2005-2008 recognises the need to explore surveillance models which better target Aboriginal and Torres Strait Islander populations at risk (DoHA 2005).