National Hepatitis C Testing Policy May 2007
7. Pre-test and post-test discussions
- Pre-test and post-test discussions form an integral part of hepatitis C testing and education about HCV and its prevention. Provision of information and support associated with testing is consistent with the goal of the second National Hepatitis C Strategy, which includes minimising the personal and social impacts of hepatitis C infection.
- The term ‘pre-test and post-test discussion’ are used in place of ‘hepatitis C test discussion and post-test counselling’.
- Healthcare workers delivering the test result should use their best judgment in establishing the most appropriate way to communicate the test result. Factors to consider include the person’s testing history, gender, cultural beliefs and practices, behaviour, ongoing risk, understanding of hepatitis C and language and literacy levels.
- Home based tests are not approved in Australia, and home-based testing is not supported.
- Test results should be given in person, wherever possible.
7.1 Informed consentGaining informed consent from the individual to be tested is a legal requirement and fundamental to an effective, best-practice testing process. Typically, informed consent should be obtained during pre-test discussion. Pre-test discussion should also incorporate an assessment of risk, an explanation of the testing process, as well as a discussion of the possible outcomes of the test, what these mean and support available to the person in the event of a positive result.
Risk assessments and testing should be conducted in a sensitive and culturally safe manner and additional consideration may be required for Aboriginal people such as time, skills and Aboriginal community specific resources. Strategies to gain informed consent from people from CALD backgrounds may include using health care interpreters (if available) or telephone interpreters who are available nationally for use by public and private health care professionals (see Appendix 7 for contact details).
Counselling is an appropriate term for the longer-term management of a person who has tested positive. Counselling may also be an option for a HCV negative person who requires support maintaining safer behaviours and/or support with changing personal behaviours that may be placing them at risk. In many cases, counselling needs to be delivered at a more specialised level of care than can be provided by generalist health care professionals.
The position of this policy is that the term “pre-test and post-test discussion” should be adopted in place of “HCV test discussion and post-test counselling”.
Hepatitis C testing is a particularly sensitive health care issue for Aboriginal and Torres Strait Islander communities (Refer to Chapter 4).
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7.2 Pre-test discussionPre-test information aims to prepare individuals for hepatitis C testing and to sufficiently equip the person requesting the test such that she/he can give informed consent. When a person requests or is offered a test, the practitioner should give appropriate information about risk, points of referral if necessary, assurances about confidentiality and privacy, and assessment of the person’s preparedness to be tested. Written information in the person’s first language (if available) should be provided when the pre-test discussion occurs (see Appendix 7 for details of relevant websites).
Specifically, the hepatitis C pre-test discussion should provide accurate information about safer practices that are appropriate to the person’s gender, cultural beliefs and practices, behaviour, ongoing risk, understanding of hepatitis C and language and literacy level. The discussion should include:
- risk assessment and discussion of the reason for testing;
- how to reduce the risk of becoming infected or infecting others-for example information about safer injecting when this is relevant;
- possible desirability for other BBV testing and/or STI testing;
- information about confidentiality and privacy;
- information about the testing process including how results are to be provided, and the window period;
- information about what happens to test results (ie the notification process);
- seeking informed consent for the test to be conducted;
- assessment of the person’s preparedness to be tested;
- information about what a negative or positive result means including basic printed information about hepatitis C; and
- assessment of support mechanisms while waiting for the test result and/or if the result is positive.
7.3 Post-test discussionTest results should be delivered to the patient as soon as possible after results are received from the lab. It is strongly recommended that test results be given in person. Other methods of communication should only be used in exceptional circumstances. Post-test discussion provides the opportunity to discuss health issues, referrals and prevention issues.
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The post-test discussion should include:
- giving the test result in person and in a manner that is confidential, sensitive and appropriate to gender, cultural beliefs and practices, behaviour, ongoing risk, understanding of hepatitis C and language and literacy level; and
- re-assessing support mechanisms and requirements of the person and making immediate referral to a support agency to be accessed at the person’s discretion.
If the result is negative, the discussion should include reinforcing harm reduction strategies, education and information messages about safer behaviours, and examining any difficulties or issues that the person may have in practising safer behaviours. It should be emphasised that a negative test result following a risk event does not indicate that it is likely to be safe to repeat risky behaviour. The relief associated with a negative test result may also impede the processing of information and advice at that time.
If the result is positive, discussion should include at an appropriate time, issues such as:
- immediate needs and support including written referral information;
- safer behaviours – education, information and support including needle and syringe programs if appropriate;
- legal requirements for disclosure and how to disclose to family and friends;
- managing or understanding strong emotions, feelings, reactions and changes;
- options in drug treatments and medical management;
- ongoing counselling or therapy if required;
- complementary/alternative management options;
- ways to deal with loss and grief, depression, anger and anxiety;
- strategies for managing hepatitis C which are flexible and appropriate to the person’s needs; and
- legislative requirements (notification, contact tracing, storage and coding).
Provision of information and support
In addition to post-test discussion, people diagnosed with hepatitis C infection may need continuing support, particularly in the period immediately after they learn their test result. The purpose is to provide reassurance, to help them work through any difficulties (such as telling others they are infected) and to help place the infection in context. This is also another opportunity to reinforce messages about the natural history of hepatitis C and to inform people of the available treatments, should treatment become necessary.
Community organisations such as hepatitis C councils and drug user organisations are well placed to provide information and support. People diagnosed with hepatitis C infection should be told how to contact these organisations. Contact details for these organisations and their peak bodies are listed in Appendix 7.
Ongoing health monitoringFor people infected with hepatitis C, the usefulness of testing will be maximised if their health status is regularly monitored.
Some groups of people infected with hepatitis C (such as people who inject illicit drugs) may have other, more pressing, health concerns. In this situation it is preferable that their overall primary health care needs, including their hepatitis C infection, be approached in a comprehensive way and in a setting that is non-discriminatory and sensitive to their situation. This will also assist in facilitating access to suitable health care, which is often limited for this group of people.
In population groups for which it is likely that infection with hepatitis C occurred a considerable time ago, there may be additional benefit in being tested: if infected, these people are more likely than those relatively recently infected to have progressed to the point where treatment might be indicated. This is most likely to apply to people infected in their country of birth, people who were infected through the receipt of blood or blood products in Australia before 1990, and people who previously injected illicit drugs.
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7.4 Home based testing in AustraliaHome-based testing refers to a process where hepatitis C testing is conducted outside a medical or clinical setting. The process is similar to conducting a home-based pregnancy test, in which the test is performed and interpreted by an individual in a non-medical setting. Home-based testing can also mean that an individual collects a sample at home and sends it to a centralised laboratory for formal testing and interpretation. For the purposes of this policy, the former will be referred to as ‘home-testing’ and the latter as ‘home-collection’.
Hepatitis C testing in Australia should always be performed in a clinical context, where there is an appropriate level of interaction between the individual being tested and a suitably qualified health professional, including pre-test discussion. Introduction of home collection and home-testing for hepatitis C in Australia is not supported.
It is important to note that home-testing and home collection-kits have not been approved for use in Australia by the Therapeutic Goods Administration. As home-testing kits are available for purchase over the internet from overseas suppliers, it is important that access to and use of these tests is monitored through social research, anecdotal reports and observation. Health promotion interventions may be necessary if the practice of home-testing becomes prevalent.