- Testing for hepatitis C provides considerable useful information for the individual, through engagement with the healthcare worker and at a population health level.
- The benefits associated with testing outweigh the risks provided the hepatitis C testing principles are followed.
- Testing is indicated for individuals who have been exposed to risk factors associated with transmission of hepatitis C or for individuals with clinical or biochemical evidence of liver disease and/or the extrahepatic manifestations of hepatitis C.
2.1. The benefits and risks of diagnostic testingIndividuals are offered hepatitis C testing on the basis of their clinical condition or risk factors for exposure. There are advantages and disadvantages of testing at individual and population levels.
- The testing process provides patients with information about hepatitis C, consequences of diagnosis and strategies to prevent transmission of HCV to or from others.
- Testing allows people to determine their hepatitis C status, whether positive or negative and, with the appropriate services and support, to be able to respond accordingly.
- A person given a diagnosis of hepatitis C can access information and support as well as treatments that offer improved health and an increasingly better chance of cure. People diagnosed with hepatitis C are also often able to cope better with the symptoms and illness of hepatitis C by improving their general physical health.
- Monitoring of testing, at the population level, provides the basis for an understanding of the changes in the rates of hepatitis C infection and distribution which, in turn, influences the planning of hepatitis C prevention and control programs (see Chapter 5: Surveillance and Research).
- As with any diagnostic test, there is a risk of false positive results; the chance of a false positive result may be higher than a true positive result in low risk groups such as pregnant women
- False negative results are rare but occur either due to technical problems, before seroconversion, or when samples are mishandled.
- People seeking testing for, or diagnosed with, hepatitis C may encounter discrimination from fears of transmission and/or assumptions of current or past drug use. This may place the person at risk of social isolation.
- A diagnosis of hepatitis C can be accompanied by feelings of fear, sadness, worry and regret, anger or disbelief.
- Access to appropriate treatment and support services may be difficult. Some people who have tested positive, feel anxious if they are unable to readily access treatment.
- In people who have tested positive, anxiety levels may be heightened by no, or inappropriate, pre-test and post-test discussion or inadequate support from healthcare services, family or friends.
Maximising the benefits and minimising the risks
Individuals who are well informed about hepatitis C and the consequences of testing are best able to assess the benefits and risks to themselves. Non-judgemental attitudes, harm reduction discussions, health promotion, pre-test and post-test discussion, provision of information and support, and ongoing health monitoring increase the likelihood of overall benefits from hepatitis C testing (see Chapter 7). In addition, taking account of the individual’s social and cultural needs (eg using interpreters) will increase the benefits of hepatitis C testing, irrespective of the test result.
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2.2. Risk assessment and indications for testingRisk assessment involves an understanding of the relationship between (past or present) risk factors and hepatitis C transmission. Knowledge of the prevalence of risk factors and the epidemiology of hepatitis C in Australia and overseas is valuable in targeting individuals, who may have been exposed to the infection, for testing.
Testing should not be conducted without a full assessment of the relative risks and benefits. When routine testing is done as a matter of course to simply make a diagnosis - the benefits will be limited. However in some cases a person may request testing, but not wish to disclose the reason for seeking the test.
People who have ever injected drugsIn Australia, approximately 80% of current infections and 90% of new infections have been caused by sharing of injecting equipment contaminated with hepatitis C infected blood or other forms of infected blood exposure within the injecting environment. Therefore, any history of injecting, however long ago, is a very strong indication to offer testing. Individuals who have injected drugs only once, without taking precautions to prevent infection are at low but real risk of infection.
People who are or have ever been incarceratedImprisonment has been shown to be an independent risk factor for hepatitis C transmission. Hepatitis C prevalence for all prisoners is estimated at 30-40% and higher for women. While a history of incarceration is a very strong indication to offer testing, hepatitis C testing in prisons should be based on risk assessments
The document Hepatitis C Prevention, Treatment and Care: Guidelines for Australian Custodial Settings (which will be available on the Department of Health and Ageing Web Site once it is completed), provides further guidance on testing in prisons.
Recipients of organs, tissues, blood or blood products before February 1990 in Australia, or at any time overseasHepatitis C is very efficiently transmitted by transfused blood or blood products. Infections acquired in this way account for 5-10% of all cases. Recipients in Australia who were transfused before hepatitis C testing commenced in February 1990 are offered tests, as are individuals who received transfusions overseas. All organs and organ donors are screened for HCV at the time a donation is made to ensure that an appropriate donation is carried out which reduces the risk of infection or complications for the recipient.
People with tattoos or skin piercingsSkin penetration practices are not independent risk factors for hepatitis C transmission. The indications to test will include a consideration of other factors that may contribute to increased transmission such as population prevalence or poor infection control procedures, e.g. tattooing and skin piercings which were carried out in some overseas countries. The risks associated with high prevalence and poor infection control procedures are also much higher if the tattoo or piercing was carried out in a custodial setting.
People born in countries with high hepatitis C prevalenceThe risk of hepatitis C infection may be greater for people born in countries where there is a high prevalence of hepatitis C infection than it is for people born in Australia. It is estimated that 11% of people in Australia who have been exposed to hepatitis C are immigrants from countries where there is a high prevalence of hepatitis C. In certain circumstances, country of birth is an indication to offer hepatitis C testing, particularly when dealing with people coming from countries in Asia, Africa and South America where hepatitis C transmission is not necessarily associated predominantly with injecting drug use.
Sexual partners of people with hepatitis C
The risk of sexual transmission of hepatitis C is very low unless blood is associated with sexual activity. There is emerging evidence of an increased risk of sexual transmission of hepatitis C for men who are also HIV positive.
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2.3. Clinical indications and case detectionIndications for hepatitis C testing in primary care should be assessed on the basis of a history of potential exposure and/or specific signs and symptoms, or requests for testing.
Clinical features of hepatitis C infection are diverse. Patients may present with abnormal liver function tests or evidence of liver disease with no apparent cause. Other presentations include symptoms and signs of acute or chronic hepatitis, extra-hepatic manifestations or advanced disease such as liver cirrhosis or hepatocellular carcinoma.
The onset of acute hepatitis C is often difficult to substantiate because of the mild or nearly absent symptoms marking the acute phase of this disease. In chronic disease mild symptoms usually persist for two to three decades before complications occur. Hepatitis C has been labelled a "silent epidemic," and the natural course is slow but progressive. Because of its ability to activate the immune system yet avoid elimination, chronic infection results in prolonged antibody production and the formation of immune complexes, which can result in extrahepatic manifestations of the infection.
While the liver is the primary target of HCV, certain non-hepatic conditions (including certain dermatological and rheumatological presentations, haematological abnormalities, renal or neurological complications3 ) can be associated with hepatitis C infection.
When considering whether a test for hepatitis C is indicated for clinical reasons, epidemiological risk factors should also be investigated.
2.4 When diagnostic hepatitis C testing might be consideredEvidence suggests that hepatitis C testing should be offered to the following groups only if they have risk factors for infection or upon request:
Pregnant women and antenatal testingThe prevalence of hepatitis C in pregnant women without other risk factors is the same as the general population. The presence of known risk factors, rather than pregnancy itself, is a strong indicator for testing. Hepatitis C screening for pregnant women should be confined only to those women who provide a history of risk factors, or request screening when counselled about relevant risk factors.
The risk of mother-to-child transmission of hepatitis C is generally low.
Factors which increase the risk of transmission from mother to child during pregnancy include:
- HIV co-infection in the mother;
- A high viral load – although this is not exclusively predictive and no cut-off point at which transmission will occur has been identified;
- An increased duration between membrane rupture and delivery; and
- The use of invasive devices such as foetal monitors.
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Nonetheless, any women identified as being at risk of hepatitis C infection should be offered testing. Testing should always be associated with specific informed consent, the provision of information about the meaning of the results (particularly in relation to the pregnancy) and post-test discussion.
Babies born to anti-HCV mothers may be anti-HCV positive at birth due to passive transfer of anti-HCV and should be retested at 18 months.
Pre-operative testingThere is no indication for routine pre-operative screening for hepatitis C. Pre-operative hepatitis C testing should be performed only if it will benefit the patient. Adherence to standard infection-control procedures offers the best protection against infection for both health care professional and patient.
Healthcare workersRefer Chapter 3.
3These extrahepatic manifestations are described in more detail in the ASHM publication HIV/Viral Hepatitis: a guide for primary care (2004).