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5.0 Conveying Hepatitis B Test Results

Posted in: HBV

The process of conveying a hepatitis B test result to the person being tested (irrespective of the specific result) is affected by:

  • the type of test performed and the need for additional testing to determine the individual’s actual hepatitis B status; 
  • the context in which the test is being performed and the setting of the consultation;
  • the attitude and level of health literacy of the patient, and the potential implications of the result in the individual circumstances of each patient.

 The health care provider who requests the test is responsible for ensuring that the delivery of the test result is carried out in a setting conducive to discussing the implications of the result and addressing the issues that the result raises. In presenting results to people with low English proficiency, professional interpreter services should be accessed (see section 4.0 for details). The use of family members should not replace the need for an accredited interpreter. In all cases, health care providers should be mindful of health literacy levels and possible misinterpretations of the terms “positive” and “negative” when discussing test results. People being tested may interpret a so-called “positive” result as good and “negative” as bad. One method to help reduce the chance of misunderstanding is the Teach-Back technique.

The decision about how results from a hepatitis B test indicating immunity or otherwise (see section 2.1) is provided (e.g. in person, by phone) should be based on the clinical judgment of the person responsible for conveying the result. This assessment should take into account the psychological capacity of the person being tested to deal with the outcome of testing and his or her understanding of the testing process as evident at the time of the sample collection. A confirmed HBV infection result should always be provided in person by the clinician, except in extenuating circumstances where, for example, it is suspected that the person who has been tested may not return for the result or may engage in risk behaviour(s) based on the wrong assumption that they are HBsAg negative.

5.1 Conveying a hepatitis B test result: susceptible (non-immune)

A susceptible individual is one in whom there is no documented history of completed vaccination, and the anti-HBs, anti-HBc and HBsAg results are all negative. It is imperative that the meaning of a negative (susceptible) result is fully understood and that the person being tested receives appropriate information about and opportunity for hepatitis B vaccination, and is made aware of other harm reduction strategies in relation to the spread of blood borne viruses and sexually transmissible infections. Further testing following a negative result (anti-HBs or HBsAg) is indicated in persons who may:

  • be in a window period prior to seroconversion (negative HBsAg, anti-HBc and anti-HBs in a high-risk situation – with consideration of post-exposure prophylaxis as appropriate);
  • have been completely vaccinated against hepatitis B without previous confirmation of anti-HBs seroconversion (possible non-response to the vaccine, or a fall in anti-HBs titre over time).

The person should be informed of the reasons why repeat testing after an interval may be necessary. In this situation the clinician should enter the person into a system for automatic recall, rather than relying on the person to follow up on their own initiative.

It is imperative that the clinician make all attempts to ensure that the result is being provided to the person who was tested. This includes:

  • confirming the person’s identity by asking for the spelling of all their names;
  • making repeated contact to ensure the person is aware of the availability of the result;
  • documenting all efforts to contact the person.

5.2 Conveying a hepatitis B test result: immune

When the anti-HBs titre is positive in the setting of previous completed vaccination, or anti-HBc is positive with or without anti-HBs also being positive, a person is regarded as immune. Isolated anti-HBc positive results most commonly indicate distant resolved infection (with the anti-HBs titre having fallen below the threshold of the assay). However, the result is occasionally falsely positive and, rarely, isolated anti-HBc results can indicate a different hepatitis B status (see section 2.0).

When a person is identified as being immune, either through natural infection or vaccination, this should be clearly entered in their medical record and conveyed to the person, to avoid unnecessary repeat serologic testing or vaccination in the future.

Patients immune through natural infection should be advised that they may be at risk in settings of immunosuppression.

5.3 Conveying a hepatitis B test result: confirmed infection

A HBsAg test result that confirms infection (HBsAg positive) can have a significant impact for an individual and his or her significant other(s). This result may indicate either an acute or a chronic HBV infection and the information provided will reflect the clinical situation. Laboratories should provide requesting clinicians with information and the opportunity for consultation and expert advice at the time of diagnosis. In providing results to people with low English proficiency, professional interpreter services should be accessed when health care staff do not speak the person’s preferred language (see section 4.0). The professional interpreter may lack the vocabulary to explain the meaning of “viral hepatitis” and it is important to check understanding and get the person to repeat back what they understand about the information that has been conveyed to them via the interpreter. The use of family members as interpreters is strongly discouraged. Resources for assessing the need for an interpreter can be found on the Centre for Culture, Ethnicity and Health (CEH) website. 

The process of conveying a result of confirmed hepatitis B infection should include:

  • giving the test result in person and in a confidential manner that is sensitive and appropriate to the gender, culture, behaviour, language and literacy level of the person who has been tested;
  • assessing the need for and providing information about the natural history of hepatitis B, and the importance of clinical monitoring to identify resolution of acute infection (95% of adults) or, in the case of chronic hepatitis B, regular, ongoing clinical monitoring to detect progression of liver disease, determine the need for treatment and prevent HCC;
  • identifying the importance of lifestyle changes - in particular alcohol consumption, for people with chronic hepatitis B, the availability, efficacy and timing of treatment options;
  • assessing  use of hepatotoxic medications and over the counter preparations
  • advising the patient how hepatitis B is and is not transmitted, and how onward transmission may be prevented, including discussion about hepatitis B vaccination for partners, household contacts and other intimate contacts;
  • disclosure strategies to partner and family members, including discussion relevant to whether the person has acute or chronic disease about:
    •  the importance of disclosure to children and
    • current and future household and sexual contacts being tested for hepatitis B and subsequently vaccinated if they are susceptible;
  • providing information about the legal considerations around disclosure of hepatitis B status;
  • the provision of information about (and referral to) available support services.

It is usually necessary to cover these issues over more than one visit, in which case a subsequent consultation should be arranged at the time of diagnosis. It is also important to consider the level of health literacy of the patient, as a positive test result, may be interpreted as a virus free result.

5.4 Contact tracing and family notification

Contact tracing of family members, partner and other household and sexual contacts of people diagnosed with hepatitis B can be complicated by reluctance to disclose their status to significant others, many of whom may be living overseas and may have limited access to health care. Discussion with the patient regarding how to proceed with contact tracing may be appropriate. Bilingual community health workers should be involved if possible. See section 5.6.3 for information on hepatitis B testing for close contacts and family members of the person with hepatitis B.

5.5 Referral for further support

The information and support needs of people who are preparing for diagnostic testing for hepatitis B, or have just received a test result are considerable and diverse. Information provided in a single clinical consultation is often insufficient to meet their needs as understanding develops and different personal factors arise over time. Community-based organisations including hepatitis organisations, multicultural health and support agencies, Indigenous health services and peer-based drug user groups can assist people who are newly diagnosed to better understand the hepatitis B testing and diagnosis process and provide appropriate support through this critical period. Providing referral to relevant community-based organisations is therefore recommended when informed consent for testing is being obtained, at diagnosis and as appropriate at other stages of the hepatitis B diagnosis and management process.

Hepatitis Australia
National Helpline: 1300 437 222 (1300 HEP ABC)
www.hepatitisaustralia.com

Multicultural Health Services in each State and Territory

Cancer Council Helpline
13 11 20
www.cancer.org.au

The National Aboriginal Community Controlled Health Organisation
www.naccho.org.au

The Australian Injecting and Illicit Drug Users’ League (AIVL)
Telephone: 02 6279 1600
www.aivl.org.au

5.6 Special situations

5.6.1 People unconvinced by their test result

Responding to the needs of this group of people can be time consuming and there may be complex psychological and sociological issues that need to be addressed. Assistance in managing these people can be obtained from a range of specialist services that can offer help to refer a person in this predicament to an alternative service for a second opinion. 

5.6.2 People who do not return for test results

These people can be unaware of factors that may help them in living with chronic infection and may unknowingly place others at risk. It is important to try and contact these individuals. Taking into account the person’s communication and language needs, it may be more effective to contact these people by phone, through professional interpreters rather than through written correspondence. Bilingual health workers can also be used. The request should be for the person to re-contact the service provider without providing the result per se. Public Health Units of Departments of Health and sexual health clinics can provide advice on individual follow-up.

The decision to stop trying to follow up a person can be a difficult one. Attempts to make contact should be documented in the person’s file. General practitioners (GPs) in particular have limited capacity to perform person follow-up and GPs should pass this responsibility to the local Public Health Unit of their State Department of Health if they have exhausted their resources.

5.6.3 Hepatitis B testing for close contacts and family members of the person with hepatitis B

Hepatitis B occurs most commonly through mother-to-infant transmission during, at or soon after delivery, or between young children early in life. It is possible that siblings in families born in high prevalence countries may all be living with hepatitis B; however, some may be unaware of their hepatitis B status until a family member is diagnosed (see section 5.4 Contact tracing). The diagnosing clinician may not always have a therapeutic relationship with the person’s close contacts and family members. Therefore, adequately preparing the person to inform their close contacts and family members about his or her positive diagnosis and the need for these contacts to be tested is critical. For people with low English proficiency, professional interpreter services should be accessed. Referral to a local hepatitis organisation may be useful. Notification of family members after a positive diagnosis may encourage screening and subsequent diagnosis, which may lead to medical management and a reduced risk of developing serious liver disease and HCC.

5.6.4 People diagnosed with hepatitis B secondary to hepatocellular carcinoma diagnosis

Infection with HBV is the most common cause of HCC worldwide. In Australia, the incidence of HCC has progressively risen over the past 20 years, with the burden of HCC being greatest among populations born in countries with high hepatitis B prevalence. Many patients remain asymptomatic from the underlying hepatitis infection until this complication develops. Although hepatitis B-associated HCC is most common in people living with cirrhosis, a substantial proportion of cases occur in people who do not have hepatic cirrhosis. Once HCC is diagnosed, testing for both HBV and HCV infection is essential to allow appropriate management of patient and family. HCC surveillance recommendations exist to assist clinicians caring for people diagnosed with hepatitis B.

 

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Development of this site and the 2014 and 2017 revisions of the testing policies was supported by: Australian Government Department of Health and Ageing