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3.0 Indications for HCV Testing

Posted in: HCV

Testing is indicated for people who have risk factors associated with transmission of HCV. A history considering risk factors for acquisition of HCV infection should be taken to help determine whether a HCV test is indicated. In appropriate clinical circumstances, the absence of a declared risk factor should not preclude HCV testing. Clinical suspicion of HCV infection may occur in the context of:

  • chronic liver disease or liver cirrhosis;
  • hepatocellular carcinoma (liver cancer);
  • evaluation of abnormal liver function tests; and
  • acute hepatitis.

A number of clinical conditions and symptoms are associated with HCV where clinical suspicion leads to a HCV test.18

Other situations where HCV testing may be indicated include:

  • health care workers who perform or may be expected to perform exposure prone procedures (EPPs) must be aware of their HCV (and HIV and hepatitis B) status;19
  • contact tracing where exposure to blood of a potentially infected person is documented;

testing of a source person in an occupational exposure;

  • diagnosis of another infection with shared mode of acquisition, such as hepatitis B virus or HIV;
  • a person who reports a reactive result on a HCV test not approved for supply in Australia; and
  • a person who requests a HCV test in the absence of declared risk factors – a small number of people may request a HCV test but choose not to disclose risk factors. A person’s choice not to declare risk factors should be recognised and HCV testing should be offered.

3.1 Risk factors for exposure to HCV infection


3.1.1 People with a history of injecting drug use

Over 80% of existing and almost 90% of all new HCV infections are among people with a history of injecting drug use (IDU). People with a history of IDU often experience significant barriers to accessing health services including HCV testing and treatment services. In this context, it is critical that testing is conducted in an appropriate, non-judgmental and non-stigmatising setting to assist people with a history of IDU through the testing and diagnosis process. This will have a profound effect on a person’s understanding of their condition and their likelihood of future engagement with the health system. Peer education and support will optimise testing uptake and reporting and is recommended where these resources are available. Staff in specialist and primary health care services should be cognisant of issues relating to illicit drug use, harm reduction, addressing stigma and discrimination and managing vein care issues. 

3.1.1.1   HCV testing frequency in People Who Inject Drugs (PWID)21      

An anti-HCV test is recommended for PWID, and if the result is positive, current infection should be confirmed by a qualitative HCV RNA test.

Recommendations for the frequency of testing in PWID with unsafe (unsterile) injecting practices are:

  • in those people who continue to inject drugs, repeat testing for anti-HCV every 3-6 months is indicated if there is high risk behavior, e.g. needles are shared, or if the individual expresses a concern that they may have been exposed to HCV.

Recommendations for the frequency of testing in PWID with safe injecting practices are:

  • annual testing (every 12 months) is indicated In PWID who avoid sharing injecting equipment and who are not infected (i.e. anti-HCV negative) on first testing. Testing should also be offered following a high risk injecting episode.

PWID who are anti-HCV antibody positive and HCV RNA negative (through spontaneous or treatment-induced clearance) should receive regular HCV RNA testing, every 12 months or following a high risk injecting episode.

3.1.1.2   Testing for reinfection in PWID

More frequent testing 3-6 monthly in high risk PWID post- treatment is important, but HCV RNA is not funded under the MBS more than annually.

Annual HCV RNA testing for reinfection, with more frequent testing if indicated by clinical symptoms or following a high risk injecting episode, is recommended.21

3.1.2 People who are or have ever been incarcerated

Imprisonment is an independent risk factor for HCV transmission. HCV prevalence for all prisoners in Australia is estimated at 30–40% and is higher for women at 50–60%. A history of previous incarceration is a very strong indication to offer testing for HCV and it should be offered with appropriate discussion of risk and benefits.

For those currently incarcerated, indicators to discuss testing should be based on thorough risk assessment, including any history of drug use or previous incarceration.

HCV treatment while in custody should be considered where treatment services are available.

3.1.3 Recipients of organs, tissues, blood or blood products before February 1990 in Australia, or before the implementation of mandatory screening of blood donors in other countries (or at any time where this is not the case)

HCV is efficiently transmitted by transfused blood or blood products.  Infections acquired in this way account for 5–10% of all cases in Australia. Individuals in Australia, or other major developed countries, who were transfused or received organ or tissue donations or blood products before HCV screening commenced (February 1990 in Australia) who have not been tested or who do not know test results should be offered testing. A number of countries (predominantly in low-resource settings) still do not screen all donated transfusion blood for transmissible infections, including HCV.25 People who received blood products or organ or tissue donations at any time in overseas countries where screening of the blood/organ donor population has not been routine, or where the screening policy at the time of transfusion or receipt of organ or tissue donation is uncertain, should be offered testing. In Australia, recipients and organ donors are screened for HCV at the time a donation is made. An HCV-positive organ may still be used in an HCV-positive recipient.

3.1.4 People with tattoos or skin piercings

Skin penetration practices are not independent risk factors for HCV 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. tribal scarring in indigenous populations, tattooing and skin piercings in custodial settings or any other situation where non-registered tattooists perform the task). 

3.1.5 People born in countries with high HCV prevalence

 

The risk of HCV infection may be greater for people born in or who have spent considerable time in countries where there is a high prevalence of HCV infection than it is for people born in Australia.27 It is estimated that 11% of people in Australia who have been exposed to HCV are immigrants from countries where there is a high prevalence of HCV. These countries include Africa, the Middle East (in particular Egypt), the Mediterranean, Eastern Europe, and South Asia. In many of these countries, HCV transmission is not predominantly associated with IDU and the disease can be acquired from medical and dental procedures or from occupational exposure to infected materials. Indications to offer testing include a history of HCV in a family member or exposure to medical procedures. In these people, HCV RNA positivity should prompt testing of other family members.

3.1.6 Aboriginal and Torres Strait Islander populations

In 2015, 929 (or 9% of the total 10,790 cases) of the newly diagnosed HCV infections in Australia were among the Aboriginal and Torres Strait Islander people. There were a further 6,419 (59%) cases where Indigenous status was not reported.

The notification rate of newly diagnosed hepatitis C infection in the Aboriginal and Torres Strait Islander population increased by 43% in the last five years whereas the rate in the non‑Indigenous population decreased by 10%.

Given that Aboriginal and Torres Strait Islander people constitute just 3% of Australia’s total population,29 the disproportionate HCV-related burden of disease borne by this group is striking. Risk factors for increased HCV antibody prevalence in this population include higher rates of unsafe injecting drug use practices, and tribal scarring. Aboriginal and Torres Strait Islander people also experience a disproportionately high rate of incarceration, which is an independent risk factor for HCV acquisition.

3.1.7 Sexual partners of people with HCV

The risk of heterosexual transmission of HCV is low. However, there is an increased risk of sexual transmission of HCV for men who have sex with men who are also HIV positive.

Testing for infection in this situation should be undertaken regularly. This should take place annually in those who are aware of risk and practicing safe sex and every six months for those who have:

  • had more than 10 partners in the past 6 months;
  • engaged in unprotected anal sex;
  • used recreational drugs; and/or
  • engaged in group sexual activities.

Testing should occur in appropriate settings, such as HIV clinics, sexual health clinics or GP surgeries for those with ongoing risk of infection.

3.1.8 Children born to HCV-positive mothers

See section 8

3.1.9 Transmission and infection control in healthcare settings

  • HCV testing of health care workers should be conducted in accordance with the general principles set out in this document with regard to privacy, confidentiality and access to appropriate health care and support services;31
  • In keeping with the CDNA guidelines, health care workers must not perform EPPs if they are hepatitis C RNA positive (by nucleic acid test);32
  • Testing for all BBVs should be undertaken for health care workers following occupational exposure to blood or body substances, for example through needle stick injury;
  • People on regular haemodialysis should be tested every six months for anti-HCV;33 and
  • In rare situations, clients of healthcare services may need to be offered testing as part of an outbreak investigation and/or due to failure of infection control practices.

Quick links to resources on this page

HIV, viral hepatitis and STIs: a guide for primary care. Ch 7: Signs and symptoms of chronic viral hepatitis

ASHM Hepatitis C Guidelines, Policy and Strategies

Hepatitis C testing and diagnosis

Hepatitis C Prevention, Treatment and Care: Guidelines for Australian Custodial Settings

Hepatitis C and the blood supply in Australia. Canberra

World Health Organization: Blood supply. Key global facts and figures in 2011

Western Australia Department of Health: Skin penetration

Centers for Disease Control and Prevention: Prevalence of chronic hepatitis C infection map

Hepatitis Australia Hepatitis C Testing information

National Health and Medical Research Council: Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010)

Guidelines for Managing Blood-Borne Virus Infection in Health Care Workers

18. Sim M, Cheng W, Dore G, Beers K. Signs and symptoms of chronic viral hepatitis. In: Bradford D, Hoy J, Matthews G, editors. HIV, viral hepatitis and STIs: a guide for primary care. Sydney: ASHM; 2008. Available at: http://www.ashm.org.au/images/publications/monographs/HIV_viral_hepatitis_ and_STIs_a_guide_for_primary_care/hiv_viral_hep_chapter_7.pdf (Cited 23 March 2012).
19. Australasian Society for HIV Medicine (ASHM). Hepatitis C Guidelines, Policy and Strategies.
Information about Australian and international hepatitis C guidelines, policy and strategies [internet]. Available at: http://www.ashm.org.au/default2.asp?active_page_id=430 (Cited 23 March 2012).
20. Australian Injecting and Illicit Drug Users League (AIVL). Hepatitis C testing and diagnosis among people with a history of injecting drug use: identifying and removing barriers to access. In: Hepatitis C models of access and service delivery for people with a history of injecting drug use. October 2010. Available at: http://www.ashm.org.au/images/HCV_Testing_portal/HCV_Testing_ Diagnosis_PWIDs.pdf (Cited 23 March 2012).
21. Recommendations for the management of hepatitis C virus infection among people who inject drugs. Available at: http://www.ijdp.org/article/S0955-3959 (15)00206-6/fulltext (Cited 14 November 2016).
22. Australian Government. Department of Health and Ageing. Hepatitis C Prevention, Treatment and Care: Guidelines for Australian Custodial Settings. Last updated July 2008. Available at: http://www. health.gov.au/internet/main/publishing.nsf/Content/phd-hepc-guidelines-custodial-h (Cited 23 March 2012).
23. Australian Bureau of Statistics. 4512.0- Corrective Services, Australia, June Quarter 2016. Available at: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4512.0 (Cited 14 November 2016).
24. Australian Government. Senate Committee Report. Hepatitis C and the blood supply in Australia. Canberra: Commonwealth of Australia; 2004. Available at: http://www.hep.org.au/documents/04HepC-blood-supply-800KB.pdf (Cited 23 March 2012).
25. World Health Organization. Blood supply. Key global facts and figures in 2011. Fact sheet No. 279. June 2011. Available at: http://www.who.int/worldblooddonorday/media/who_blood_safety_factsheet_2011.pdf (Cited 23 March 2012).
26. Government of Western Australia Department of Health Public Health. Skin penetration [internet]. Available at: http://www.public.health.wa.gov.au/3/1085/2/skin_penetration.pm (Cited 23 March 2012).
27. Centers for Disease Control and Prevention. CDC Health Information for International Travel 2016. New York. Oxford University Press. 2016. Available at: http://www.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/hepatitis-c (Cited 14 November 2016).
28. The Kirby Institute. Bloodborne viral and sexually transmissible infections in Aboriginal and Torres Strait Islander people: Annual Surveillance Report 2016. Available at: http://kirby.unsw.edu.au/sites/default/files/hiv/resources/2016%20ATSI%20BBVSTI%20Annual%20Surveillance%20Report.pdf. (Cited 14 November 2016).
29. Australian Bureau of Statistics. Estimates of Aboriginal and Torres Strait Islander Australians, June 2011.Available at: http://www.abs.gov.au/ausstats/abs@.nsf/mf/3238.0.55.001 (Cited 14 November 2016).
30. Hepatitis Australia. Hepatitis C. Testing information. 2010. Available at: http://www. hepatitisaustralia.com/data/assets/pdf_file/0015/1347/Testing_Info.pdf (Cited 23 March 2012).
31. Australian Government. National Health and Medical Research Council. Australian Guidelines for the Prevention and Control of Infection in Healthcare (2012) - online version only. Reference number: CD33. Available at: http://www.nhmrc.gov.au/node/30290 (Cited 23 March 2012).
32. Australian Government Department of Health and Ageing. Australian National Guidelines for the Management of Health Care Workers known to be Infected with Blood-Borne Viruses. Endorsed 27 February 2012 by the Communicable Diseases Network Australia (CDNA). Available at: http://health. gov.au/internet/main/publishing.nsf/Content/cda-cdna-bloodborne.htm (Cited 15 July 2013).
33. The dialysis and transplant subcommittee of the AKF and the ANZSN. Consensus statement – 2001 recommendations for hepatitis B, C, G and HIV in maintenance dialysis patients. Available at: http:// www.ashm.org.au/images/HCV_Testing_portal/Consensus_Statement_Hepatitis_Dialysis_ Patients.pdf (Cited 23 March 2012).

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