Despite significant effort to encourage testing within the communities at highest risk of having acquired hepatitis C, there continues to be a significant proportion of people living with hepatitis C who are disengaged from care or lost to follow-up, or undiagnosed.
Hepatitis C should be considered, and testing offered in anyone with current or past risk factors for infection as well as anyone presenting with an illness that could be related to hepatitis C. This includes people with abnormal liver function tests, acute hepatitis, chronic liver disease or liver cirrhosis, hepatocellular carcinoma (liver cancer), or the presence of other clinical conditions associated with hepatitis C (e.g. porphyria cutanea tarda, vasculitis, cold agglutinin presentations).46
A person’s history considering risk factors for acquisition of hepatitis C should be taken and where risk exists, people should be informed of their risks and of the benefits of testing.
In appropriate clinical circumstances, the absence of a declared risk factor should not preclude hepatitis C testing.
Other situations where hepatitis C testing may be indicated include:
- healthcare workers who perform or may be expected to perform exposure-prone procedures (EPPs) must be aware of their hepatitis C (and HIV and hepatitis B) status47
- contact tracing where exposure to blood of a person with a potential infection 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
- the report of a reactive result on a hepatitis C test not approved for supply in Australia
- a person who requests a hepatitis C test in the absence of declared risk factors – a small number of people may request a hepatitis C test but choose not to disclose risk factors. A person’s choice not to declare risk factors should be respected and hepatitis C testing should be offered.
All people with a risk factor for hepatitis C should be tested. These include:48
- People with any history of injecting drug use
- People who have spent time in custodial settings
- People with tattoos or body piercings performed in non-sterile settings
- People who received a blood transfusion or organ transplant before 1990
- People with coagulation disorders who received blood products or plasma-derived clotting factor treatment products before 1993
- Children born to mothers with hepatitis C
- Sexual partners of a person with hepatitis C (people at higher risk of sexual transmission include men who have sex with men and people with HCV–HIV co-infection)
- People with HIV or hepatitis B virus infection
- People with evidence of liver disease (persistently elevated alanine aminotransferase level)
- People who receive haemodialysis
- People who have had a needle-stick injury, sharps or mucosal exposure
- Migrants from high hepatitis C prevalence regions (Egypt, Pakistan, Mediterranean and Eastern Europe, Africa and Asia).
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.49 Testing in this population includes diagnosis, any individualised monitoring during treatment and monitoring possible re-activation or re-infection post treatment.
Hepatitis C testing frequency in people who inject drugs
Recommendation for the frequency of testing in people who inject drugs who disclose sharing injecting equipment:50
- In people who inject drugs who are HCV antibody (anti-HCV) negative, repeat testing for HCV antibody (anti-HCV) every 3-6 months is indicated if there is high risk behaviour, e.g. sharing injecting equipment, or if the person expresses a concern that they may have been exposed to HCV.
Recommendations for the frequency of testing in people who inject drugs who report not sharing injecting equipment:
- Annual testing (every 12 months) is indicated in people who inject drugs who report not sharing injecting equipment and who do not have HCV infection (i.e. HCV antibody negative) on first testing. Testing should also be offered following a high risk injecting episode.
People who inject drugs who are HCV antibody (anti-HCV) positive and HCV RNA negative (through spontaneous or treatment-induced clearance) should receive regular HCV RNA testing every 12 months or from 2 weeks following a high risk injecting episode.51
People who are, or have ever been, incarcerated
Imprisonment is an independent risk factor for HCV transmission.52 It is estimated at least 20% of all people who are incarcerated in Australia are seropositive for hepatitis C and more than 50% of people in prison report a history of injecting drug use.53 A history of previous incarceration is a very strong indication to offer testing for hepatitis C with appropriate discussion of risk and benefits.
It is recommended that people should be offered hepatitis C testing and results provided within 2 weeks of incarceration, and all those identified with hepatitis C should be offered and supported to undertake antiviral therapy. Re-testing should be offered at least annually for all those incarcerated and offered at any time for people who disclose risk factors or request testing.53
Recipients of organs, tissues, blood or blood products
HCV is efficiently transmitted by transfused blood or blood products.54 Infections acquired in this way have accounted for 5–10% of all cases in Australia. People in Australia, or other major developed countries, who were transfused or received organ or tissue donations or blood products before hepatitis C screening commenced (February 1990 in Australia) who have not been tested or who do not know their status 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 hepatitis C.55 People who received blood products or organ or tissue donations at any time in overseas countries where screening of the blood and 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 hepatitis C at the time a donation is made. Organs from HCV-positive donors may be offered to both HCV-positive and HCV-negative recipients according to clinical circumstances.
People with tattoos or skin piercings
Skin penetration practices are not independent risk factors for HCV transmission.56 The indications to test will include a consideration of other factors that may contribute to increased transmission such as population prevalence and 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).
People born in countries with high hepatitis C prevalence
The risk of hepatitis C may be elevated for people born in or who have spent considerable time in countries where there is a high prevalence of hepatitis C.57 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 hepatitis C. These regions include Africa, the Middle East (in particular Egypt), the Mediterranean, Eastern Europe and South Asia. In many of these regions, HCV transmission is not predominantly associated with injecting drug use and the virus can be acquired from medical and dental procedures or from occupational exposure to infected materials. Indications to offer testing include a history of hepatitis C in a family member or exposure to medical procedures. In this population, HCV RNA positivity should prompt testing of other family members.
Aboriginal and Torres Strait Islander populations
In 2023, 1,499 (or 19.7% of the total 7,602) people newly diagnosed with hepatitis C in Australia identified as Aboriginal and Torres Strait Islander people.2 Thirty percent, or 2,310 people, of new hepatitis C cases were notified without an indication of Indigenous status. This is a critical gap which must be addressed through better data capture and reporting processes.
In people aged under 25, the rate of hepatitis C notification in 2023 among Aboriginal and Torres Strait Islander people was more than 10 times higher than in non-Indigenous people (236.1 vs 22.4 per 100,000).2 Given that Aboriginal and Torres Strait Islander people constitute just 3.8% of Australia’s total population,58 the disproportionate hepatitis C-related burden of disease borne by this group is striking. Risk factors for increased HCV antibody prevalence in this population include higher rates of syringe and other drug equipment sharing59 and higher rates of incarceration, both of which are driven by ongoing and generational impacts of systemic racism, poverty and poorer access to health and related services.60
Sexual partners of people with hepatitis C
The risk of heterosexual transmission of HCV is low.61 Certain sexual practices increase the risk of HCV transmission and in all instances the use of drugs (injected or orally administered) increases risky behaviours. These behaviours include having:
- had more than 10 partners in the past 6 months
- engaged in condomless anal sex
- engaged in unsterile injecting drug use
- engaged in group sex and drug use.
Testing for hepatitis C should take place annually in those who are aware of risk and practising safe sex and some evidence indicates that more frequent (6 monthly testing) in high risk behaviour groups increases early detection and treatment.61
Children born to HCV-positive mothers
See Section 8. Antenatal and Perinatal Testing for more information.
The rate of mother-to-child transmission of HCV is low and is essentially confined to women with detectable HCV RNA. Thus, pregnant women who are HCV antibody (anti-HCV) positive on routine screening need to be tested for HCV RNA. The diagnosis of hepatitis C in neonates is complicated by the passive transfer of maternal antibodies to the baby. Pregnant HCV-positive women should be encouraged to seek specialist advice from a clinician who understands hepatitis C and mother-to-child transmission and can provide support and expertise to the mother, parent, parents and to the people supporting the pregnancy, birthing and early parenting of the child. HCV antibody testing in babies is not recommended before 18 months of age (see Section 8. Antenatal and Perinatal Testing).
Transmission and infection control in healthcare settings
- People on regular haemodialysis should be tested every 6 months for HCV antibody62
- In rare situations, clients of healthcare services may need to be offered testing as part of an outbreak investigation or due to failure of infection control practices.
A risk assessment with regard to the type of injury and type of bodily fluid is required to determine management of the person exposed following an occupational exposure to blood or mucosal fluids containing blood. The risk of hepatitis C transmission following a needlestick injury where the source is known to be HCV RNA positive is very low, estimated to be 1.8% (range 0-7%). Saliva where there is no visible blood is not infectious. The exception to this statement is in dental settings where blood is likely to be present even if not visible.63 Hepatitis C cannot be transmitted by spitting, touching, hugging, kissing or sharing food and drink.
Clinical services should have an evidence-informed occupational exposure policy and procedure implemented so that anyone at any risk of exposure receives training during their onboarding process or as soon as possible thereafter. These policies and procedures should include information about the extremely low risk of a transmission occurrence, followed up with additional education and support should an occupational exposure occur.
In the event of a potential occupational exposure, the person exposed should be referred to an appropriately qualified healthcare practitioner such as a GP, nurse or specialist to undertake a risk assessment. Establishing the hepatitis C status of the source person will help inform the management of the exposed person. Testing of both the source person, if known, and the exposed person should be voluntary and with informed consent.
The window period for hepatitis C seroconversion is 6 to 12 weeks. Qualitative HCV RNA testing between 6 and 12 weeks is recommended. If at 12 weeks both RNA and antibody are negative, then there is no evidence of transmission, and the exposed person can be advised that the risk of transmission is negligible. If the HCV RNA test is not MBS reimbursable, the employer may arrange with the pathology laboratory to pay for the test privately.
If the occupational exposure is determined to be high risk, monitoring of clinical status and liver function tests is warranted. However, high risk occupational exposure is uncommon in the Australian context. One example would be intentionally being injected with a syringe containing someone else’s blood. Needlestick wounds that break the skin of the worker or single or multiple injuries resulting in broken skin of the worker would be considered low-medium risk.
Recommended baseline HCV testing for source person if known
|
Status |
Recommended baseline testing |
|
HCV antibody positive |
HCV PCR at baseline |
|
HCV unknown or potentially in the window period |
HCV antibody with reflex HCV PCR at baseline |
Recommended testing for exposed person if the assessment determines there is a transmission risk
|
Status |
Baseline 6 -12 weeks 12 weeks |
||
|
HCV positive or unknown |
HCV antibody with reflex HCV PCR* |
HCV PCR |
HCV antibody |
|
HCV negative |
HCV antibody with reflex HCV PCR* |
No further testing required |
|
* Only HCV PCR if exposed person is known to be antibody positive