Despite significant effort to encourage testing of populations within the community which are at high risk of having acquired HCV infection, it is evident many have still not been tested.
HCV infection should be considered in patients with abnormal liver function tests, acute hepatitis, chronic liver disease or liver cirrhosis, hepatocellular carcinoma (liver cancer), or in the presence of other clinical conditions associated with HCV (e.g. porphyria cutanea tarda, vasculitis, cold agglutinin presentations).24
Other situations where HCV 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) status25
- 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 HCV test not approved for supply in Australia
- 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 respected and HCV testing should be offered.
A history considering risk factors for acquisition of HCV infection should be taken and where risk exists, patients 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 HCV testing.
- People who inject drugs or who have ever injected drugs
- People in custodial settings
- People with tattoos or body piercing
- 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 HCV infection
- Sexual partners of a person with HCV infection (individuals 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 have had a needle-stick injury
Migrants from high-HCV 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 (IDU).27 Testing in this population includes diagnosis, monitoring treatment and monitoring possible re-activation or re-infection post treatment.
HCV testing frequency in people who inject drugs (PWID)28
Recommendation for the frequency of testing in PWID who disclose sharing injecting equipment:
- In those people who continue to 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. 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 who disclose not sharing injecting equipment:
- Annual testing (every 12 months) is indicated in PWID who avoid 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.
PWID 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 following a high-risk injecting episode.
People who are, or have ever been, incarcerated29
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%.30 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.
Imprisonment poses an immediate risk for infection and a thorough risk assessment should be undertaken on all individuals currently incarcerated and testing offered with appropriate counselling.
HCV infection treatment is now offered in most custodial settings and those in custody should be made aware of their options for treatment after testing.
Recipients of organs, tissues, blood or blood products31
HCV is efficiently transmitted by transfused blood or blood products. Infections acquired in this way have accounted 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 their 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.32 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 HCV 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 piercings33
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).
People born in countries with high HCV prevalence34
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.34 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 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 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.
Aboriginal and Torres Strait Islander populations35
In 2017, 1,210 (or 11% of the total 10,530) people newly diagnosed with HCV infections in Australia identified as Aboriginal and Torres Strait Islander people. Unfortunately, 49% (or 5,182 individuals) of new HCV cases were notified without an indication of Indigenous status. This is a critical gap which can be addressed through a greater focus by medical staff on the identifier.
In people aged under 25, the rate of hepatitis C notification in 2017 among Aboriginal and Torres Strait Islander people was six times higher than in non‑Indigenous people (76.7 vs 12.2 per 100 000).2
Given that Aboriginal and Torres Strait Islander people constitute just 3.3% of Australia’s total population,36 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 syringe and other drug equipment sharing.35 Aboriginal and Torres Strait Islander people also experience a disproportionately high rate of incarceration, which is an independent risk factor for HCV acquisition.37
Sexual partners of people with HCV38
Testing for infection should take place annually in those who are aware of risk and practising safe sex.
Testing for infection should take place every 6 months for those who have:
- had more than 10 partners in the past 6 months
- engaged in unprotected anal sex
- engaged in unsterile injecting drug use
- engaged in group sexual activities.
Children born to HCV-positive mothers
See section Antenatal and Perinatal Testing.
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 HCV in neonates is complicated by the passive transfer of maternal antibodies to the baby: HCV antibody testing is not recommended before 18 months of age (see section Antenatal and Perinatal Testing).
Transmission and infection control in healthcare settings
- People on regular haemodialysis should be tested every 6 months for HCV antibody39
- 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
The risk of hepatitis C transmission following a needlestick injury where the source is known to be hepatitis C RNA positive is very low, estimated to be 1.8% (range 0-7%). 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. Saliva where there is no visible blood is not infectious. The exception to this is in dental settings where blood is likely to be present even if not visible.40 Hepatitis C cannot be transmitted by spitting, touching, hugging, kissing or sharing food and drink.
If a potential occupational exposure has occurred, 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. To reassure the person exposed, qualitative HCV PCR testing between 6 and 12 weeks is recommended. If at 12 weeks both PCR 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 PCR 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 of 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
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
Baseline 6 -12 weeks 12 weeks
HCV positive or unknown
HCV antibody with reflex HCV PCR*
HCV antibody with reflex HCV PCR*
No further testing required
* Only HCV PCR if exposed person is known to be antibody positive