Clinical Guidelines for the Medical Management of Hepatitis C
H. Prevention and Counseling
The medical team should have an understanding of the significance and importance of the available HCV tests.
Prior to ordering testing, assess the patient's ability, regardless of age, to comprehend the nature and consequences of HCV antibody testing. Defer testing if the patient's ability to understand is temporarily impaired.
Hepatitis C counseling, before and after HCV testing, (see Table 4) should be carried out to provide health education and to strengthen the therapeutic alliance between the medical provider and the patient. Signed consent is not required for HCV testing. However, when testing for HCV, HIV testing should also be recommended, if not done previously or to update a previous HIV test. HIV testing will require signed consent in these situations.
After the initial counseling visit is completed, document in the medical record that the counseling was done. Once the HCV test results are available and counseling based on the test results is completed, document in the medical record that counseling was done, the test results, and what the patient was told. Document any recommendations for partner/spousal notification, referrals to other providers or agencies, and the plan for follow up/treatment plan. For patients with positive tests, consider a second counseling visit.
Elements of Hepatitis C Counseling
Counseling Prior to HCV Testing
Initial counseling should review the following elements:
- Patient's prior history of HCV testing and counseling;
- Incidence and prevalence of HCV;
- HCV transmission;
- Relationship to other diseases such as substance dependence, HIV, sexually transmitted diseases;
- Benefits of early diagnosis and intervention– prevention of transmission to others, reduced risk of long terms complications of HCV infection; and
- Treatment options.
The second part of hepatitis C counseling prior to testing is the explanation of specific test issues:
- Testing is voluntary;
- Tests and procedures, purpose of the test and that blood specimens are needed to perform the test;
- Explain the meaning of possible test results;
- When results should be expected and that results are occasionally delayed, which does not necessarily indicate a positive test; and
- Explain the confidential nature of clinician/patient relationship.
The final part of hepatitis C counseling prior to testing includes:
- An explanation of risk reduction behaviors associated with HCV and other bloodborne diseases;
- A discussion of possible test results and that there will be post-test counseling; and
- Reassurance and/or referral for emotional support for the patient during the waiting period.
Counseling after HCV Testing*
For the patient with a negative test result:
- Discuss the meaning of the test result;
- Discuss possibility of HCV exposure during the past three months and the need for repeat testing if risk factors are significant;
- Emphasize that a negative test result does not imply immunity to future infection;
- Reinforce that the patient should not:
- share needles;
- ink or needles for tattoos;
- needles for body piercing;
- razors, toothbrushes or other personal items that could have blood or secretions on them; and
- Reinforce personal risk reduction strategies such as using latex condoms.
For the patient with a positive HCV antibody test result, discuss:
- Meaning of the test result (antibody test vs. viral load test);
- Possible risk factors that were present in the history; and
- Follow-up testing with a qualitative HCV RNA.
For the patient with a positive HCV antibody test result and a negative qualitative HCV RNA, discuss:
- Need for repeat qualitative HCV RNA in several months, if there are significant risk factors present, as the viral load can fluctuate;
- That a positive antibody and two negative qualitative HCV RNA tests at least 6 months apart means that the patient cannot transmit hepatitis C;
- That a positive antibody test does not confer immunity from future hepatitis C infections and that risk reduction is still important; and
- The possibility of acute infection that may have resolved spontaneously.
For the patient with a positive qualitative HCV RNA:
- Discuss that all new medications, including herbal medications and over-the-counter medications, need to be discussed with their physician prior to their use, as they could have deleterious effects on the liver;
- Inform the patient to minimize transmission to others, that he/she should not donate blood, body organs, tissue or semen, share anything that could have blood on it such as toothbrushes, razors, dental appliances, nail clippers, etc.;
- Cover all open sores to prevent spreading of possible infectious secretions;
- Discuss the harmful effects of alcohol use and HCV disease;
- Encourage partner/spousal notification with the options of self-notification or clinician-assisted notification;
- Encourage referral of needle sharing partners for HCV testing;
- Encourage referral of children of chronically infected women for HCV testing;
- For pregnant women infected only with HCV:
- Breast-feeding should not be discouraged unless there are bleeding or cracked nipples and
- When the mother is infected only with HCV, the vertical transmission rate is approximately 5% (range 3-7%);
- If the person has a long-term steady sexual partner the risk of transmission to the uninfected partner is low, though not absent. Barrier protection should be emphasized;
- Provide counseling or refer to counseling for coping with the emotional consequences of testing positive and behavior changes that will be needed to prevent the spread of HCV;
- Discuss availability of specialized medical care;
- Encourage vaccination for hepatitis A and B if the patient is susceptible;
- Provide or refer to HCV medical care for treatment; and
- Provide or refer the patient, family or significant others to support groups for counseling as needed.
*Refer to Hepatitis C Screening Algorithm (Figure 1) for HCV test interpretations