POPS Chapter 7 – HCV Testing
Subchapters
7.1 HCV Testing with Department of State Health Services Resources
7.2 Persons for Whom HCV Testing will be Referred to other Testing Sites
7.6 HCV-Positive Clients Who Fail to Return for Results
7.9 List of DSHS Websites Referenced in Chapter 7
Confidential hepatitis C virus (HCV) testing will be offered to those clients who are considered at highest risk for HCV infection. Portions of the standards were adapted from the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report, October 16, 1998/Vol. 47/No.RR-19 edition.
These standards will assist HCV testing sites to identify, test, counsel, and refer clients for HCV.
The Department of State Health Services (DSHS) provides limited funding for this HCV targeted intervention initiative. Testing will only be offered at specifically funded sites across the state and to clients considered at highest risk. HIV/STD sites that do not provide HCV testing will refer clients at highest risk for HCV to the closest testing site.
7.1 HCV Testing with Department of State Health Services Resources
DSHS’ limited testing resources will be targeted to persons in the following risk categories:
- Persons who have ever shared needles or shared any drug equipment (“works”) used in preparation or storage of an injectable drug;
- Health care workers who received a needlestick, a puncture from a contaminated sharp instrument, or had a mucosal exposure from a hepatitis C-infected client; and
- Persons with HIV infection.
As with other DSHS supported services, the inability to pay clinic fees may not be the sole reason for denial of services. If the client meets the testing criteria, services must be provided regardless of the client’s ability to pay.
Although there is less evidence supporting testing of persons in the following risk categories, they may be tested at DSHS sites with supervisory approval as funding resources permit:
- Long-term sex partners of persons who are HCV-positive; and
- Sex partners of Persons Who Inject Drugs (PWID).
7.2 Persons for Whom HCV Testing will be Referred to other Testing Sites
Clients who do not indicate they have a risk for HCV will not be tested through DSHS funded HCV testing sites, but will be referred to private physicians or other local resources.
Referrals will be provided to persons without the risks cited above including but not limited to:
- Health care, emergency medical, and public safety workers who have not had a needlestick or been exposed to contaminated blood;
- Pregnant women;
- Household (non-sex) contacts of those who are HCV-positive;
- The general population;
- Men who have sex with men (MSM), unless HIV positive; and
- Persons with an STD or history of STD, unless HIV positive.
7.3 Counseling
Except for differences described in this chapter, HCV client-centered counseling strategies and techniques will follow the procedures and standards described in Chapter 1, HIV/STD/HCV Testing, Counseling, and Linkage to HIV Medical Care. If the client refuses prevention counseling the provider will, at minimum, gather the demographic information necessary to complete the Specimen Submission Form G-1A before drawing a tube of blood.
7.3.1 HCV Counseling Messages
Persons who receive positive HCV test results should seek further medical evaluation from their health care provider to determine how the test results affect their health.
To reduce the risk of transmission to others, all persons with HCV infection will be advised to:
- Not donate blood, body organs, other tissue or semen;
- Not share toothbrushes, dental appliances, razors, or other personal-care articles that might have blood on them; and
- To cover cuts and sores on the skin to keep from spreading infectious blood or secretions.
To protect their liver from further harm, persons with HCV infection will be advised to:
- Abstain from drinking alcohol and using other recreational drugs, or drugs that are known to impair liver function;
- Check with their doctor before starting any new medicines, including over-the-counter and herbal medicines;
- Discuss proper nutrition and a prudent exercise routine with their health care provider;
- Discuss vaccination against hepatitis A & B with their health care provider; and
- Not eat raw or under cooked shellfish.
Persons who are HCV-positive will be advised to discuss with sex partners:
- The risk of sexual transmission of HCV(which is very low but not absent);
- The use of barrier precautions (e.g., latex condoms) in sexual activities; and
- The options available to partners for counseling and testing.
7.3.1.1 Persons who are HCV-positive and use or inject drugs
Persons with HCV infection who use or inject drugs will receive appropriate client-centered prevention counseling that may address the following range of risk-reduction options:
- Abstinence from or reduction in use of injecting drugs;
- Referrals for substance abuse treatment, as appropriate;
- Abstinence from sharing needles or “works” (e.g., cotton, cooker, water);
- Use of only new, unused needles and works to inject; and
- Use of bleach to disinfect needles and works to reduce (but not eliminate) the risk of HCV infection.
7.3.1.2 Pregnant Females with HCV
HCV-positive women do not need to avoid pregnancy or breast-feeding. Potential, expectant, and new parents will be advised to consult their private health care provider for guidance on prenatal care. They will be informed of the following:
- The average rate of HCV infection among infants born to HCV-positive women is 5%-6%;
- Children tested for HCV antigens before 12 months of age may reflect the mother’s infection status, not the infant’s; and
- There is no evidence that breast-feeding spreads HCV, although HCV-positive mothers should consider abstaining from breast-feeding if their nipples are cracked or bleeding.
NOTE: HCV-positive woman co-infected with HIV have an increased chance of transmitting HCV infection to their baby.
7.3.1.3 Other Possible Counseling Messages
- HCV is not spread by sneezing, hugging, coughing, sharing eating utensils, drinking glasses, food or beverages, or through casual contact.
- Persons may not legally be excluded from work, school, play, childcare, or other settings on the basis of their HCV infection status. Health care workers with HCV infection may be subject to review by an expert review panel through their employer.
7.4 Testing
Testing will only be offered confidentially and with informed consent. DSHS General Consent and Disclosure form L-36 is acceptable for HCV testing. Anonymous testing is not available for HCV. Confidential HIV and HCV testing can be done with one specimen tube of blood. If a client requests anonymous HIV testing and confidential HCV testing, one blood draw with two specimen tubes and two serology submission forms will be required. As a minimum standard, anonymous HIV testing combined with confidential HCV testing will be discouraged because the testing site will have knowledge of the client’s name and address. Therefore, if the anonymous HIV test is positive and the client does not return, the testing site will have a “duty to warn” and will inform the client of their test results. Therefore, the HIV test is not truly anonymous.
HCV tests identify antibodies to HCV. The majority of people (97%) will develop antibodies to HCV within six months after infection. Testing for HCV will be deferred until six months after the initial exposure to allow for seroconversion. Clients who previously tested negative for HCV and continue to engage in high-risk behaviors should be offered repeat testing no sooner than six months after their previous HCV negative test result.
This is a targeted intervention; due to the limited number of test kits available, clients with private insurance will be encouraged to seek HCV testing from their private provider. Medicaid and Medicare do not cover HCV testing.
7.4.1 Point of Care Testing
HIV and HCV point of care (POC) testing sites must have policies and procedures in place to delineate how the program will administer a test, maintain client confidentiality, and secure the privacy of client information. Refer to Guidelines for Conducting HIV and HCV Point of Care Testing for more information on POC testing requirements and recommendations.
7.4.2 Serology Submission Forms
HIV Serology – Used with blood specimens requesting an HIV test only. The top right corner of the form will be designated with a large “H.”
Hepatitis C Serology – Used with blood specimens requesting a hepatitis C test only. The top right corner of the form will be designated with a large “C.”
HIV and hepatitis C Serology – Used with blood specimens requesting both HIV and hepatitis C tests. The top right corner will be designated with a large “HC.” One tube of blood is sufficient for the combined form.
7.4.3 Lab Results
All blood specimens will be processed using the Enzyme Immunoassays (EIA) antibody test. This is a screening test. EIA test results will be reported to the client as non-reactive (negative) or reactive (positive). All reactive tests will be run at least twice. Clients who receive a reactive result will need to follow up with their health care provider to determine if the virus is resolved, acute or chronic.
7.5 Partner Referral
Unless the client is co-infected with another reportable disease such as syphilis or HIV, HCV positive clients will be encouraged to refer their needle-sharing partners for HCV counseling and testing. HCV testing contractors are encouraged to develop or revise current client referral forms to include HCV. Referral forms will need to include: name and location of HCV testing contractor, phone number and clinic hours. When the referral card is received by the clinician or qualified staff, it will be documented as a client referral. There are no HCV spousal notification requirements.
7.6 HCV-Positive Clients Who Fail to Return for Results
If an HCV-positive or indeterminate client fails to return for results, the site staff will make and document(at a minimum), three telephone calls at three different times on three different days within one week. If the client does not respond to the phone calls, at least one certified letter will be mailed. If the client has no phone, the testing site will mail a certified letter.
7.7 Referrals
St. Luke’s Liver Health Outreach provides HCV confirmatory testing through Polymerase Chain Reaction (PCR) analysis. St. Luke’s Liver Health Outreach can be reached toll-free at 800-72-LIVER or at stlukestexas.com.
Clients who test positive for HCV antibodies will be referred to St. Luke’s Liver Health Outreach or another appropriate resource for HCV medical follow-up.
Qualified staff will supply persons with HCV infection with the name, phone number, and contact of the support group nearest them. Qualified staff will be ready to refer clients to non-hepatitis services, such as prenatal care, food, shelter, alcohol, and drug treatment facilities, referrals for psychosocial needs, and other human services available through local resources. If the testing site is unable to provide vaccination against hepatitis A and B, the client will be referred for vaccination.
7.8 Educational Resources
HCV informational brochures will be available in the client waiting room. All educational materials and presentations will be culturally and linguistically appropriate and sensitive. Topics covered will include basic information on HCV, signs and symptoms, treatment, and prevention.
7.9 List of DSHS Websites Referenced in Chapter 7
DSHS General Consent and Disclosure form L-36: dshs.texas.gov/sites/default/files/hivstd/pops/forms/L-36.pdf
Guidelines for conducting HIV and HCV Point of Care Testing
St. Luke’s Liver Health Outreach: stlukestexas.com
Centers for Disease Control and Prevention: cdc.gov
Texas Constitution and Statutes: statutes.legis.state.tx.us
Health and Safety Code: statutes.legis.state.tx.us/?link=HS
Texas Family Code: statutes.legis.state.tx.us/?link=FA
U.S. Code: law.cornell.edu/uscode/text