Post-its from Practice:
Check people's Hepatitis C is active (Jul 2008)
One of the local outreach services had asked us to take over the care of Janet, aged 35 years, as they were worried about her failing health. They were particularly worried about her hepatitis C. Janet had known she was positive for Hepatitis C for 10 years and she was complaining of increasing tiredness and feeling more unwell. She had been in drug treatment and prison a few times during that period but had not been offered either further investigations or treatment.
We agreed to take over her health care and after a full assessment we began counselling for her heroin and crack problems and a methadone titration. She also agreed to have her tiredness, including her hepatitis C further investigated. Full examination revealed little except old and new track-marks, large groin injecting sites and marked skin damage from crack injecting.
Before taking blood for hepatitis A, B and C and HIV antibodies, a PCR HCV test, full blood count and kidney and liver functions tests, I undertook a pre-test discussion about hepatitis and HIV. I included that initial HIV and HCV tests are for antibodies only and explained that a positive HCV antibody test, the only test Janet had had, was insufficient to show whether the HCV infection is active or not. For that she needed a HCV PCR (viral load) test. She willingly agreed to all these tests.
In HIV the test always indicates ongoing infection but does not indicate for how long the infection has been present or the current state of the immune system. HIV has a long natural history and it may be 5-10 years or longer before an untreated person develops symptoms or signs.
With HCV about 75% of people will (eventually/or by when time period?) develop a chronic infection. In time many of these will develop cirrhosis of the liver (over an average 20-40 years) or some long-term symptoms or signs of liver inflammation, and of those who develop cirrhosis, 5% per year will develop liver failure or cancer (Ref 1).
Janet's HCV PCR showed that her hepatitis C was inactive so would not be causing her any symptoms. Her other results were normal except mild iron deficiency anaemia (from chronic blood loss from her groins, which was rapidly solved by stopping injecting and taking iron supplements). I was excited to be able to give her these results a week after she registered. Janet entered my room looking unwell, then on receiving her results she skipped out the room saying she felt instantly better!
Now two months on, settled on methadone mixture of 120mg daily, with her blood count back up to normal and her skin damage largely healed, she feels well and says she can begin to think about the next steps in her own recovery process.
There are many people like Janet, feeling unwell and thinking they have active hepatitis C and they don't (as well as thousands who don't know they have HCV). I personally feel it is now bad practice to test for HCV antibodies without also testing to see if it is active or not.
In our area you still need 2 blood tests, which can be taken at the same time and the laboratory will only do the PCR if HCV antibody positive. In other areas if requested they do it on the same sample. So if you don't know what happens in your area, find out the system and don't allow anyone, such as PCT, to say the PCR is not required (as recounted in a recent email from a GP) because it is!
Last year the HCC and the NTA improvement reviews looked at commissioning and harm reduction. The weakest scoring area was that for needle exchange and blood borne virus screening, vaccination and treatment. The national mean percentage for injecting drug users that had been tested for hepatitis C was 21.5% and this was only for the antibody test (Ref 2).
If we are going to have any effect on this epidemic we need to test all who consent, find if it is active or not and refer all people who have active hepatitis C.
1. "Guidance for the prevention, testing, treatment and management of hepatitis C in primary care".