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Hepatitis C Testing and Prevention Counseling Guidelines for VA Health Care Practitioners

for Health Care Providers

Hepatitis C Testing and Prevention Counseling Guidelines for VA Health Care Practitioners

Please contact the Centers for Disease Control Hepatitis C DivisionLink will take you outside the VA website. if you require additional information.

Objective of Hepatitis C Testing and Prevention Counseling Guidelines for VA Health Care Practitioners:

To offer guidelines to providers in a variety of VA settings who assist veterans in identifying their hepatitis C status, provide education, and help facilitate behavior changes that will reduce their risk of acquiring or transmitting the hepatitis C virus.

Importance of the Testing and Prevention Counseling Guidelines to the Department of Veterans Affairs Medical Centers and the People We Serve:

The hepatitis C virus is a blood-borne virus that affects over four million individuals in the United States and is one of the leading causes of liver transplantation in this country. Studies conducted at Department of Veterans Affairs Medical facilities have shown a significant prevalence of hepatitis C infection among the veteran population. In response to the physical, social, and emotional challenges of being tested and counseled for hepatitis C, the Department of Veterans Affairs through the Hepatitis C Resource Centers has developed the following guidelines to assist health care providers who counsel and test patients for hepatitis C.

Goals of Hepatitis C Testing and Prevention Counseling at VA Medical Centers:

  • Assist patients in the decision process to be tested for hepatitis C.
  • Provide education and information on hepatitis C including transmission, treatment and resources.
  • Assess patient risk and develop an individualized risk-reduction plan.
  • Prepare the patient for delivery and interpretation of test results.
  • Identify those with hepatitis C and link them to medical resources and treatment.
  • Provide appropriate referrals to support services.

Stages of Counseling

4.1 Stage 1: Pretest Counseling

A. Introduction to testing:
  • Discuss the VA's commitment to testing and screening for hepatitis C in response to the significant prevalence of hepatitis C among veterans.
  • Reinforce with patient that anti-HCV testing is voluntary. Refusal by the patient to have an anti-HCV test performed will not impede the patient's access to health care.
B. Establish and identify your patient's risk for hepatitis C:
  • Identify and discuss behaviors and history that may pose risk for hepatitis C .
  • Document risk factors for hepatitis C.
C. Utilize the VA Screening Guidelines for antibody testing for hepatitis C:
  • Patient desires to be tested, or
  • One or more of the following risks are identified:
    • Prior or current intravenous drug use
    • Blood transfusion or organ transplantation prior to 1992
    • Hemodialysis
    • Vietnam-era Veteran, defined by dates of service from 1964 through 1975
    • Health care, emergency medical care, emergency medical and public safety workers after a needlestick injury or mucosal exposure to HCV-positive blood
    • Tattoos or body-piercings obtained in non-regulated settings
    • Intranasal drug users who have shared paraphernalia
    • Past sexual exposure to an HCV infected partner or 10 or more lifetime sexual partners
    • Current sexual partners of HCV-infected persons
    • Persons with HIV infection
    • History of hemophilia and received clotting factor concentrates prior to 1987
    • History of unexplained liver disease or abnormal liver function test
    • Persons who have alcoholic hepatitis or a diagnosis (DSM-IV) of alcohol abuse or dependence.
    • Born to a mother with HCV
D. Discuss referrals for voluntary screening and testing for other diseases that may share some risk factors with hepatitis C such as HIV and hepatitis B, particularly if the risk history reveals that the patient is engaging in the following:
  • Unprotected sex with multiple partners, or a partner known to be infected with HIV or hepatitis B
  • I.V. drug use, especially sharing works with others
  • Exchange of sex for money and/or drugs
E. Work with patient to develop a risk-reduction plan:
  • Discuss ways to prevent transmission of the hepatitis C virus to self or others based on risk factors identified during the risk assessment.
  • Based on risk factors identified, encourage the patient to undergo testing and screening for other conditions such as hepatitis B , HIV and STDs and provide possible referrals for testing and screening.
  • Address strategies to reduce risk based on the Centers for Disease Control and Prevention guidelines.
F. Assess patient's readiness and resources for prevention of hepatitis C virus infection and transmission:
  • Inquire into patient's ability and willingness to minimize infection and perceived self-efficacy in prevention of infection.
  • Discuss any cultural issues and/or barriers that prevent the patient from reducing risk of hepatitis C virus infection, including previous attempts at preventive behaviors that were unsuccessful.
  • Based on the individual risk for hepatitis C virus infection, assist the patient in identifying and generating risk-reduction strategies that the patient would be comfortable using, such as utilizing needle-exchange programs in the community instead of reusing needles.
  • Provide information and referrals if necessary which may assist patient in reducing risk for hepatitis C such as chemical dependence counseling and/or support groups.

Prevention messages for persons with high-risk drug or sexual practices (1)

  1. Persons who use or inject illegal drugs should be advised:
    • To stop using and injecting drugs.
    • To enter and complete substance abuse treatment, including relapse prevention programs.
    • If continuing to inject drugs;
    • never reuse or "share" syringes, needles, water, or drug preparation equipment; if injection equipment has been used by other persons, first clean the equipment with bleach and water;
    • use only sterile syringes obtained from a reliable source (e.g., pharmacies);
    • use a new sterile syringe to prepare and inject drugs;
    • use sterile water to prepare drugs; otherwise, use clean water from a reliable source (such as fresh tap water);
    • use a new or disinfected container ("cooker") and a new filter ("cotton") to prepare drugs;
    • clean the injection site before injection with a new alcohol swab; and
    • dispose safely of syringes after one use.
    • To get vaccinated against hepatitis B and hepatitis A.
  2. Persons who are at risk for sexually transmitted diseases should be advised:
    • That the surest way to prevent the spread of HIV infection and other sexually transmitted diseases is to have sex with only one uninfected partner or not to have sex at all.
    • To use latex condoms correctly and every time to protect themselves and their partners from diseases spread through sexual activity.
    • To get vaccinated against hepatitis B, and if appropriate, hepatitis A.
G. Assist patient with the decision to be tested for hepatitis C:
Use risk assessment and risk-reduction plan as a guide.

  • If patient does not decide to test, provide written information and document decision and pertinent risk factors discussed.
  • If patient decides to test, proceed with steps below.

H. Discuss testing methods and procedures:
  • Testing is voluntary.
  • Refusal to have a hepatitis C antibody test performed will not impede the patient's access to health care.
  • Explain to the patient that blood will be drawn and tested for the hepatitis C antibody.
  • Explain conditions of confidentiality. Emphasize to patient that the result of the test will be stored in the patient's medical chart. Any illegal or unauthorized use of the hepatitis C antibody test result or any other aspect of the patient's medical history is strictly prohibited by the Department of Veterans Affairs.
I. Briefly discuss the natural history of hepatitis C:
  • The majority of people with hepatitis C present with few or no symptoms, but many of these people can still transmit the hepatitis C virus.
  • Many people develop chronic hepatitis C infection and a subset of this population may develop significant liver disease.
  • The antibody can be detected in roughly 80% of patients within 15 weeks of exposure and >97% within six months of exposure.
  • Elevated liver enzymes (e.g., serum ALT levels) are usually the first indication of infection, but normal liver enzyme levels do not indicate resolution of hepatitis C virus infection.
J. Discuss some ways in which hepatitis C is not spread:

According to the Centers for Disease Control and Prevention, the hepatitis C virus is not spread by

  • sneezing
  • coughing
  • hugging
  • food or water
  • sharing eating utensils or drinking glasses
  • casual contact
K. Discuss the advantages and disadvantages for the patient of knowing his/her serological status.

Advantages:

  • Patients may find reassurance in knowing their test results.
  • Education on transmission education for those who test positive can help prevent transmission to family members, sexual partners and others.
  • The patient can develop strategies to keep his/her liver healthy. For example, through the avoidance of alcohol and certain drugs which are hepatotoxic, the patient can prevent additional damage to the liver.
  • The patient may develop a better awareness of his/her risk for other types of viral hepatitis such as hepatitis A virus and hepatitis B virus and be vaccinated for those viruses, if appropriate.
  • Early diagnosis and additional tests can help the practitioner refine the diagnosis as well as determine the severity of liver injury caused by hepatitis C.
  • Although there is neither a predictable cure nor a vaccine for hepatitis C, there are treatments currently available.

Disadvantages:

  • The patient may experience anxiety related to being tested for hepatitis C, regardless of the test outcome.
  • There is neither a vaccine nor a predictable cure for hepatitis C. There are treatments for hepatitis C. However, these medications are still being tested and refined. Therefore, being tested and found positive will not ensure that treatment will work for the patient.
  • The patient needs to be informed that testing positive for hepatitis C could cause potential
    • disrupted personal relationships
    • inability to obtain life and health insurance
    • difficulties in employment or educational opportunities
  • The majority of individuals who are diagnosed with hepatitis C are chronic carriers. The patient may experience psychological and physical distress related to being diagnosed with a chronic illness.
L. Prepare patient for possible test result outcomes and posttest counseling:
  • The patient will receive one of the following test results: negative, positive or indeterminate. Explain that possible re-testing may be needed depending on the result outcome and risk factors.
  • Refer to the Hepatitis C Antibody Screening Flow Chart for the Veteran Population.
  • Discuss the limitations of the ELISA test (2)
    • The newer version of the ELISA test has a greater sensitivity of ≥97%. This means that the test will detect antibodies in infected patients approximately 97% of the time. ELISA will fail to detect antibodies in patients with hepatitis C about 3% of the time.
    • The hepatitis C antibody can be detected in roughly 80% of patients within 15 weeks of exposure and >90% of patients within 5 months of exposure, and in greater or equal of 97% of patients by 6 months after exposure. Blood drawn during the period of initial infection and emergence of antibodies may yield false-negative test results.
    • False-negativity sometimes occurs in those with hepatitis C who are immunocompromised.
    • Presence of antibodies does not differentiate between acute, chronic or resolved infection.
  • Discuss the reliability of the antibody test, and the need for confirmation of test results.
    • Discuss the sensitivity and specificity of tests used to diagnose infection. The newer version of the ELISA test has a sensitivity of greater or equal than 97%. This means that the test will detect antibodies in infected patients approximately 97% of the time.
    • Address the possible need for supplemental testing such as RIBA or PCR. RIBA (recombinant immunoblot assay) is a highly specific test. It is useful in minimizing false-positive results in a low-risk population for infection (i.e. blood donors). PCR (polymerase chain reaction) identifies hepatitis C virus RNA.
  • Discuss the need for possible confirmation of positive test results or indeterminate results through supplemental testing such as RIBA or PCR.
    • RIBA is a highly specific test. It is useful in minimizing false-positive results in a low-risk population for infection (i.e. blood donors).
    • PCR identifies hepatitis C virus RNA and is highly sensitive, but has not been approved by the FDA (Food and Drug Administration).
    • RIBA and/or PCR for hepatitis C virus RNA may be required in a high-risk population for infection, i.e. injection drug users with normal liver function tests.
  • Schedule a return date to meet with physician, nurse, or counselor to discuss test results and schedule appropriate follow-up appointments. (Each VA medical facility should have a knowledgeable health care professional to provide results and education in a confidential manner. This person should also be available for the patient during the waiting period for test results. This person ideally should be a trained counselor who is skillful at providing test results such as a physician, nurse, and/or HIV counselor.)
  • Emphasize the need for the patient to return to clinic for the test result on the scheduled date.
  • Encourage the patient to contact the VA center prior to the return appointment if he/she has any questions and/or concerns relating to the testing process.
M. Provide written information on hepatitis C testing and prevention counseling:
  • Reinforce and supplement testing, prevention counseling and education.
  • Provide current and accurate information geared toward the veteran patient being tested for the hepatitis C antibody and patient appropriate risk-reduction activities. (See the Publications and Products)

Stage 2: Posttest Counseling

A. Inform the patient of the test result. Assist the patient in understanding the meaning of the test result.
Negative Results:
  • A negative result means that the test did not detect antibodies in the blood, suggesting that the patient is unlikely to be infected with the hepatitis C virus unless the patient is immunocompromised.
  • Explain to the patient that the antibody tests are not fail-safe and can yield incorrect results, especially in persons who are immunocompromised. In certain cases, additional testing may be necessary.
  • Evaluate patient's emotional status upon receiving test result.
  • Suggest the necessity of re-testing if exposure was recent (within 6 months) and the patient is in a high-risk category (i.e. recent history of injection drug use).
  • Suggest the need for testing for hepatitis C virus RNA if the patient is immunocompromised.
  • Allow time for the patient to ask questions regarding test result and assess the patient's comprehension of the test outcome.
  • Reinforce risk-reduction plan discussed in pretest counseling session.
  • Provide educational materials on hepatitis C prevention and risk-reduction strategies.
  • Discuss resources available to patient within the VA health care system and community. Strongly encourage patient to utilize mental health, substance abuse programs and other resources/referrals at VA Medical and Vet Centers.
  • Provide a list of resources within the VA health care system and community that may address the needs of the patient.
  • Document posttest counseling, risk-reduction plan discussed and referrals made.
Indeterminate Results:
  • This means that it is uncertain as to whether or not the patient has hepatitis C. The patient could be in the process of forming antibodies, or other viral or immune factors are present that are not related to hepatitis C. In addition, this result could indicate a laboratory processing error.
  • Additional screening and/or antibody testing is needed to make a formal diagnosis.
  • Document posttest counseling, risk-reduction plan discussed and referrals made.
Positive Results:
  • Inform the patient that antibodies were detected in his/her blood, suggesting that the patient may be infected with the hepatitis C virus. This result does not indicate whether infection is acute, chronic, resolved or an incorrect result.
  • Evaluate the patient's emotional status upon receiving test result.
  • Discuss the necessity for confirmatory testing. Explain to the patient that the antibody tests are not fail-safe and can yield incorrect results.
  • Discuss the natural history of hepatitis C, emphasizing that while the virus can cause significant morbidity and impair the quality of life, only a minority of infections leads to life-threatening complications.
  • Discuss how the virus is transmitted.
  • Discuss how the virus is not transmitted.
  • Discuss resources available to the patient within the VA health care system and in the community. Identify VA resources for further assessment, evaluation and support.
  • Provide a list of resources for the patient within the VA and in the community.
  • Discuss issues of disclosure with patient such as notifying others such as household members, sexual partners, and health care providers.
  • Emphasize and illustrate ways to maintain wellness:
    • Avoid alcohol
    • Practice good nutrition
    • Exercise
    • Encourage patient to check with his/her health care provider before beginning new medications including herbal treatments
    • Encourage the patient to get vaccinated against hepatitis A virus and hepatitis B virus to prevent superimposed infections if he/she has not had these illnesses or been vaccinated previously
  • Identify when the patient will return for confirmatory testing and/or medical evaluation.
  • Explain to the patient that supplemental tests may help refine the diagnosis.
  • Encourage the patient to discuss results with all sexual or IV drug-sharing partners. Make recommendations for partner testing and where testing is available. Provide a list of resources within the community for partner or family testing.
  • Document posttest counseling, risk-reduction plan discussed and referrals made.

CDC Recommendations for Patients Who Receive Positive Hepatitis C Virus Test Results

  1. Protect the liver from further harm
    • Avoid alcohol consumption
    • Do not start new medications, including herbal or over-the-counter medications, without consulting a physician
    • Get vaccinated for hepatitis A if liver disease is present
  2. Minimize the risk of transmission to others
    • Do not donate blood, body organs, tissue, or semen
    • Do not share appliances that may have blood on them, such as toothbrushes, dental appliances, razors and nail clippers.
    • Cover sores or open wounds on the skin to prevent spreading of infectious blood or secretions
  3. Persons with hepatitis C who have one long-term steady sex partner do not need to change sexual practices
    • Explain that the risk of transmitting the virus to the uninfected partner is low, but not absent
    • Discuss the risk with the partner and the possibility of the need for counseling and testing
    • Discuss the consistent and effective use of barrier precautions, e.g. latex condoms, which may further lower the risk of transmission
  4. Persons with hepatitis C should be evaluated for the presence or development of chronic liver disease
    • Assess biochemical test results for evidence of liver disease
    • Assess the severity of liver disease
    • Discuss and evaluate possible treatment strategies according to current practice guidelines with a knowledgeable specialist
  5. Other important counseling points
    • Hepatitis C is not spread by sneezing, hugging, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact
    • Persons with hepatitis C should not be excluded from participating in normal, everyday activities, such as work, school, play, childcare, etc.
    • Hepatitis C support groups may help and educate the patient in dealing with the infection

For a list of organizations providing information on hepatitis C, please see our Web Resources.

The Hepatitis C Testing and Prevention Counseling Guidelines for VA Health Care Practitioners can be used to assist health care providers in the Department of Veterans Affairs Medical Centers who are counseling and testing their patients for the hepatitis C virus. We urge health care providers to use these guidelines in conjunction with the recommendations and reports provided by the Centers for Disease Control and Prevention and the National Institutes of Health.

References

  1. Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease.Link will take you outside the VA website. MMWR 1998; 47(No. RR-19): p. 18.
  2. IbidLink will take you outside the VA website.. pp. 10-12.