Activity 2. “Testing” Facilitators Copy
Case 1
Lukas is a 29 year from Tashkent in the former USSR who
has been in the UK for 2 years working in a restaurant. He
has been presenting with general malaise, and weight loss over
the last 3 months. Standard investigations for fatigue,
including LFTs, have been negative but he is feeling worse.
 Why might this be a presentation of a BBV infection?
Facilitators Notes
High prevalence of HIV, Hepatitis B and C in Eastern
Europe. This presentation could be associated with liver
damage due to Hepatitis B or C infection , normal LFT do
not exclude this. Symptoms such as malaise and fatigue,
depression can be directly due to Hepatitis C infection
which infects brain cells. HIV infection, especially at
time of initial infection or late in the infection, can
present with non-specific symptoms such as those Lukas
has.
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You explain that you would recommend testing for Hepatitis
B, Hepatitis C and HIV infection. Lukas absolutely refuses
to be tested for any BBV infection.
 Why might Lukas refuse BBV testing despite your
advice?
Facilitators Notes
Stigma and perceived stigma about BBV infections remains
common. People in risk groups are also often stigmatized.
Lukas might have fears about employment, his partner and
family finding out about BBV infection – or drug use/
unprotected sex with men that placed him at risk of
infection.
Another issue may be lack of knowledge about treatment
which may not be available in his home country - or not
know if he would be able to access treatment in the UK.
Fears about immigration status and deportation also deter
people from seeking medical advice athough treatment for
Hepatitis B and C is free for anyone regardless of
entitlement to other NHS treatment. HIV treatment is
also free to all in England but not officially in Scotland.
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Case 2
Simon is a 23 yr old on a substitute script for methadone at
your practice. He is presenting today because his
prescription is due. You have not met him before but have
not been able to find a result for Hepatitis C testing in his
notes.
 What history do you need to know to assess his risk of BBV
infection?
Facilitators notes:
Assessment of risk could include:- Asking about how they have used drugs, recently and in the
past – even if it was many years ago. Risks are through
injecting drugs and sharing any injecting equipment but also
through snorting drugs such as cocaine. Remember people
may not feel able to disclose injecting drug use,
especially current if they are in treatment.
- Asking about when he has used drugs – to ascertain if he is
in the window period and if he may require repeat testing
for ongoing risk.
- Asking about sexual risk, he is young man and likely to be
sexually active. Does he have sex with men or women, or
both? What sort of sex does he have and does he use
condoms consistently?
- Has he been immunized against Hepatitis B?
- Other risks could include period in prison, travel abroad to
countries of high risk and tattooing/body piercing.
BUT advice would be that he should be tested for Hepatitis C,
Hepatitis B and HIV even if he does not disclosing injecting.
He tells you that he has injected drugs in the past but that
he has never shared needles and syringes. He thinks he last
injected about 3 months ago.
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 How would you raise the issue of BBV testing?
 What would you discuss in pre-test discussion and what
other infections would you discuss?
Facilitators Notes:
Raising issues about blood borne viruses should be routine with
drug users and many of them will expect this.
‘Has any one ever discussed testing for infections such as
Hepatitis C, Hepatitis B and HIV with you?’
‘I was looking through your records and could not see a test
result for Hepatitis C or HIV, have you ever been tested for
these infections’?
Pre-test discussion should include
- Explaining the benefits of testing which include
access to monitoring and treatment for Hepatitis B,
Hepatitis C and HIV – treatment can potentially cure
Hepatitis C and can control HIV and Hepatitis B
infection , preventing the serious consequences of
untreated infections.. These include severe liver
damage, cirrhosis and liver cancer with Hepatitis B
and C. For HIV severe immune damage and lethal
infections.
- Explaining how the patient will get the result – given
an appointment to get the infection usually Give them
an opportunity to ask questions?
Could also include:
- Discussion of the window period
- Discussion about coping whilst waiting for the result and
support available then and after getting a result.
- Who do they have to tell – and who do they not have to tell?
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Simon says that he does not want tested as he has feels he
has never shared and he does not like needles
 How could you encourage him to take up the offer of a
test?
Facilitators Notes:
Explore reasons for his refusal, are there other reasons than
needle-phobia? Concerns about confidentiality, anxiety about
waiting for a test result and needing time to think about it are
reasons for refusal.
Emphasise the benefits of testing already explored – if he is not
at risk in the future he will not need tested again.
Discuss the possibility of risk from injecting that he may not
recall, the risk of HIV and Hepatitis B infection from sexual
contact and even the risk of Hepatitis B from close household.
contact
Offer dried blood spot testing as an alternative to venepuncture.
Oral testing is available but not so sensitive and specific as DBS
and not available on the NHS.
If he continues to refuse give him written information, let him
know other sites that he can obtain testing - including anonymous
testing and same-day testing sites in case these are acting as
deterrents.
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Simon agrees to have the test
 What arrangements would you make for him to have the
test and get the result?
 Is there anything else you would consider doing at this
appointment?
Facilitators Notes
Discuss the benefits of testing immediately rather than
returning to another appointment, especially with someone else
such as the nurse, as he may not come back to the appointment.
Giving the result is usually face to face but may need to think
about how to do this using the telephone to give negative result
and recall for patients with positive results when testing large
numbers of patients. Discuss how this could be done to minimize
alarm to patients recalled – and also how not to lose prevention
opportunities if giving the result over the telephone?
Discuss what can be achieved in 10 minute appointments. Think
about giving Hepatitis B immunization if previously un-immunised,
uncertain immunization or if due further doses.
Could use opportunity to give prevention advice especially if
specific risks have been identified in history taking – such as
advice on safer injecting and directing towards IEP sites.
Giving written information on BBV testing for him to take away
with him.
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 Activity 2 :Testing
Case 3
Marianne is a 60 year old married social worker who has
deranged LFTs (liver function tests). She denies a high
alcohol intake and her auto-immune screen has come back
negative.
 How might she have been at risk of Hepatitis B and
Hepatitis C infection?
 How would you raise the issue of Hepatitis B and C testing
with her?
Facilitators Notes
Marianne could have been at risk of Hepatitis C and B through
injecting drug use or snorting drugs – but this could have been
many years ago. She may not remember this or may not want to
disclose this, for example through fears about it affecting her
employment.
Risk could also be through tattoing, piercing if unsterile.. Also
medical treatment or transfusion prior to screening for Hepatitis
C and B.
She could have been at risk of Hepatitis B infection through
sexual activity, travel related risks (including medical treatment
abroad) or even potentially occupationally.
In these cases, when the test is being used as a screen, it is
often best to normalize the test and make it routine.
“As part of the investigations for abnormal liver tests I
recommend that we test for two infections that affect the liver,
they are Hepatitis B and C. Have you heard of them?”
Discuss other ways that people suggest for raising the issue of
testing – challenge stigmatizing language or complex terminology.
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You raise the issue of testing for Hepatitis B and Hepatitis C
with her. She tells you that she has heard of these
infections – she asks why you want to test her for them.
 What would you discuss with her about testing for
Hepatitis B and C?
Facilitators Notes
Again think about a 10 minute consultation and what you will be
able to cover in that time. Essentials for testing are as
before – the benefits of testing for that individual, how they
will get the result.
However as she has asked why you want to test her you may
have to discuss the risk factors for these infections –
including drug use, sexual transmission and other blood
exposures.
“even if you do not feel you have been at risk I recommend
that we test you because there is treatment for them if we
did detect them”
She tells you that she is worried about having a test because
of her work as a social worker with children.
 What are the concerns that people may have about BBV
testing and confidentiality? What would you say to her
in this case?
People may have concerns about issues such as:
- life assurance and mortgages – insurance companies should
not ask about negative tests. Postive tests can affect the
terms on which insurance is offered but is does not matter
where the positive test is taken for this. ( ie no benefit in
having the test taken at GUM).
- Employment – You have no legal obligation to inform your
employer unless you are a health care professional.
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However, you do have a legal duty to ensure your own health
and safety and that of others while at work. The type of
work that you do will influence the level of risk to others.
Working with your employer means you can prevent others
being infected. If you do decide to tell your employer they
are obliged to keep this information confidential and cannot
pass it on without your consent. (Health and Safety
Executive. Blood-borne viruses in the workplace: Guidance
for employers and employees. April 2008; INDG342.)
- Confidentiality within the practice – need to reassure
people about confidentiality, consider having a
confidentiality policy in the practice leaflet and waiting
room.
- Fears about telling family and friends. Advice is that if you
are diagnosed with hepatitis B you will need to inform close
family members, such as your partner or children, so that
they can consult a doctor to be tested and vaccinated
against the virus. People may need help and support with
this process.
- Need to let her know that any doctor who diagnoses
Hepatitis B is legally required to report this information, in
confidence, to local public health doctors who are
responsible for preventing the spread of infection. These
public health doctors work under the strictest guidance
about confidentiality. National data is then reported
anonymously to help monitor the spread and to inform the
prevention and treatment of hepatitis. (British Association
for Sexual Health and HIV. United Kingdom National
Guideline on the Management of the Viral Hepatitides A, B
& C. 2008.)
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She agrees to have test for Hepatitis B and Hepatitis C.
She asks what are the risks to her husband and children if
she is infected?
 What are the risks and what would you say to her at
this stage?
Facilitators Notes
Hepatitis C – extremely low risk of passing infection to
heterosexual sexual partners, household contacts and
vertically to children.
Hepatitis B – higher risk of transmission sexually and
vertically (depends on when she was infected) and a low, but
present, risk of transmssion to household contacts – if she was
positive these people would need tested and immunized.
Marianne is clearly still very anxious about the test and
the implications of a BBV infection.
 Where else could you direct her for support and
information?
Continue to offer support yourself, give written information (eg
British Liver Trust Leaflets)
Direct to websites such as:
http://www.britishlivertrust.org.uk/
http://www.hepctrust.org.uk/
Find out about local support organizations eg C-Plus in Lothian,
Waverley Care in Glasgow and Highland, C-Clear in Fife, Body
Postive in Tayside (see below)
http://www.hepatitisscotlandc.org.uk/contact-andsupport/support-services.aspx
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