Activity 3-Giving Results-Facilitators Copy
Case 1
John is a 24 year old patient in your practice. He injects
heroin 3 or 4 times per day, on most days. He was tested
for BBVs using DBS as part of your work up whilst
referring him to the local drug service. Currently he is
homeless and spends nights on the floors of various friends.
There are some nights where he sleeps rough. He has a
partner who lives with her parents. He occasionally sells
sex to fund his drug use.
Result
HCV antibody positive
HCV PCR positive
HIV antibody test negative
Hep B core antibody positive
Hep B surface antigen negative
 What do his results show?
 What will you say to John about his test results?
What else would you want to know from him? Does he
require any further tests?
Facilitators Notes
Results show that John has active Hepatitis C infection and that
he has had Hepatitis B infection but does not have evidence of
current infection on this blood test, nor does he have evidence of
HIV on this blood test.
However he is at very high risk of BBV infection due to ongoing
injecting behaviour and sexual risk so he will be in the window
period for HIV infection and will require repeat testing. You will
want to know more about his injecting behaviour especially sharing
of equipment and where he obtains supplies for injecting.
Homeless people are at higher risk of injecting and sharing because
they cannot store equipment safely and reliably.
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He needs to be told that he has active Hepatitis C infection
currently and that he has evidence of Hepatitis B infection in the
past. It is likely that this infection is from his injecting drug use
BUT you need to know more about his sexual activity – unprotected
intercourse, especially anal intercourse, is a risk for Hepatitis C
and Hepatitis A infection.
He should be told that there is treatment for Hepatitis C which is
potentially curative – that he needs specialist referral to assess
his infection (genotype) and how his liver is.
You need to ask a sexual history including his sexual activities with
his sex work partners and with his female partner. He sounds as if
he is at risk of STI and may require testing for other STI
(syphyllis, gonorrhoea, chlamydia) – as he is MSM this may be best
done at GUM (requires rectal and pharyngeal swabs)
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 What do you feel are the main issues for John in
relation to blood born virus infections at the moment?
 What other help could you offer him? Who else might
you involve?
Facilitators Notes
Main issues are probably around his chaotic drug use and poor social
situation. Although these should not prevent referral for assessment
of his Hep C infection they are likely to affect his chances of
attending the clinic and certainly his ability to adhere to treatment.
Addressing these issues as early as possible will help to improve his
chances of successfully completing treatment.
They also are putting him at very high risk of further infection with
BBV – superinfection with anther strain of Hep C or with HIV.
As well as referring to the Hepatitis C clinic (ASK PEOPLE WHO
THEIR LOCAL CLINICS ARE) – he should be referred in for
treatment of his drug problem urgently. A social work referral,
especially to a specialist drug team, could be very useful to help with
his housing and benefits – as Interferon treatment needs to kept in
the fridge, stable housing is very important.
Support may be available more readily in a specialist GP practice for
the homeless where they will have attached drug workers, CPN, social
work and BBV workers – but all of this should be available at specialist
drugs agency,
THESE OTHER REFERRALS SHOULD NOT DELAY REFERRAL TO
THE HEP C CLINIC – but letting everyone know about concurrent
referrals is helpful.
Other agencies that could help are local Drugs agencies to help engage
with drug treatment and also access to IEP and prevention advice. Hep
C specialist voluntary organizations who can offer information and
sometimes practical support in getting to appointments.
GP unlikely to want to initiate treatment for his drug misuse but can
refer and remain in touch for support if he is awaiting appointment to
be seen. Can offer him prevention advice (see below) and also offer
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support with telling friends and family –especially his partner who is
going to need BBV testing for HIV, Hep B and Hep C (sexual risk –
need to ask if she injects and shares too)
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 What prevention advice would you give John at this
stage?
Facilitators Notes
Clearly he needs advice on safer injecting and directed to local IEP
site, Also advice on safer ways of using drugs – smoking or UYB – and
the referral to drug treatment asap. Safer injecting advice includes
no sharing of any drug using paraphernalia, possibly advice on cleaning
injecting equipment if he is not able to access new equipment.
He needs advice on safer sex, consistent condom use and access to
free condoms
He should be offered Hep A immunization – as he is already immune to
Hepatitis B. He should also have Tetanus booster if not up to date.
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Activity 3-Giving Results
Case 2
Sam is a 45 year old man who had abnormal LFTs on
routine testing. An initial liver screen was carried out to
investigate this which included screening for hepatitis B and
C infection. He is married with two children. He was
consented for the BBV tests but did not have a risk history
taken before testing.
Result
HCV antibody positive
HCV PCR (or antigen) positive
Hep B core antibody negative
Hep B surface antigen negative
 How would you discuss these results with Sam?
Facilitators Notes
Sam is likely to be shocked – it is good that he has been tested as
his infection has been discovered but he will need a lot of support
to cope with the diagnosis.
Tell him the result quickly in the consultation- the tests have
shown no evidence of Hepatitis B infection but have shown an
active infection with Hepatitis C infection.
Could ask him if he has heard of Hepatitis C infection and how it is
acquired.
If he has no knowledge or only partial knowledge tell him about
Hepatitis C
Important points are
- it is a virus spread through blood to blood contact
- the commonest route of spread is through injecting or snorting
drugs, especially through sharing of equipment – even on one
occasion
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It can also be transmitted through unsterile medical treatment
(especially in a high prevalence country) or tattooing/piercing or
blood transfusion in the UK prior to screening
it can be present in the body for many years with no symptoms
or non-specific symptoms of malaise, poor concentration
it infects the liver and can, after many years infection, cause
liver damage and scarring.
The tests already taken do not tell us how much the liver is
damaged.
AND MOST IMPORTANTLY IT IS TREATABLE WITH UP TO
95% CURE RATE.
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 What further information do you need from Sam at
this stage and why?
 Does he require any further tests?
Facilitators Notes
After hearing about Hepatitis C ask Sam if he can identify a risk that
he may be aware of that could have put him at risk. Some people
cannot identify any risk – or may not want to tell you about it- and the
most important thing is that the infection has been identified and he
can access treatment.
Recent risk eg drug use is important as he may be in the window period
for Hep B infection. As he has one BBV the advice is that he should
be tested for them all and that includes HIV.
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 Sam asks about treatment that is available to him –
what are the main points that you would cover with
him at this stage?
Facilitators Notes
He should be told that there is treatment for Hepatitis C which is
potentially curative – that he needs specialist referral to assess
his infection (genotype) and how his liver is. This will include more
blood tests and scans of his liver but not usually a liver biopsy
nowadays. He can be told success rate of treatment is up to 95%
cure and that he could have to take treatment for 3-6 months.
The treatment depends on the Genotype of the Hepatitis C virus
that he has acquired and that will be determined by the tests
taken at the specialist clinic. Treatment will involve the use of
injectable interferon once weekly plus one or two types of oral
medication depending if he has Genotype 1 or one of the other
genotypes. Side-effects include malaise, flu-like symptoms,
depression, skin rashes and blood problems such as anaemia, but
these are all monitored and treatments for the side-effects are
offered. People who start treatment manage to finish it in most
cases. It will require regular monitoring and hospital attendance.
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 Sam asks what this means for his wife and family –
what issues do you need to discuss with him? How
could you support him with these issues?
Facilitators Notes
Although Hepatitis C infection has a low risk of heterosexual
transmission (<5% lifetime incidence) and a very low risk of household
transmission, the advice is that his wife and family should be offered
testing for Hepatitis C and the other blood borne viruses. Risk of mother
to child transmission is also very low.
His wife may be very shocked and angry – these viruses and their routes
of transmission can carry a high level of stigma. He may have to disclose
drug use to her – now or in the past.
It may be useful to offer to help to tell her about the diagnosis, with
both of them present. You could also suggest a Hep C voluntary agency
locally to help with this and the use of written materials ,eg from the
British Liver Trust.
They should be advised about not sharing razors, tooth brushes and
clippers at home but that cups, toilet seats and cutlery are absolutely
safe. How to deal with a blood spillage using gloves and bleach/Milton.
Advice is that although sexual transmission is very low risk that they
should practice safer sex with condoms. Kissing is fine.
They should all be offered Hepatitis B immunization.
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Activity 3-Giving Results
Case 3
Precious is a 21 year old female who was born in Zimbabwe
and moved to Scotland with her family.
Precious was tested for BBVs when she came to the
practice saying her partner had been diagnosed with
‘hepatitis’
When she comes back for the result she tells you that she
has had a positive pregnancy test.
Results
Hep B surface antigen positive
Hep C antibody negative
 What would you say to Precious about her test
results?
 Does she require any further tests?
Facilitators Notes
The tests show that she has active Hepatitis B infection but no
evidence of Hepatitis C infection. Hepatitis B is a sexually
transmitted infection although the most common route of
transmission is from mother to child.
From the information that you have it is not possible to say that
she acquired her infection from her husband – she may have given
it to him or they may both have acquired it separately. These
tests cannot tell how long she has had the infection and do not tell
us if her liver is damaged significantly.
She is infectious and can spread the infection to others sexually or
through blood to blood contact. Her household and sexual contacts
will need tested and immunized if not infected or immune.
Hepatitis B is a notifiable condition and public health department
will be informed about this diagnosis even if she does not give her
consent, they will contact her to ask about contact tracing.
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A risk assessment is important to try and determine if she could
be at risk Hep C infection and is in the window period. She comes
from a country of high HIV prevalence and had not had an HIV
taken – she should have this done asap.
She needs URGENT referral to the specialist unit (ASK WHICH
THEY WOULD USE) – to assess for treatment.
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 Precious asks about the risks to her baby – what will
you say to her about this?
Facilitators Notes
Important message is that her baby is at risk of infection but that
this can be prevented by treatment for the baby. .
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Vertical transmission (mother to infant) of infection occurs in 90%
of pregnancies where the mother is HBeAg-positive and in about
10% of HBsAg-positive, HBeAg-negative mothers.
All babies born to infected mothers should receive a complete
course of vaccine at birth, one month and 6 months of age.
Babies born to highly infectious mothers (HBeAG) should receive
HBIG (preferably given within 24 hours of delivery) as well as
active immunisation
HBIG may be given simultaneously with vaccine but at a different
site.
This reduces vertical transmission by 90%.
Caesarean section is not required and immunised babies can be
breast fed.
There is some evidence that treating the mother in the last month
of pregnancy with lamivudine may further reduce the transmission
rate if she is highly infectious (HBVDNA> 1.2 x 10 9 geq/ml), but
this needs to be further substantiated.
Hepatitis B may exacerbate after the end of pregnancy.
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 Would you refer Precious to a specialist and, if so,
who?
Facilitators Notes
She needs URGENT referral to the viral hepatitis specialist unit
(ASK WHICH THEY WOULD USE) – to assess for treatment. Her
pregnancy will influence the decision to treat at this stage but
should not delay referral.
The decision to treat depends on pattern of disease, HBVDNA
level, and presence or absence of significant necro- inflammation
and hepatic fibrosis.
In addition she needs a medical referral to the Obstetricians so
that they are aware of her diagnosis and can ensure that she and
the baby are treated to prevent vertical transmission.
A helpful resource around giving results can be accessed on utube
on the link below:http://m.youtube.com/watch?v=1HWQxXdHMxg
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