Hepatitis B and C testing: people at risk of infection

Evidence statement Q1

Understanding and awareness of hepatitis B among people born in countries with intermediate and high endemicity may be strongly influenced by their personal experiences and cultural beliefs (two [++], one [+])^1,2,3.

¹ Burke et al. 2004.

² Burke et al. 2011.

³ Wallace et al. 2011.

Evidence statement Q2

People born in countries with intermediate and high endemicity for hepatitis B may confuse the various forms of hepatitis and the relationship between hepatitis and HIV, and they may commonly hold inaccurate beliefs about transmission risks (two [++], one [+])^1,2,3. The lack of, or gaps in, knowledge about hepatitis B identified among some healthcare professionals (two [++])^3,4 may contribute to or compound inadequate knowledge about hepatitis B among groups at a high risk of infection.

¹ Burke et al. 2011.

² van der Veen et al. 2009.

³ Wallace et al. 2011.

⁴ Hwang et al. 2010.

Evidence statement Q3

People born in countries with intermediate and high endemicity for hepatitis B may commonly cite access to or contamination of food, or cultural practices associated with sharing food and communal eating, as the main cause of hepatitis B transmission (three [++] and one [+])^1,2,3,4. Although vertical transmission of hepatitis B was acknowledged in some studies, sexual transmission of hepatitis B was infrequently mentioned; overall, the evidence suggests that groups at a high risk of infection do not perceive hepatitis B as a sexually transmitted infection (three [++])^4,5,6.

¹ Burke et al. 2004.

² Burke et al. 2011.

³ Chen et al. 2006.

⁴ Choe et al. 2005.

⁵ van der Veen et al. 2009.

⁶ Wallace et al. 2011.

Evidence statement Q4

As with their beliefs about the causes and prevention of hepatitis B, people born in countries with intermediate and high endemicity may express beliefs about prevention that are influenced by their personal experiences and cultural background (four [++])^1,2,3,4. Among people originating from East and South East Asia, prevention strategies may commonly reflect the practice of traditional medicine and vaccination may not generally be considered as a primary means of prevention(five [++] and one [+])^1,2,5,6,7,8. Religious influences on preventive health strategies may also be apparent, for example among Muslim men (one [++])³.

¹ Choe et al. 2005.

² Chen et al. 2006.

³ van der Veen et al. 2009.

⁴ Wallace et al. 2011.

⁵ Burke et al. 2004.

⁶ Burke et al. 2011.

⁷ Chang et al. 2008.

⁸ Hwang et al. 2010.

Evidence statement Q5

Despite some participants expressing generally positive attitudes towards hepatitis B vaccination and people at high risk being receptive to vaccination (one [++] and one [+])^1,2 some studies (two [++] and one [+])^1,3,4 indicated that there is significant confusion and uncertainty surrounding vaccination among groups at a high risk of infection.

¹ Buck et al. 2006.

² van der Veen et al. 2009.

³ Chen et al. 2006.

⁴ Chang et al. 2008.

Evidence statement Q7

Barriers to testing for hepatitis B include an absence of clear symptoms of infection, practical obstacles such as inconvenience and time constraints, and language and cultural barriers, all of which may discourage some people from seeking care and may limit the role that healthcare providers play in providing education and outreach to immigrant communities (one [++])¹.

¹ van der Veen et al. 2009.

Evidence statement Q8

The perception of hepatitis B as a 'liver' or 'blood' illness rather than a sexually transmitted infection (STI) appears to play an important role in tempering stigma associated with hepatitis B. Increasing awareness of hepatitis B as a sexually transmitted infection was viewed by one study ([++])¹as potentially contributing to increased stigma.

¹ van der Veen et al. 2009.

Evidence statement Q9

One study ([++])¹ reported that people with a diagnosis of chronic hepatitis B, including first- and second-generation immigrants, had little recollection of providing consent to test and did not receive adequate information at diagnosis. This lack of information and knowledge was perceived as impacting negatively on their health and preventing opportunities for behaviour change. Both patients and community workers expressed concerns about a lack of provider knowledge with regards to hepatitis B.

¹ Wallace et al. 2011.

Evidence statement Q10

There was evidence that safe and responsible injecting practices are employed by injecting drug users (IDUs) to avoid the transmission of hepatitis C from 6 studies (5 [++] and 1 [+]^1,2,3,4,5,6. There was a lack of consensus as to whether safe practices are strictly adhered to in relation to the sharing of drug related paraphernalia^3,5,7.

¹ Davis et al. 2004.

² Ellard 2007.

³ Rhodes et al. 2004.

⁴ Southgate et al. 2005.

⁵ Wright et al. 2005.

⁶ Fraser 2004.

⁷ Coupland et al. 2009.

Evidence statement Q14

There is strong evidence from 18 studies (eleven [++], five [+], one [-] and one not rated [NR])^{1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18} that IDUs have an uncertain and incomplete knowledge of hepatitis C. Studies showed that IDUs are confused over what the disease is, how it differs from other forms of hepatitis, how the infection is transmitted and what symptoms are involved. This confusion was reinforced by the perception that expert and scientific knowledge on hepatitis C is shifting and uncertain (three [++] and one [NR])^4,11,12,17. There is evidence that some IDUs are aware of their limited knowledge of hepatitis C (three [++])^3,4,12.

¹ Copeland 2004.

² Coupland et al. 2009.

³ Davis and Rhodes 2004.

⁴ Davis et al. 2004.

⁵ Ellard 2007.

⁶ Fraser 2004.

⁷ Fraser 2010.

⁸ Gyarmathy et al. 2006.

⁹ Harris 2009a.

¹⁰ Munoz-Plaza et al. 2004.

¹¹ Rhodes and Treloar 2008.

¹² Rhodes et al. 2004.

¹³ Sosman et al. 2005.

¹⁴ Southgate et al. 2005.

¹⁵ Sutton and Treloar 2007.

¹⁶ Swan et al. 2010.

¹⁷ Tompkins et al. 2005.

¹⁸ Wright et al. 2005.

Evidence statement Q15

Hepatitis C is often understood in relation to HIV in a way that trivialises the seriousness of contracting hepatitis C and may have implications for the use of safe injecting practices and the uptake of hepatitis C services (eleven [++], two [+] and two [NR])^{1,2,3,4,5,6,7,8,9,10,11,12,13,14,15}.

¹ Copeland 2004.

² Davis and Rhodes 2004.

³ Davis et al. 2004.

⁴ Ellard 2007.

⁵ Faye and Irurita 2003.

⁶ Harris 2009a.

⁷ Munoz-Plaza et al. 2010.

⁸ Rhodes et al. 2004.

⁹ Roy et al. 2007.

¹⁰ Southgate et al. 2005.

¹¹ Sutton and Treloar 2007.

¹² Swan et al. 2010.

¹³ Rhodes and Treloar 2008.

¹⁴ Treloar and Rhodes 2009.

¹⁵ Wozniak et al. 2007.

Evidence statement Q16

A number of barriers to hepatitis C testing among IDUs were identified. People perceiving themselves to be at low risk of hepatitis C infection, a lack of visible symptoms of hepatitis C infection, fear of a positive test result, the use of needles and fear of disclosure were found to prevent the uptake of hepatitis C testing among IDUs (seven [++], eight [+], one [-] and one [NR])^{1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17}. Three studies (two [+] and one [-])^7,18,19 reported barriers to testing specific to the prison setting including long waiting times, lack of information provision, prioritisation of detoxification and withdrawal, and movement between prisons.

¹ Craine et al. 2004.

² Davis et al. 2004.

³ Fraser 2004.

⁴ Fraser 2010.

⁵ Gyarmathy et al. 2006.

⁶ Harris 2009a.

⁷ Khaw et al. 2007.

⁸ Lally et al. 2008.

⁹ Perry et al. 2003.

¹⁰ Rhodes and Treloar 2008.

¹¹ Rhodes et al. 2004.

¹² Temple-Smith et al. 2004.

¹³ Sosman et al. 2005.

¹⁴ Southgate et al. 2005.

¹⁵ Strauss et al. 2008.

¹⁶ Sutton and Treloar 2007.

¹⁷ Swan et al. 2010.

¹⁸ Dyer and Tolliday 2009.

¹⁹ Munoz-Plaza et al. 2005b.

Evidence statement Q18

Convenient and opportunistic testing and a 'one-stop shop' approach for all hepatitis C services was regarded as a convenient approach among IDUs (three [++] and five [+])^{1,2,3,4,5,6,7,8}. There is evidence (two [++] and two [+])^3,9,10,11 that some IDUs were unaware that they had been tested for hepatitis C and concern over informed consent to testing was noted by a number of authors. Although an opportunistic approach can increase testing compliance, a lack of informed consent may also contribute towards uncertain knowledge of hepatitis C among IDUs and limit the impact of testing on behaviour.

¹ Gyarmathy et al. 2006.

² Munoz-Plaza et al. 2004.

³ Rhodes et al. 2004.

⁴ Roy et al. 2007.

⁵ Sosman et al. 2005.

⁶ Swan et al. 2010.

⁷ Strauss et al. 2008.

⁸ Temple-Smith et al. 2004.

⁹ Munoz-Plaza et al. 2005b.

¹⁰ Perry and Chew-Graham 2003.

¹¹ Tompkins et al. 2005.

Evidence statement Q20

Trust and rapport with healthcare professionals and drug treatment staff motivated people to get tested. Support and encouragement from healthcare professionals also facilitated testing among IDUs (four [+])^1,2,3,4.

¹ Munoz-Plaza et al. 2004.

² Perry et al. 2003.

³ Sosman et al. 2005.

⁴ Strauss et al. 2008.

Evidence statement Q21

Studies showed that the experience of being informed about the outcome of hepatitis C testing can be highly confusing (nine [++], two [+], one [-] and one [NR])^{1,2,3,4,5,6,7,8,9,10,11,12,13}. Limited and inadequate information provision by healthcare professionals can lead to confusion over the meaning of a positive diagnosis and substantial gaps in knowledge.

¹ Copeland 2004.

² Cullen et al. 2005.

³ Faye and Irurita 2003.

⁴ Khaw et al. 2007.

⁵ Kinder 2009.

⁶ Lally et al. 2008.

⁷ Rhodes and Treloar 2008.

⁸ Rhodes et al. 2004.

⁹ Southgate et al. 2005.

¹⁰ Strauss et al. 2008.

¹¹ Sutton and Treloar 2007.

¹² Swan et al. 2010.

¹³ Tompkins et al. 2005.

Evidence statement Q23

Fear of the adverse effects associated with hepatitis C treatment and the circulation of 'horror stories' and unsuccessful treatment cases among peers discouraged IDUs from engaging with treatment (three [++], one [+] and two [-])^1,2,3,4,5,6. A fear of needles was also common and using needles during the treatment process was a challenge to overcome when considering treatment (two [++] and one [+])^3,5,7. In contrast, anxiety over hepatitis C, witnessing peers suffer from symptoms of hepatitis C infection and hearing stories of successful treatment cases among peers encouraged treatment uptake (two [++] and one [+])^3,5,8.

¹ Cullen et al. 2005.

² Fraser 2010.

³ Kinder 2009.

⁴ Munoz-Plaza et al. 2008.

⁵ Swan et al. 2010.

⁶ Treloar and Holt 2008.

⁷ Strauss et al. 2008.

⁸ Munoz-Plaza et al. 2004.

Evidence statement Q24

Socioeconomic and family circumstances can lead to treatment being de-prioritised among IDUs (three[++] and one [-])^1,2,3,4. Studies have shown that a preoccupation with drug use, chaotic lifestyles, long waiting times between appointments and employment contributed towards IDUs missing and forgetting treatment appointments, thus increasing the possibility of treatment dropout (three [++])^1,3,5. The assumption of abstinence as a requirement for hepatitis C treatment and continued substance use among IDUs acted as a barrier to treatment (six [++] and one [-])^{1,3,5,6,7,8,9}.

¹ Coupland et al. 2009.

² Fraser 2010.

³ Swan et al. 2010.

⁴ Treloar et al. 2010.

⁵ Lally et al. 2008.

⁶ Cullen et al. 2005.

⁷ Roy et al. 2007.

⁸ Wozniak et al. 2007.

⁹ Wright et al. 2005.

Evidence statement Q25

Receiving support from family, partners and peers, starting family life and concerns over the impact of hepatitis C on significant others (for example partners and children) motivated IDUs to engage with hepatitis C treatment (three [++])^1,2,3.

¹ Faye and Irurita 2003.

² Kinder 2009.

³ Swan et al. 2010.

Evidence statement Q27

One study ([-])¹ found that being in prison was viewed by healthcare professionals as both a barrier and a facilitator for hepatitis C treatment. Transportation of prisoners between prisons and short sentences were viewed as interfering with the treatment process whereas the structured environment of prison and availability of peer support during treatment were regarded as beneficial.

¹ Dyer and Tolliday 2009.

Evidence statement Q28

Two studies found that a lack of access to treatment and a lack of information on treatment options act as barriers to hepatitis C treatment (two [++])^1,2. Increasing knowledge of hepatitis C through the provision of information by healthcare professionals encouraged IDUs to consider their treatment options (one [++], two [+] and one [-])^1,3,4,5.

¹ Swan et al. 2010.

² Treloar et al. 2010.

³ Cullen et al. 2005.

⁴ Munoz-Plaza et al. 2004.

⁵ Munoz-Plaza et al. 2008.

Evidence statement Q29

The experience of stigma prevented IDUs from seeking hepatitis C testing because of fear of disclosure, and prevented IDUs from disclosing a positive hepatitis C status because of fear of a negative reaction, isolation and social exclusion (eight [++], three [+], one [-] and one [NR])^{1,2,3,4,5,6,7,8,9,10,11,12,13}. Stigma also prevented engagement with further prevention education, investigations and treatment and resulted in IDUs receiving inadequate and judgemental care by healthcare professionals (seven [++], six [+], one [-] and two [NR])^{5,6,7,9,12,14,15,16,17,18,19,20,21,22,23,24}.

¹ Craine et al. 2004.

² Ellard 2007.

³ Harris 2009b.

⁴ Khaw et al. 2007.

⁵ Lally et al. 2008.

⁶ McCreaddie et al. 2011.

⁷ Roy et al. 2007.

⁸ Sosman et al. 2005.

⁹ Strauss et al. 2008.

¹⁰ Sutton and Treloar 2007.

¹¹ Tompkins et al. 2005.

¹² Treloar and Rhodes 2009.

¹³ Wright et al. 2005.

¹⁴ Carrier et al. 2005.

¹⁵ Coupland et al. 2009.

¹⁶ Faye and Irurita 2003.

¹⁷ Habib and Adorjany 2003.

¹⁸ Munoz-Plaza et al. 2004.

¹⁹ Paterson et al. 2007.

²⁰ Perry et al. 2003.

²¹ Swan et al. 2010.

²² Temple-Smith et al. 2004.

²³ Treloar and Hopwood 2004.

²⁴ Treloar et al. 2010.

Evidence statement Q30

Perceiving health care professionals to be supportive, concerned and caring, and being encouraged to undertake treatment by healthcare professionals was found to motivate IDUs to engage in hepatitis C treatment (four [++], one [+] and one [-])^1,2,3,4,5,6. There was evidence across a number of studies that IDUs preferred hepatitis C services, including treatment, to be situated in one setting such as drug treatment programmes and methadone substitution settings (two [++] and one [+])^5,7,6. These services were also seen as useful in providing information on hepatitis C treatment (one [++] and three [+])^5,6,8,9.

¹ Fraser 2010.

² Coupland et al. 2009.

³ Kinder 2009.

⁴ McCreaddie et al. 2011.

⁵ Munoz-Plaza et al. 2004.

⁶ Swan et al. 2010.

⁷Treloar et al. 2010.

⁸ Munoz-Plaza et al. 2005a.

⁹ Munoz-Plaza et al. 2006.

Evidence statement E1

There is moderate evidence from three randomised controlled trials (RCTs) (one [++] and two [+])^1,2,3 and one uncontrolled before and after (UBA) study (-)⁴ to suggest that providing information and education on hepatitis B to migrant populations may improve their knowledge about risk, screening and prevention; moderate evidence from three RCTs (one [++] and two [+])^1,2,3 to suggest that providing information and education on hepatitis B to migrant populations does not improve testing uptake; and weak evidence from one case series (-)⁵ to suggest that testing supplemented with culturally appropriate education may encourage the uptake of follow-up care among migrant populations.

¹ Taylor et al. 2009a.

² Taylor et al. 2009b.

³ Taylor et al. 2011.

⁴ Hsu et al. 2007; 2010.

⁵ Chao et al. 2009.

Evidence statement E2

There is moderate evidence from one RCT (+)¹ to suggest that a strategy to promote cancer prevention activities among doctors serving migrant populations does not improve their practices in relation to hepatitis B testing. There is weak evidence from one UBA study (-)² to suggest that providing information and education on hepatitis B to complementary and alternative medicine practitioners (including those practising traditional Chinese medicine and acupuncture) may improve their knowledge about risk, screening and prevention. However, the wider impact of this change in knowledge on their practices regarding referral for testing is not clear.

¹ Nguyen et al. 2000.

² Chang et al. 2007.

Evidence statement E4

There is moderate evidence from one RCT (+)¹ and one controlled before and after (CBA) study (-)² to suggest that offering dried blood spot testing to IDUs attending substance misuse services may increase uptake of hepatitis C testing compared to venepuncture alone being offered. The increase in uptake may reflect an increase in testing availability, as more staff can be trained to deliver dried blood spot testing than venepuncture, as well as higher acceptability to IDUs. There is weak evidence from one case series (CS) study (-)³ to suggest that providing high-risk groups with access to dried blood spot testing kits via a telephone hotline is not an effective use of resources compared to testing via state laboratories.

¹ Hickman et al. 2008.

² Craine et al. 2009.

³ Rainey et al. 2005.

Evidence statement E5

There is moderate evidence from one RCT (+)¹ to suggest that although providing GPs with both training and assistance with screening (through the use of patient-targeted materials) may increase patient requests for testing, it does not impact upon the number of patients tested for hepatitis C overall. There is moderate evidence from two non-randomised controlled trials (two [+])^2,3 to suggest that targeted case finding in primary care for patients with a history of injecting drug use may have a positive impact on the number of patients who are offered and accept a hepatitis C test. Although the level of referral of patients identified with infection was relatively high, the number of subsequent dropouts prior to treatment indicates that there is a need for further support beyond the intervention offered in these studies.

¹ Roudot-Thoraval et al. 2000.

² Anderson et al. 2009.

³ Cullen et al. 2012.

Evidence statement E6

There is moderate evidence from one RCT (+) and two case series (two [-])^1,2,3 to suggest that providing hepatitis C services in community settings may have a positive impact on testing acceptance and uptake. In particular, there is weak evidence from two case series (two [-])^4,5 to suggest that a multidisciplinary or shared care approach to hepatitis C testing and treatment for IDUs is associated with high uptake of follow-up services and treatment outcomes comparable with non-drug-using populations. In two studies conducted in the USA (two [-])^6,7, hepatitis testing was added to routine blood work undertaken on entry to drugs services and therefore a high testing rate was inevitable. There is moderate evidence from one RCT (+)⁸ to suggest that the provision of testing services via outreach may have a positive impact on testing acceptance and uptake. The impact may be greatest when testing is offered on-site rather than by referral. There is weak evidence from one UBA study (-)⁹ to suggest that the provision of hepatitis C outreach services for new prisoners may lead to relatively low uptake of testing.

¹ Rosenberg et al. 2010.

² Lindenberg et al. 2011.

³Jack et al. 2009.

⁴ Lindenberg et al. 2011.

⁵ Jack et al. 2009.

⁶ Harris et al. 2010.

⁷ Hagedorn et al. 2007.

⁸ Sahajian et al. 2011.

⁹ Skipper et al. 2003.

Evidence statement E7

There is weak evidence from one case series (-)¹ to suggest that offering a non-invasive liver evaluation technique in outreach settings provides an opportunity to subsequently test IDUs for hepatitis C. There is weak evidence from one case series (-)² that education by a peer outreach worker may improve short-term knowledge about hepatitis C transmission among IDUs.

¹ Foucher et al. 2009.

² Aitken et al. 2002.

Evidence statement E8

There is moderate evidence from one RCT (++)¹, one non-randomised controlled trial (+)² and one UBA study (-)³ to suggest that complex interventions that provide support to primary care professionals when offering hepatitis C testing may have a positive impact on testing acceptance and uptake. One repeated cross-sectional study (+)⁴ demonstrated that without support, offers of testing may increase, but not within the desired high-risk groups. There is weak evidence from three UBA studies (three [-])^1,5,6 to suggest that educational interventions aimed at healthcare professionals may have short-term benefits on knowledge about hepatitis C. However, there is no clear evidence that an increase in knowledge leads to an increase in testing. Weak evidence from one UBA study (-)⁴ suggested that a continuing medical education programme had a limited impact on testing uptake. There is mixed evidence from two studies (one [++] and one[+])⁷ that examined the effectiveness of interventions aimed at professionals on treatment initiation. There is moderate evidence from a repeated cross-sectional study (+)⁴ that a national campaign had no impact on the management of drug users following a positive hepatitis C test. However, there is strong evidence from one RCT (++)¹ that a complex intervention providing support in primary care had a positive impact on number of referrals and attendance at follow-up appointments after testing.

¹ Cullen et al. 2006.

² Helsper et al. 2010.

³ Sahajian et al. 2004.

⁴ Defossez et al. 2008.

⁵ D'Souza et al. 2004.

⁶ Fischer et al. 2000.

⁷ Garrard et al. 2006.

Evidence statement E9

There is weak evidence from one controlled before and after (CBA) study (-)¹ and one case series (-)² to suggest that the provision of hepatitis C treatment in community settings for IDUs had a positive effect on treatment initiation and outcomes. There is weak evidence from two case series (both [-])^3,4 that attendance at a support group for hepatitis C may have a positive effect on treatment initiation. However, it was unclear due to the study design used whether attendance at the support group was higher among more highly motivated individuals who may have been more likely to initiate treatment regardless of their attendance at the group. There is weak evidence from one cohort study (-)⁵ to suggest that allowing patients, such as those who have not been referred by their doctor, to self-refer to speciality liver clinics for assessment was associated with treatment uptake and completion at rates similar to those referred by healthcare professionals. There is weak evidence from a CBA study (-)⁶ to suggest that ensuring patients receive education about hepatitis C prior to referral appointments may have a positive effect on attendance at follow-up appointments, and on short to medium-term knowledge.

¹ Moussalli et al. 2010.

² Wilkinson et al. 2008.

³ Grebely et al. 2007.

⁴ Grebely et al. 2010.

⁵ Doucette et al. 2009.

⁶ Surjadi et al. 2011.

Evidence statement E11

There is moderate evidence from one cost utility analysis (+)¹ to suggest that community-based screening and treatment for hepatitis B among migrant populations is cost effective.

¹ Veldhuijzen et al. 2010.