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Hepatitis B and C Testing: Why? Who? How? a Guidance Paper on Testing in Community and Harm Reduction Settings 1 Colophon

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Hepatitis B and C Testing: Why? Who? How? a Guidance Paper on Testing in Community and Harm Reduction Settings 1 Colophon Hepatitis B and C testing: why? who? how? A guidance paper on testing in community and harm reduction settings 1 Colophon This paper is a product of the Correlation Hepatitis C Initiative. You can access the paper at www.hepatitis-c-initiative.eu Author: Danny Morris Review: M. Harris, A. Kautz, A. Leicht, H. Lochtenberg, E. Schatz Copyright © 2016 Copyrights remains with the publisher Correlation Network PO Box 10887 1001 EW Amsterdam The Netherlands Phone.: +31 20 5317600 Fax.: +31 20 4203528 [email protected] Correlation Network is a part of the international activities of the Regenboog Groep. For more information: www.deregenboog.org The production of this paper has been supported by an unrestricted grant from Gilead Sciences Europe Ltd 2 Acknowledgements We want to thank the author Danny Morris and all who helped to draft this paper and the Regenboog Group, Abbvie and GILEAD for their financial support of the Hepatitis C Initiative. Eberhard Schatz Correlation Hepatitis C Initiative Amsterdam, December 2016 “The Hepatitis C Initiative aims to enhance the momentum of current HCV treatment opportunities and strives for universal access to essential HCV prevention and treatment for the most affected and under-served communities: people who use drugs.” 3 Content Chapter 1: Introduction 6 1.1 Hepatitis B and C infect one in fifty adults in the European Region 9 1.2 Higher rates of hepatitis among vulnerable groups 9 1.3 A public health approach to hepatitis 9 1.4 Harm reduction as prevention 10 1.5 Diagnosing hepatitis B and C 10 1.6 Awareness raising - key recommendations 11 1.7 Testing and diagnosis - key recommendations 13 Chapter 2: Who should be tested 14 2.1 Barriers to testing 16 2.2 Barriers to testing and treatment may include 16 2.3 Overcoming barriers to testing 17 2.4 Testing as standard practice 18 2.5 Pre and post-test discussion 18 2.6 Serological testing for viral hepatitis 20 4 Chapter 3: Screening technologies and development of non-invasive techniques 22 3.1 Venapuncture 23 3.2 Dried blood spot testing 24 3.3. Rapid diagnostic tests (RDTs) 25 3.4 Benefits of RDTs 26 3.5. Self testing 28 3.6 Interpreting hepatitis C serology 28 3.7 Anti HCV negative (non-reactive) 29 3.8 HCV antibody positive (reactive) 29 3.9 The second stage is a confirmatory (HCV RNA) test 30 3.10 Antigen test - HCV Core Antigen as a serologic marker 30 3.11 Hepatitis C testing pathway 31 3.12 Interpreting hepatitis B serology 32 5 1: Introduction The shorter treatment periods of the new hepatitis C direct antivirals with almost no side effects and high cure rates shift the focus of the HBV and HCV treatment cascade to non-medical settings. That many of those infected with HBV and HCV are unaware of their infection has significant consequences, both for the health of the individual and the continued transmission of the viruses. This underlines the importance of raising public and professional awareness around the need for diagnosis and increased access to testing for viral hepatitis. Identifying if someone has hepatitis B or hepatitis C can be the first step to accessing healthcare, treatment and support. People who use drugs are the main risk group for hepatitis c with infection rates up to 90%.1 6 Community centres,why harm reduction and low threshold? services have to play a crucial role in order to link potential patients to testing and treatment in the future. The Correlation Manifesto17 strongly recommends the scale-up of harm reduction and community-based programs ensuring high quality, effective and sustainable coverage. Research showed that a combination of integrated interventions in low threshold settings such as needle distribution programmes, opioid substitution therapy, access to medicalised heroin and community based, peer led harm reduction programs are not only cost effective regarding HCV prevention, but also ensure that marginalised populations stay connected to direly needed services17. Moreover - considering the easier transmission of HCV when compared to HIV - it is crucial to ensure even higher quality standards for harm reduction services in order to prevent HCV infections. This paper aims to stimulate services to engage in HCV and HBV awareness raising and in particular to inform community members, social and health care practitioners about current HBV/HCV testing and diagnosis methods, screening technologies and other aspects around the issue. 7 8 1.1 Hepatitis B and C infectwhy one ? in fifty adults in European Region Over 13 million adults are living with hepatitis B and 15 million with hepatitis C in the WHO European Region 1 – indicating a huge burden of treatment and care. New estimates suggest that almost one in fifty adults is infected with 1.3 A public health approach to hepatitis B and a similar amount of people have chronic hepatitis C and yet most people hepatitis infected with hepatitis B or C are unaware of For decades hepatitis has been largely ignored their infection. 2, 3 as a health and development priority. In recognition of the public health burden – 1.2 Higher rates of hepatitis comparable to other major communicable among vulnerable groups diseases, including HIV, tuberculosis and malaria - the WHO published its Global Health 5 People who inject drugs are the most affected Sector Strategy on Viral Hepatitis , calling on (15% for hepatitis B and 44% for hepatitis C), specific action to combat and eliminate viral but infection is also common in other hepatitis. vulnerable population groups such as men The strategy calls for a reorientation of hepatitis who have sex with men (8.7% and 4.2%, programmes towards a comprehensive public respectively), and sex workers health approach. This approach requires (3.3% and 11%, respectively). people-centred health services that can reach populations most affected, an appropriately By comparison, rates in the general population trained health workforce, adequate public of countries in the European Region outside funding for essential harm reduction services, the European Union and European Free Trade testing and treatment interventions and active Association are 3.8% for hepatitis B and 2.3 % involvement of affected communities including for hepatitis 4C. people who inject drugs (PWID). 9 1.4 Harm reduction as prevention A package of harm reduction services for and hepatitis B vaccination programmes, are people who inject drugs can be highly effective all well evidenced and established as central in preventing the transmission and acquisition components in effective hepatitis B and of viral hepatitis as well as HIV and other blood- hepatitis C prevention strategies.8, 9, 10, 11 borne infections. Current coverage of these interventions and the hepatitis strategy calls for Studies have highlighted that there are a major increase in interventions and services grounds for greater optimism in preventing that should be integrated into a comprehensive and treating viral hepatitis in PWID. 12, 13, 14, 15, 16 package for PWID. Recent advances in hepatitis C treatment and increasingly effective hepatitis B medications, As part of the comprehensive package of care in line with adequate prevention, vaccination for PWID, WHO, UNODC and UNAIDS 6 have and harm reduction measures, can have a defined a set of five intervention areas that will significant impact in reducing hepatitis B and C have greatest impact on hepatitis epidemics: transmission. • sterile needle and syringe programmes, However, while the coverage of these • opioid substitution therapy for opioid approaches for PWID remains variable and users, suboptimal, hepatitis B and C continue to • risk reduction communication, affect millions of people every year across • hepatitis B vaccination, Europe - with most people unaware of their • treatment of chronic hepatitis infec- infection. 17, 18 tion. Although available across Europe, current 1.5 Diagnosing hepatitis B and C coverage of these interventions is too low to have a significant impact on hepatitis epidemics and Early testing and diagnosis of hepatitis infection there is wide variation in their implementation is the gateway for access to both treatment across the European region. 7 Combined harm and prevention services.19 It is critical for reduction approaches, in particular needle and effective treatment and care and crucial for syringe exchange, opioid substitution therapy an effective hepatitis epidemic response. 10 However, awareness around viral whyhepatitis is universally ? lacking and there is a need for education and awareness training among policy makers, the general public, healthcare workers and affected communities to overcome this deficit. Certainly, although there are exceptions such as England, Austria, Scotland and France which have viral hepatitis plans, most European countries are yet to develop targeted, locally relevant policies or the tools to implement them. 20 1.6 Awareness raising - key recommendations (From Hepatitis B and C – an action plan for saving lives in Europe) • Secure government funding for awareness campaigns • Use mass media campaigns to raise awareness among the general population • Provide stigmatised groups such as people who inject drugs, migrants, homeless people and men who have sex with men, with appropriate knowledge and support to help them overcome stigma • Improve awareness of healthcare professionals working in areas of high prevalence • Raise awareness among the prison population • Involve civil organisations at a national level • Involve civil society in World Hepatitis Day Hepatitis B and C – an action plan for saving lives in Europe, 2016 11 In contrast to HIV, where awareness and policy development has led a more systematic approach to testing, hepatitis testing remains fragmented and limited to a few countries. In Europe the number of undiagnosed people is high. Around 90 per cent of an estimated 10 million people who have hepatitis B and C, are unaware of their condition. Without diagnosis, millions of people are at risk of developing serious and potentially life threatening liver disease.
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