Notes Testing: Follow Up and Giving Results

Transcription

1

2

3 As you do more tests it may become impractical to give all results face to face. You need to think of a system for calling in patients with a positive test promptly and without giving the result on the telephone. Examples may include Something has come up with your test and the doctor needs to see you - call best done by receptionist. Negative results can be given over the telephone but do not lose the opportunity to give prevention advice and to consider if re-testing is required after the window period. Take care that patients with positive results do come back for those results.

4 Hepatitis C antibody positive but PCR negative no protection conferred. Two studies have shown that IDUs who clear the Hepatitis C virus can be re-infected with the same or a different genotype. Risk of Hepatitis C re-infection following spontaneous viral clearance in injecting drug users: A systematic review. Corson S, Greenhalgh D, Palmateer N, Weir A, Hutchinson A. Int J Drug Pol 2011;22:

5 If there is no surface antigen, the viral particle, there is no active infection. Then you need to ask - is this patient immune? The two tests looking for antibodies are used to answer this question. In particular antibody to SURFACE shows immunity.

6 Advice to patient about a negative Hepatitis C or B test is the same. The two main issues are to ensure that they do not need a repeat test because of the window period and to give advice about avoiding risk in the future.

7 Tailor the prevention advice to the individual, use written back up material if available. Know where your local IEP sites are and contact details to give to patients.

8 You may have to do the confirmatory test if the patient fails to attend their specialist appointment - DNA rates at clinics can be high.

9 Do not confuse the test for anti-hepatitis B surface with the test for surface antigen itself.

10 There is effective treatment for Hepatitis B and Hepatitis C infection and this is an important message to give to patients who may have misconceptions about treatment effectiveness and tolerability. Whom to tell and not to tell? Very few people that they have to tell sexual partners, occupational health if health worker.

11 Prevention is also important for people who are infected with a BBV - to avoid the risk for them of superinfection with a different strain of the same virus or another BBV infection. We will see in the next slide that giving advice on how not to pass on the infection is also very important. Hepatitis B immunisation - use every opportunity to immunise, starting new courses or giving further doses to those who are partially immunised.

12 Medico-legal issues for us as professionals to show that we have informed patients about the risk of transmission and how they can avoid this. This issue has particularly arisen around HIV where there have been prosecutions for reckless transmission and the courts have looked at the advice given by professionals to the patient. Telling partners, who may have been infected prior to diagnosis or who could have been the source of infection is always difficult for people. Offer to help in telling or advice on local BBV voluntary agencies who can help. Offer to see people who are at risk of infection. Who do people have to tell? Anyone who may have been at risk of infection from the patient (i.e. through needle sharing, sexually or, for Hepatitis B, even close household contacts) should be told of the risk, especially if they may be at ongoing risk. Hepatitis B immunisation for family of any PWID.

13 Give written information to back up what you are saying. Put them in touch with appropriate support agencies locally. Offer to see them back and ongoing support with yourself. Specialist units are very happy to talk about patients in advance.

14 Especially with Hepatitis C there is a major issue with patients not accessing treatment. Some people do not come back for their result, DNA rates at clinics are high at first and second appointments, repeated referrals can result in repeated non-attendance. This is due to the nature of the population affected by Hepatitis C who may have chaotic lifestyles or may feel they have more pressing needs in their life at the time of diagnosis. All people, regardless of lifestyle issues or medical conditions, should be offered referral to the specialist unit.

15 Patient often think treatment is difficult and not successful - dispel myths about treatment. Stability through drug treatment helps engagement with Hepatitis C treatment services. It is often very useful to refer them or encourage engagement with specialist voluntary agencies for people with Hepatitis C or drug issues who can offer support into Hepatitis C treatment.

16 Early treatment depends on early testing and diagnosis. Hepatitis C treatment is curative and now has a high success rate for all types of Hepatitis C.

17 A liver biopsy is not an absolute requirement before treatment fibroscanning (like an ultrasound) can determine liver scarring.

18 Patients usually learn to self inject peg interferon weekly.

19 Treatment has been revolutionised with the introduction of new direct acting anti-viral medications. Interferon and ribavirin are really promoting eradication of the virus by your own immune system whereas the new drugs interfere with viral replication. Their use now means that SVR rates for most patients are more than 90%, independent of Genotype and even patients with advanced liver disease have a high SVR rate. They reduce the side-effect burden considerably and also allow courses of treatment as short as 8-12 weeks.

20

21 The new drugs cost about 5 times more than traditional Hepatitis C treatment, because they have much higher cure rates they are cost-effective to use in the long term. The high costs means that the NHS cannot currently afford to offer the treatments to everyone infected with Hepatitis C in the short term. Across Scotland there has been decisions to target patients with more advanced liver disease and more severe symptoms for treatment.

22

23 Many of the drugs used in Hepatitis B treatment are also used in HIV treatment.

24 Primary care can have a role in supporting people through the weeks of treatment, with psychological support but also management of troublesome side-effects. We also have an important role in the management of patients not in treatment. This includes advice on liver protection, management of drug issues which may be preventing the person accessing treatment, monitoring liver damage and encouraging people back into treatment services when they are ready.

25 Many patients do not access specialist treatment for their Hepatitis C infection. Primary care has a vital role in continuing to engage with them, promoting recovery so that they can achieve stability for Hepatitis C treatment. Encouraging engagement with Hepatitis C support services and specialist treatment services on a regular basis. We should also be offering advice on protecting the liver and be monitoring liver function and disease to detect advancing liver disease requiring more urgent treatment.

26

27

28