Alan Gilman, General Practitioner, Stockport
Hepatitis C: Who should take the test?
One might think that ‘Have you ever injected drugs?’’ is never going to be an easy question for a GP to ask a patient. The reality of the location in which I practise is that this is a question I ask patients almost every week. I’ve been working as a GP in Stockport for the past 20 years. Soon after starting practice in the area, we identified intravenous drug use (current and previous) as a major problem and our team started routinely testing for blood-borne viruses. As soon as antibody testing became available, we began testing for hepatitis C (HCV).
In 1997 I carried out research into HCV prevalence in Stockport, which was funded by Primary Care Research. I screened the blood of 400 individuals who had a history of being, or had a relationship with, an intravenous drug user. This was based on a cohort of identified drug users and their partners and children (where we were able to gain consent). Around 70% of the population with a history of intravenous drug use had HCV antibodies present, but interestingly, we found no sero-positivity in any of the partners or children.
Unlike some other parts of Manchester, which also see high levels of HIV infection, we currently have no identified HIV positive patients. However, with HCV antibodies present in 70% of the drug-using patients, our levels of HCV infection are significantly above the national average of 40% (among current injecting drug users). We also have serological evidence of a wave of hepatitis B from about 20 years ago but currently only three patients with a carrier status.
It is estimated that 200,000 people have chronic HCV in England, and sharing equipment for injecting drugs, even once or twice, is the most common transmission route. Although the majority of patients we diagnose have either recently stopped using drugs or are still using, we also see patients who have not injected drugs for years. They may have only injected drugs and shared equipment once or twice a long time ago.
People who have experimented with injecting drugs in the past are, of course, at risk of HCV infection, but can be very difficult to identify. They can be of any age and from any background - a local mechanic or a bank manager. I often ask my patients, where relevant, whether they have ever used drugs, along with a routine series of screening questions on smoking and alcohol. Although this might not always seem appropriate in the first instance, sensitively managed it never seems to cause any offence. I feel that it’s worth asking a patient this sort of question, if it means we can detect early those who may be at risk of HCV or HIV.
As GPs, we have an important role in educating patients on prevention, diagnosis and treatment. Those at risk with HCV often do not feel ill, so are unlikely to come forward proactively for a test. As we see patients for other issues, GPs are in an ideal position to offer testing without a patient having to come in specifically to talk about HCV.
We offer a HCV test to anyone who:
- has unexplained abnormal liver function tests (e.g. elevated ALT), or unexplained jaundice
- has ever injected drugs in the past (including anabolic steroids) using shared equipment, however long ago, even if this was only once or twice
- has had a blood transfusion in the UK before September 1991 or received any blood products before 1986
- has received medical or dental treatment abroad (including blood transfusions), in countries where hepatitis C is common and where infection control may be poor
- is the child of a mother with HCV
- is a regular sexual partner of someone with HCV
- has been accidentally exposed to blood where there is a risk of transmission of HCV
- has had tattoos, piercings, acupuncture or electrolysis where infection control procedures are poor
- has shared razors or toothbrushes of someone with HCV.
When we offer patients an HCV test, I prepare them for it to be positive (as it often is here) and talk to them about treatment and recovery rates. About 60-80% of people who acquire an HCV infection become chronically infected, with the rest clearing the infection spontaneously. Overall treatment with pegylated interferon alpha and ribavirin is successful in treating up to 55% of patients with moderate to severe chronic hepatitis C. Success rates vary depending on the genotype, being up to about 45% in those infected with genotype 1, but rising to about 80% in those infected with genotypes 2 and 3. I would advise anyone dealing with HCV patients in their surgery to emphasise these success rates and encourage those who have tested positive to at least talk to the experts about their need for treatment or, if appropriate, long-term monitoring.
With HCV so prevalent for those who have used drugs, much of its usual associated stigma has been lost among them. This means we can often approach testing with an assumption of a positive result. Our next task is to then dispel myths that discourage people from getting treatment, like insensitivity of our treatment services or the low success rate of the available treatment, and prepare them for the outcome.
Hope VD, Judd A, Hickman, M, Lamagni T, Hunter G, Stimson GV et al. Prevalence of hepatitis C among injection drug users in England and Wales: is harm reduction working? Am J Public Health; 2001; 91: 38-42