Australian injecting drug users are commonly tested for hepatitis C, hepatitis B and HIV/AIDS, but while a considerable literature exists in relation to human factors involved in testing for HIV/AIDS, there appears to be little or no literature related to human factors in testing for hepatitis C and B, or vaccinating against hepatitis B. Some studies suggest that being tested is not necessarily a valuable or useful experience for individuals and/or that failure to take account of the complex human factors involved in testing can either deter individuals from presenting for testing, or render testing ineffectual for both the those tested and her/his community.
In 1997 the NHMRC funded the National Drug Research Institute (NDRI) to conduct an investigation of some of the human issues involved in testing injectors for blood borne viruses (BBVs) and vaccinating them against hepatitis B. Two hundred injectors and 39 test service providers participated in the research. The study showed that the process of testing was, in many cases, far from satisfactory and that the only purpose served by much of the testing appeared to be the diagnosis of infection and the implementation of appropriate medical interventions. This falls well short of the intention of NHMRC Guidelines for Pre- and Post-test Counselling for Hepatitis C which suggest that the outcomes should be the provision of psychosocial support, prevention of the transmission of hepatitis C and the optimisation of treatment outcomes. The data suggested that, in the main, only the last of these outcomes was being met. Reported low levels of hepatitis B vaccination were also a concern.
The present study is an examination of clinical and practical difficulties with the NHMRC Guidelines. This project aimed to deepen knowledge about the process of testing injectors for hepatitis C and other blood borne viral infections and to develop concrete recommendations for changes to the Guidelines for pre- and post-test counselling. The project was informed at every stage by consultants drawn from a range of relevant organisations. The data collection methodology was primarily qualitative, using a number of different techniques (interviews, focus groups and consultations) to develop a total data set upon which conclusions and recommendations were based.
There were two phases in the study. In Phase 1, 19 tested injectors and 21 health professionals (test service providers and key informants) were interviewed about the Guidelines. As part of the interviews, test service providers were presented with two scenarios relating to hypothetical requests for BBV tests and asked what they would do in each situation. The data from Phase I were discussed by the consultants and investigators and led to the development of proposed modifications to the Guidelines.
In Phase Two, the draft modified guidelines were presented to two focus groups for their comments, and their comments were further discussed by the consultants.
Our final proposals for modifications to the existing NHMRC Guidelines for hepatitis C testing have taken as many as possible of these disparate points of view into consideration. We also suggest that the modified guidelines should be generalised to all BBV testing with injectors, since most tests occur in batteries rather than singly. Our proposed guidelines, therefore, relate to BBV testing with injectors. The proposed guidelines are attached at the end of this summary.
There are a number of other issues which have emerged as concerns and need to be addressed:
_ The specific resource needs of rural/regional test service providers (TSPs) in relation to BBV testing
_ The importance of effective relationships between TSPs and injectors
_ The appropriateness of the language used in the guidelines
_ The use of the terms 'pre- and post-test discussion' rather than 'pre- and post-test counselling' to reduce confusion, more accurately reflect the focus of these sessions, and defuse any concern or anxiety as to what might be expected from 'counselling'
_ If new guidelines are suggested, TSPs will need to be made aware of them and receive some support in their implementation. A further strategy would be to inform injectors about what they could expect when they request BBV testing.
In conclusion, we believe that a test event is a not only a medical but also a psychosocial intervention to prevent risk behaviour. Both injectors and TSPs need to have the expectation that a test event is an opportunity for them to discuss why the injector could be infected and how further risk to the individual and the community could be avoided.