Testing

Testing in prisons is an effective way to expand testing uptake among key populations, as people living in prison are at increased risk of acquiring and having hepatitis B and C infection.

Active case finding and early diagnosis are the key measures for the prevention and control of viral hepatitis in prison settings. Active case finding can be defined as the ‘systematic identification of people with a disease (regardless of symptoms), in a predetermined target group, by using tests, examinations or other procedures that can be applied rapidly’ (ECDC, 2018).

Testing should be offered on a voluntary basis – voluntary being divided into opt-in testing (testing is offered to all, and a person chooses whether to have the test) and opt-out testing (a person is informed that the test will be performed unless they actively refuse). Opt-in testing is commonly provided in European prisons, however modelling studies from the United States of America suggest that opt-out testing is a more cost-effective approach (He T, 2016).

For hepatitis C, testing may be offered at different timepoints at the prison setting; at entry, during imprisonment (periodically or ad hoc), or at release from prison. Testing upon entry to prisons can be cost effective if there is linkage to treatment that can be completed in prison or after release through continuity of care.

Detailed public health guidance relating to HBV, HCV and HIV testing is clearly outlined in the ECDC guidance published in 2018 (ECDC, 2018). This guidance promotes an integrated approach to testing which is particularly relevant in the prison setting where those most at risk of one of these infections are also more vulnerable to infection with one or both the viruses and a synergistic approach in tackling these infections is recognised as more effective and efficient.

Testing for hepatitis C

Testing for the hepatitis C virus usually involves an initial test to check for antibodies (anti-HCV) which indicates if someone has been ever infected with the virus (table x). As some individuals may resolve their infection spontaneously or may have received curative treatment and are no longer infected with the virus, it is necessary to check whether the individual has viraemic (active) infection.

Thus if the antibody test is positive then a confirmatory blood test is needed to check for chronic infection (HCV RNA or HCV-Antigen). Reflex testing should be considered, where blood samples that test positive for anti-HCV are routinely checked for HCV RNA or HCV-Antigen.

Table 1. Simple guide to the hepatitis C blood tests

Type of blood test	What does the blood test check for?	What does a positive test result mean?
Antibodies to hepatitis C (anti-HCV)	The test checks for antibodies to the virus which develop after someone has been infected with the virus.	A positive test indicates that the person has at some point been exposed to the hepatitis C virus. Antibodies will remain for life, even if someone is able to clear the virus spontaneously or through curative treatment.
Test for viraemic infection (HCV RNA or HCV-Antigen)	The blood test checks whether someone is currently infected with the virus.	A positive test indicates that the person has current hepatitis C infection and would be eligible for treatment.

Adapted from Hepatitis Australia. Testing for hepatitis C. Available at: https://www.hepatitisaustralia.com/testing-for-hepatitis-c

Testing for hepatitis B

Testing for hepatitis B virus can be undertaken through a blood test to determine if someone is infected with HBV or has been vaccinated against it (table x). The HBV testing should include testing for hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and total antibody to hepatitis B core antigen (anti-HBc).

Table 2. Simple guide to the hepatitis B blood tests

Type of blood test	What does the blood test check for?	What does a positive test result mean?
Hepatitis B surface antigen (HBsAg)	The blood test checks for whether someone has current hepatitis B infection.	If the test is positive then the person is currently infected with the hepatitis B virus and should be assessed medically.
Antibody to hepatitis B surface antigen (anti-HBs),	This test checks whether someone has immunity to hepatitis B infection.	A positive test indicates that someone has immunity to the virus, through either vaccination or after recovering from the virus. A positive test indicates that the person cannot be infected with hepatitis B again.
Total antibody to hepatitis B core antigen (anti-HBc)	This test checks for antibodies to the core antigen which will develop after someone has been infected with the hepatitis B virus.	A positive test indicates that the person has at some point been exposed to the hepatitis B virus. The presence of antibodies may indicate that a person still has the virus or had it in the past.

Adapted from Hepatitis Australia. Testing for hepatitis B. Available at: https://www.hepatitisaustralia.com/testing-for-hepatitis-b

Testing for hepatitis D

Reflex testing for hepatitis D virus (HDV) is recommended by WHO for those who are identified to have hepatitis B virus infection (HBsAg positive). HDV requires the presence of the HBV for replication and whilst only a small proportion of people with HBV are coinfected with HDV, it is important to check as the combination of both viruses is associated with very severe liver disease.

Testing approaches

Several effective case studies demonstrate how hepatitis testing can be undertaken in prison settings. One case study from Luxembourg has evidenced very high adherence rates to their testing and treatment program through their comprehensive screening model (see models of care – case study). Indeed, there are many ways to screen and test for hepatitis in prison settings, which largely mirror the options which may be available in the community. Each method varies on the sample collection method, time to diagnosis, touch-points with the person being tested, and cost.

Venepuncture and diagnoses of HBV and HCV infections that are performed with conventional serological and molecular laboratory testing are the standard of care in many European countries.

However, clear access to veins can be challenging for people who have injected drugs and long turnaround times for laboratory tests can be problematic in some circumstances. There are options which can circumvent these challenges such as the use of dried blood spot testing or the use of rapid and point-of-care tests which are becoming increasingly available and have demonstrated suitability in prison settings due to their simplicity to administer. Rapid tests can be performed by the user (self-test) or a healthcare provider in different settings and when rapid tests are performed by healthcare professionals they are called point of care tests as they permit rapid diagnosis and entry into care in a single visit (Shenge J, 2021).

More information regarding testing strategies for viral hepatitis testing can be found in the Global Guidelines for Viral Hepatitis Service Delivery in Prisons. Including viral hepatitis testing within a broader point-of-care testing (PoCT) strategy offers several benefits:

Cost-effectiveness: PoCT for viral hepatitis can be more cost-effective than traditional laboratory-based testing in some settings, as it reduces the need for transportation of samples, specialised equipment, and lengthy laboratory processing times.
Rapid results: PoCT provides rapid results, often within minutes to hours, allowing the opportunity for immediate diagnosis and initiation of care.
Reduced follow-up visits: With PoCT, patients can receive test results during the same visit, reducing the need for multiple follow-up appointments and improving adherence to testing and treatment protocols.
Early detection and intervention: PoCT enables early detection of viral hepatitis infections, allowing for prompt initiation of treatment, counselling, and preventive measures to reduce disease progression and transmission.
Improved public health outcomes: By integrating viral hepatitis testing into a broader PoCT strategy, public health authorities can enhance disease surveillance in the prison, monitor trends, and implement targeted interventions to control and prevent viral hepatitis transmission within people living in prison.

Venepuncture

Venepuncture is the standard of care in many countries. A whole blood sample is drawn from a person’s vein and sent to a laboratory for testing. The sample allows for testing for the full range of molecular or serological markers for HBV and HCV. Venepuncture is a simple, flexible method of sample collection. However, it has a number of challenges:

Access to veins can be challenging for people who have injected drugs.
There’s a longer wait time for results – usually between 2 days and 2 weeks depending on the local facilities.
It requires an additional visit to the medical clinic where the healthcare provider will share the laboratory results and offer treatment options, if required. If the person being tested has other priorities or is unable to return to the clinic, they may miss the opportunity to access treatment.

Dried blood-spot testing

This 'self-sampling' collection method can be used by the person or administered by a healthcare worker. A small quantity of blood is collected using a finger-stick blood draw, and then several blood spots are applied to a test card. When the samples are dried, the test card is posted to a laboratory for testing.

WHO guidelines recommend that the use of capillary whole-blood dried blood spot specimens for both serological and NAT testing for HBV and HCV infection may be considered for persons with poor venous access (WHO, 2022).

Compared with other sample collection methods, dried blood-spot testing:

Has the advantage of avoiding venous blood testing and is simple to administer and requires minimal training.
Requires the person to wait for a result, similar to other laboratory-based testing.
Requires careful planning to ensure the person is supported and connected with care in the event of a positive result.
Can run multiple tests for multiple viruses from the one test card.

Point-of-care testing

Point-of-care testing typically requires a finger-stick blood sample that can then be used with a testing device to indicate whether the person has HCV antibodies or RNA. For hepatitis B, point-of-care tests can test for different markers, including antibodies and surface antigens.

Testing devices vary depending on the manufacturer. Some examples include:

Lateral flow tests using a test cassette
Flow-through test devices that use membrane units
GeneXpert testing, in which the sample is placed in a cartridge within a computerised processing unit that can test for the presence of antibodies, and then identify RNA if antibodies are present

Point-of-care testing has several advantages:

Quick to administer and return a result – usually within 15-60 minutes.
They do not require access to veins. This can be a barrier to testing for people who have injected drugs.
The person being tested can wait for their results and receive treatment on the day – a single visit, rather than multiple visits, reducing the burden on the person. Point-of-care testing can increase the likelihood that a person receives treatment for HCV.
People in prison and people who inject drugs consider point-of-care testing to be an acceptable testing modality.

The availability of point-of-care testing options in prisons globally is varied and only some countries utilise point-of-care testing as part of standard of care. Where point-of-care antibody-only tests are used, they usually require additional follow-up testing where an additional blood sample is taken for RNA testing via either point-of-care or traditional pathology testing. This is also the case where genotyping is required.

Challenges and solutions: testing

Challenge	Proposed solution
Limited Testing Infrastructure: Many prisons in Europe lack the necessary infrastructure for conducting widespread viral hepatitis testing, especially if using standard venepuncture. Insufficient access to laboratories equipped for diagnostic testing may impede timely and accurate diagnosis.	Implement point-of-care testing (POCT) testing where available and accessible. The collection of samples through dried blood spots (DBS) may be an alternative approach considered under certain circumstances e.g. among individuals with poor venous access. These methods can facilitate increased uptake of testing. Training prison healthcare staff on the use of POCT and DBS testing can enhance diagnostic capabilities without requiring extensive infrastructure investments.
Resource Constraints: The two main constraints within prison healthcare settings are the lack of availability of testing resources, including diagnostic kits, and trained personnel.	Identify and define specific policy plans for prisons where hepatitis elimination is one of the objectives and determine whether funds are available to support this. More often these funds are public rather than private. Partner with external health organisations and/or NGOs to secure donations or discounted rates for diagnostic kits. Additionally, implement training programs for prison staff, leveraging online modules, in-person workshops, and mentorship from experienced healthcare professionals to build capacity for viral hepatitis testing.
Complex Logistics: The logistics of sample collection and processing within the environment of prisons can pose challenges.	Develop standardised protocols for sample collection, storage, and transportation within the prison system. Collaborate with local health bodies to establish dedicated transportation routes and schedules for transferring specimens to external laboratories. Use tamper-evident containers and detailed chain-of-custody documentation to ensure sample integrity.
Timely Result Reporting: The timely reporting of test results is essential for effective healthcare interventions, especially given the high proportion of people in prison with short sentences. Delays in result reporting, often due to inadequate communication channels or bureaucratic processes, can hinder prompt clinical management and public health responses.	Implement electronic medical records (see monitoring section) systems with secure, real-time data transfer capabilities between prison healthcare units and external laboratories. Streamline administrative processes to reduce delays and establish clear communication channels for prompt result reporting. Regularly review and refine these processes for quality purposes to maintain efficiency.
Quality Assurance and Accreditation: Ensuring the quality and reliability of testing services based on national quality assurance procedures is essential for accurate diagnosis. Establishing and maintaining accreditation standards for prison-based laboratories may pose logistical and financial challenges.	Develop a phased approach to achieve accreditation for prison-based laboratories, starting with basic quality control and quality assurance measures and progressively meeting higher standards. Engage external accreditation bodies for guidance and periodic assessments. Additionally, implement internal quality control practices, such as proficiency testing and regular equipment calibration.
Integration with Community Services: Coordinating viral hepatitis testing services between prison and community healthcare settings can be complex.	Establish formal agreements and information-sharing protocols between prison healthcare services and community health providers. Create a standardised referral system and ensure that patient health records are transferable and accessible by both prison and community healthcare providers. Consider using shared EMR systems to facilitate seamless transitions and continuity of care.
Ethics: Lack of clear ethical framework leads to poor acceptability of the interventions.	Develop and adhere to a robust ethical framework for viral hepatitis testing in prisons, ensuring that all procedures comply with national ethical standards. Establish processes that respect prisoners’ autonomy and confidentiality. Engage an ethics committee to review and approve testing protocols and address any ethical concerns that arise during implementation.