Early testing questions

[Beautifulsky]

I might have been exposed to hepatitis c about a month ago and would like to test to make sure everything is ok.

How early can infection be detected? And what testing method would provide an accurate result this early on?

Thanks and best regards.

[mikesimon]

If you are concerned an HCV RNA test would show the virus if you were infected 1 month ago. You probably wouldn't show antibodies yet so an RNA would be the test you'd want to get. Many members here use the Heptimax which is very sensitive - detects a small amount of hepatitis c in the blood - but there are others such as Amplicor  that are available.

From: http://www.medscape.com/viewarticle/457918_4

"Any clinical sign compatible with hepatitis, elevated aminotransferase levels, or a plausible risk contact (injection drug use, high-risk sexual behavior [early age at first intercourse or 50 or more lifetime sexual partners], occupational risk contact [eg, needle-stick injury], or history of transfusion of blood products [especially before 1990]) should lead to a diagnostic workup, including tests for HBsAg and HAV IgM antibodies and an HCV antibody assay. HCV antibodies appear 7 to 8 weeks after infection, whereas HCV RNA becomes detectable within the first 2 weeks.[10]"

Mike

[Beautifulsky]

Thank you, Mike.

I'm not really sure where to take the test.

I don't have a primary care doctor or insurance, whenever I needed to see a doctor I would go to those clinics(that open late and you don't need an appointment, not sure what those are called)

Any idea how much testing might cost? And where I could get either the heptimax or amplicor testing?

Again thank you kindly.

[mikesimon]

The Heptimax is available at Quest Diagnostics. I don't know the price but it would likely be more than one hundred dollars and maybe more than $200. I'd call your clinic and see if they have any advice. Good luck, Mike

[Beautifulsky]

Again thank you!

I'm going to be contacting them tomorrow for testing. I was wondering if any herbal treatment effects testing results?

I think I read something like that on here, however I'm not sure. I have been taking schizandra and shitake mushrooms in pill form.

Also, how long do test results take and how do they inform you of the result?

[jmjm530]

If you think exposure was as close as a month ago, the virus may not be picked up with a viral load test. That' because in the acute stage viremia may be intermittent, i.e. going in and out of the detectible range. For that reason, you're best off with both a viral load test like Heptimax AND an antibody test AND a liver enzyme panel. In the acute stage, liver enzymes are often sky high. Then repeat all three tests at an appropriate interval, which I do not have handy but my guess would be 3 months and then 6 months, and possibly after 6 months.

-- Jim

[jmjm530]

The overall point I was trying to make is that it's not always easy to detect acute Hepatitis C with a single test, especially if one has no symptons. The antibody test may not be accurate for some time, and as stated, the viral load test may also not be accurate within the acute window. Lastly, "acutes" are a very understudied population (compared to chronics) because so few people are caught in the acute stage, mainly because it's usually asymptomatic, or at least the symptons are not picked up by patient or doctor. For this reason, a mix of tests, on a periodic schedule makes the most sense, and "how often" is in no doubt a mix of how serious an infection risk you exposed yourself to as well as how much you want to pay. For example, if you shared needles with a HCV positive IV drug user, then that would be very high risk and probably warrant agressive testing. On the other hand, if you had a 'normal' sexual contact (no anal, nothing rough, especially in a monagamous relationship) then that risk is quite small, and even smaller if you're a male.

-- Jim

[Beautifulsky]

Hi, thanks for your advice.

I'm not really sure what to do, I've been worrying pretty much all the time since possible infection and would like some modicum of peace in terms of a testing result.

I wanted to take the test so I could know(good or bad) because every waking hour I'm kind of in a fog, one minute thinking I might be ok or the other I might be positive.

It would pain me to have a good result and think I'm ok but only to find out the results don't have much meaning now, and could change at the drop of a hat months later.

Would the three testing procedures give a good indication now of possible infection? or would the fact that fluctuations occur this early on give a deceptive result?

The back and forth thoughts in my mind have left me depressed, sad, and drained.

I really would like to know now if I am ok or if not so I can concentrate on learning and fighting, the not knowing and waiting is so hard.

Again thank you kindly.

[jmjm530]

I think the modicum of peace you are looking for would be in the percentages of what the respective tests results say at a given point in time. If you're looking for 100 per cent assurance that you're not infected, then you probably will have to wait awhile because it appears that early-on testing in a non-symptomatic acute is inconclusive as to both whether you have the virus and whether it will turn chronic.

That said, if you do test positive on the viral load test, current thought seems to be to treat as opposed to waiting to see if you're one of the minority (20-30 per cent) who clear the virus naturally.

The best person to guide you through this uncertainty would be a liver specialist (hepatologist). Hopefully one in a large, teaching hospital who has some experience with acutes. Of course, a very important part  of the  equation -- and I'm sure one of the first questions a doctor would ask, is why do you think you have Hep C? Because
the nature of your potential exposure in itself should generate its own set of odds as touched on in my last post.

All the best,

-- Jim

[Beautifulsky]

Thanks Jim.

After I last posted I thought hard about being anxious and wanting to know 100% and right away. The more introspective I got within myself, exploring my thoughts and feelings, I began I to feel an inner peace and that sense of anxiety went away.

It's probably the most normal I felt since I started worrying.

Also, from your posts I realized that I'm not going to resolve the issue of knowing with one shot and I'm ok with that and I can wait till more time passes.

Would it just be best to wait and test at a more appropriate time? and then in the intervals you suggested previously for a more accurate diagnosis?

I don't have health insurance and have limited funds so taking the tests at a more advantageous time would be really beneficial.

I posted in this thread previously, I lost my password and started a new name, warning it's graphic and for 99% of people probably disgusting. Yes, I feel ashamed, stupid, and don't know why I did this. It's not something I would ever want to do again ever in my life and my apologizes to grossing anyone who reads this out.

http://www.medhelp.org/posts/show/340430

One thing I forgot to add is later on I realized that I had burst a zit or boil on my face a few days earlier, and I'm not sure if by rubbing that on it if I opened up the wound.

The next day or so I rubbed my towel hard on my face after showering and the wound opened with blood so that's primarily where my worries are stemming from and from the idea(not sure if this is off base or not) is that microscopic amounts of blood could be on the feces causing infection when rubbed into an open wound.

Thank you.

[Jakied]

If you need a place to test, call 'request a test' at 1-888-732-2348.  they can set you up with a local testing facility.

[Jakied]

The Pcr test is VERY expensive, $400 or so.  Anti body test is about $65.

With antibodody testing, the greater number of days since exposure, the more accurate the test is.

Average time to show antibody is 50 days or so, meaning 50% will be + at 50 days.  A three month neg is reliable and 6 month neg is home free.

[Jakied]

What was your risk?  If sexual, you PROBABLY don't have to worry.  Hcv is not considered a Std as Hbv and Hiv are.

If your risk is Idu, then you are definitely at risk and should be tested.

One thing you might do is ask the other person to be tested.  If he/she is neg, then a lot of your worry is gone.

[mikesimon]

Everything I see indicates that an HCV RNA does detect acute HCV within weeks of infection - even in infected chimpanzees. What is your source for the premise that this test doesn't necessarily detect HCV?

"Confirmation of active infection is made by a qualitative HCV RNA test with a low limit of detection of 50 IU/ml (100 viral particles/ml).1,13 HCV RNA can be detected after 1–2 weeks of infection by commercially available assays which are 98% specific....Patients with acute hepatitis C would typically also have a negative antibody test but be positive for HCV RNA, as the RNA is detectable within 1–2 weeks of infection whilst HCV antibody may not appear for 7–8 weeks after infection".
http://bmb.oxfordjournals.org/cgi/content/full/70/1/51

:Hepatitis C diagnosis depends on demonstration of anti-HCV detected by an EIA. Anti-HCV is generally not detectable in patients with initial signs or symptoms of hepatitis C. Anti-HCV develop in acute infection generally between 2 and 8 weeks after evidence of liver injury. Some persons may not test positive for 6-9 months after onset of illness. Hepatitis C viremia may be detected by RT-PCR within days after infection."

"..... HCV RNA testing can be used to establish acute HCV infection after an exposure because HCV RNAcan be detected in 1 to 2 weeks while antibodies to HCV are detectable an average of 8 weeks later25-27. ...."
http://www.natap.org/2004/HCV/032204_01.htm

Mike

[jmjm530]

Even the article you cite, hedges with words like "can be detected" as opposed to for example "will be present".

My source is Dr. Mitchell Shiffman's teaching module/web cast  "Hepatitiis C: Epidemiology, Diagnosis and Treatment". Slide 9 "Hepatitis C Virus” Response to Acute Infection"

"...During the acute phase of HCV infection, if you test for HCV, sometimes the virus will be detectable, but at other times the virus is undetectable. Because of this intermittent viremia, virologic assays are not the best assays to screen for acute hepatitis C..."

http://webcasting.clinicaloptions.com/p41111200/
(For those not familiar an excellent web site but free registration is required)

[mikesimon]

Thanks. That is the first I heard of this possibility though I believe that it is possible and perhaps somewhat dependent on the sensitivity of the test. But Jim, if you want to try and find out early what else could you do aside from a "watch and wait" approach other than get an  HCV RNA test? I think it's clear that an antibody test would not be reliable so soon after infection so what choice is there? We'd just have to assume the risk of falling into the "sometimes" category - whatever the statistical basis for "sometimes" is. I know what I would do - I'd get a Heptimax test without question. What would you do Jim? I am serious here and I would like to know how you would approach a possible acute infection from a few weeks ago.
Mike

[jmjm530]

"...Another difficulty of this exam (of dx HCV acutes) is that it is carried out in specialized laboratories prepared for molecular biology studies. Besides the technical characteristics of this method, another problem related to the intermittent viremia in these patients, is the need to carry out the exams repeatedly, representing a technical limitation and increasing costs."

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1855320
------------------------
"...CONCLUSIONS: Intermittent low-level HCV viremia can occur as much as 2 months before the periods of exponential increase in viral load and the high-titer plateau-phase viremia that usually precede seroconversion. Animal inoculation studies are in progress to evaluate if transfusion of low-level viremic plasma can transmit HCV infection..."

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1537-2995.2005.04390.x

[jmjm530]

Our last two posts crossed.

Yes, you're correct about the antibody test not picking up HCV in the early stages as well, and that's why I suggested monitoring all three indicators -- HCV RNA, antibodies and liver enzymes -- especially in cases where a high risk exposure occured or where someone really wanted to be sure.

So "what would I do" -- I generally fall into the "really want to be sure" camp, so I'd do Heptimax (or a TMA qual) plus sensitivity antibody plus liver enzyme testing on a monthly basis starting at what I deemed to be exposure, and probably continue for six months or more, depending on symptons and risk level of exposure.

What it seems to come down to is that early-on, testing can often be inconclusive and therefore the more tests, the better chance of early diagnosis.

-- Jim

[mikesimon]

Perhaps a portion of those who fall into the "sometimes" category Shiffman alluded to are hemodialysis patients because some of those can display intermittent viremia. Mike

[mikesimon]

Early testing could give a false negative and, if the results were negative, follow up testing would be prudent.
But, if virus was detected with RNA, which seems likely with infection, then you'd be ahead of the curve and my thinking is always - the earlier the better. So,  though I too like absolutism, I would want to know as early as possible so I would test.
But, if  financial  concerns make this approach out of reach, then I guess you wait a few weeks or a month and run the whole gamut of tests. We're probably not too far apart on this really.
Mike

[jmjm530]

I'm sure Shiffman means it as a general principle, that also applies to hemodialsis patients as well as others, but probably more studied in settings like hemodialysis where high-risk exposure can be more easily identified. Note that the other study did not mention hemodialysis, and you research this out, there are other similar articles, but at least the ones I found required either a subscription or a fee to access. But again, if it were me, and I really needed to know, I'd test on a periodic basis.

-- Jim

[jmjm530]

Yes, any RNA positive suggests Hepatitis C exposure with 100% certainty, and frankly I would start testing immediately upon suspected exposure and then probably test monthly, or even more often if symptomatic, or overly concerned.

But like you say, in the average physcian's office setting where time and medical economics often rule -- then I wouldn't be surprised if they just run an antibody test at first, and if negative tell you to come back in six months. Or, if they're a bit better, they might follow up with a viral load test in month, but if negative probably would tell you that "you don't have it" but to be sure let's run another test in six months or so. My guess is that either of us were in that circumstance, we would get a bit more agressive with the testing.

[jmjm530]

Forgot to mention that the intial diagnosis and subsequent test scheduling  is often (and nderstandably) heavily dependent on the likelihood of infection from a particular exposure. So, if someone presents a "I kissed my cousin on the cheek who later told me he had Hep C" scenario, and then tests antibody negative (after they request the test) the physician would probably just send the person home with a pat on the back. At the other end of the spectrum would be an IV drug user who found out they were sharing needles mutltiple times with a HCV positive person. In that case, I would assume any knowledgeable doctor would go beyond the antibody test, or even an early PCR negative.

[Jakied]

Mike, what about someone with an indeterminate screening test (1.0 score) and neg riba/neg pcr qualitative at 4 months after exposure?  Is that enough testing?

[Beautifulsky]

From the scenario I posted would my exposure be very high?

Thank you.