In November 2023 the UKHSA and University of Bristol shared a report that reveals the results of an NHS England emergency department opt-out testing programme. The report was commissioned by NHS England to evaluate the first year of the programme, which tests for bloodborne viruses. It tests people in emergency departments who are having a blood test, regardless of symptoms. UKHSA states that this programme will increase diagnoses and treatment for HIV, hepatitis B, and hepatitis C, supporting elimination goals.
Testing for BBV
In April 2022 an NHS England funded programme of testing for bloodborne viruses (BBVs) in emergency departments (EDs) began. This was focused in “areas of very high diagnosed HIV prevalence” (5 or more people per 1,000 people between the ages of 15 and 59). Across 33 EDs 857,117 HIV tests, 473,723 hepatitis C virus (HCV) tests, and 366,722 hepatitis B virus (HBV) tests were conducted during the first year.
“The scale of the programme makes it a substantial contribution to all BBV testing in England.”
The report offers an interim public health evaluation from the first 12 months of the programme. Dr Sema Mandal, Deputy Director of Blood Safety, Hepatitis, STI, and HIV division at UKHSA, believes that the programme has already had a “significant” effect. The report “highlights how many people are living with an undiagnosed bloodborne virus.”
“Fewer new diagnoses of HIV and hepatitis C were made compared to hepatitis B, highlighting the significant efforts and financial investment made to enhance diagnosis and treatment for HIV and HCV. Similar efforts are necessary for HBV to meet disease elimination targets.”
Interim recommendations
The following recommendations are offered.
Delivery of testing:
- Develop and implement standard operating procedures (SOPs) for opt-out testing for all BBVs if these are not yet in place and ensure ED staff are fully briefed.
- Adopt opt-out procedures recommended as good practice, using verbal prompts where appropriate.
- Continue to work with electronic patient record (EPR) teams in sites that do not yet have automated test ordering in place to replicate approaches taken by other sites with high uptake.
- Develop procedures to contact individuals in the event of insufficient blood samples and to inform individuals if no BBV test has been performed.
- Continue to work with sites with low test uptake to understand barriers to testing and to facilitate higher testing rates.
Linkage to care:
- Map and optimise care pathways for people newly diagnosed with HBV in ED as part of roll out of ED testing to new sites.
- Continue to improve linkage to care from ED by identifying the needs of individuals diagnosed in ED and structural facilitators to linkage to care, including additional interventions such as community support.
- Continue to share learning from different care pathways used within the programme.
Evaluation and surveillance:
- Collaborate to increase recruitment of laboratories to SSBBV to improve representative coverage across sites, including those outside London.
- Work with laboratories to understand and address data incompleteness and recording of ED test setting SSBBV surveillance data.
- Investigate ways to identify confirmatory testing for HIV in SSBBV surveillance data.
- Undertake a deep dive with selected sites to understand why some people with positive HIV results are not matching to HARS and are not categorised as ED test setting.
- Work with HIV and sexual health clinics to improve recording of first site of HIV test to better understand the extent of ED testing nationally.
- Encourage sites to work with UKHSA on monitoring HBV linkage to care.
What does the report conclude?
The report states that the programme has demonstrated that opt-out ED BBV testing “can be delivered at scale” and “equitably”, despite large differences between sites. Although the programme has not yet reached the target of 95% of eligible people being tested, the data represent early stages.
Identified issues include the confusion caused by a “no news is good news” approach, where individuals might assume that they have been tested. Therefore, sites are encouraged to develop procedures to “mitigate this risk”. The programme was “effective” at identifying new diagnoses for all 3 BBVs, the highest number being HBV. This high number has “implications of how to meet the increased need for HBV care when considering expansion”. Linkage to care is described as “sub-optimal” for all 3 BBVs, but more so for HBV and HCV than HIV.
“There were limitations in the coverage and completeness of surveillance data for this evaluation.”
Making contact count
Matt Fagg, NHS England’s director for prevention and long-term conditions, said that “thanks to our routine opt-out testing programme” the NHS has been able to “identify and treat thousands more people” living with HIV and hepatitis.
“Without this testing programme, these people may have gone undiagnosed for years, but they now have access to the latest and most effective life-saving medication.”
The NHS, he says, is “committed to making all contact with patients count”. Public Health Minister Neil O’Brien agrees that the “amazing programme” is already making a “real difference”. He is “grateful” to the NHS for its “excellent work”. Professor Kevin Fenton, Chief Advisor on HIV and Chair of the HIV Action Plan Implementation Steering Group reflected that the “flagship initiative” is effective in “identifying people living with undiagnosed HIV” so they can be “signposted to support and treatment”.
“While we know there are improvements to be made, this data gives us confidence that this essential part of our strategy is working. It’s crucial that we continue scaling up HIV testing, so people receive high quality care as we work towards ending HIV transmission in England by 2030.”
Detecting silent threats
Pamela Healy, Chief Executive of the British Liver Trust, described hepatitis B as an often “silent virus” with “thousands of people” in the UK unaware that they have it. If this virus is left undetected, it can cause liver damage or increase the risk of liver cancer.
“It is crucial to find and provide treatment to these people to stop the virus causing further health issues and transmission.”
Daniel Fluskey, Director of Policy at National AIDS Trust, suggests that “at least 340 people” who now know they are living with HIV can “access transformative treatment”. He encourages the NHS to take the “vital” lessons from the evidence to ensure that more people get diagnosed.
Expansion plans
Rachel Halford, The Hepatitis C Trust Chief Executive, commented that the pilot scheme has proven to be a “successful way to find people” who are living with HIV, hepatitis B, or hepatitis C. She offers the example of people who are experiencing homelessness and “only interact with healthcare services via emergency departments”. This scheme is a “great way to reach and treat these people”.
“This life-saving initiative must now be expanded across the whole of the UK to ensure that everyone who is living with a bloodborne virus is found and offered treatment.”
Anne Aslett, CEO at Elton John AIDS Foundation, reflected that “opt-out HIV testing works to diagnose HIV and find those who have dropped out of care” due to “stigma and other challenges facing treatment”. However, there are still 4,400 people who live with undiagnosed HIV, she suggests.
“We need to ensure that we reach all communities across the country and roll out this successful method of HIV diagnosis to other high prevalence areas.”
Richard Angell, Chief Executive of Terrence Higgins Trust, agrees.
“It’s now time to urgently expand opt-out to more A&Es in England to change even more lives and ensure we make the rapid progress necessary to end new HIV cases by 2030.”
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