Opt-out HIV/HBV/HCV testing for patients attending emergency departments identifies significant number of new infections

A week-long pilot study involving nine UK emergency departments has shown that routine, opt-out testing for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) can identify a significant number of previously undiagnosed infections. The results are published in HIV Medicine. Adult patients having blood tests as part of their care were offered opt-out screening for HIV/HBV/HCV. Over a quarter of patients consented to be tested and 3% of these individuals were identified as being infected with a blood-borne virus (BBV), and 45% of these infections were new diagnoses.

“We identified a high number of newly diagnosed viral hepatitis cases, especially hepatitis C, in addition to the HIV diagnoses,” comment the authors. “Had these patients only been tested for HIV during the campaign week (as per UK guidance), and not for HCV or HBV, these viral hepatitis diagnoses may well have been missed.”

In the UK, blood-borne viruses, especially HIV and HCV, are often diagnosed late. Guidelines recommend routine, opt-out, HIV testing for all patients accessing primary care in settings where local HIV prevalence exceeds 0.2%. Research conducted in other countries has shown that hospital emergency (or casualty) departments can be feasible settings for routine screening for blood-borne viruses. A team of investigators therefore designed a pilot study to determine the prevalence of HIV, HBV and HCV among patients accessing emergency care in the UK.

The 'Going Viral' campaign was conducted for one week between 13-19 October 2014 and involved nine hospital emergency departments in UK areas with high HIV prevalence: five of the participating hospital emergency departments were in London, two were in Essex, one was in Leeds and one was in Glasgow.

All adult patients having blood tests as part of their care were offered opt-out testing for blood-borne viruses. Demographic data were obtained. Patients newly diagnosed with a blood-borne virus were linked to care.

During the campaign, 7807 patients attended the nine emergency departments and had blood tests. Uptake of testing for blood-borne viruses was 27% (2118), but this varied between participating hospitals (10-60%). Overall, 52% of those testing were women, the median age was 47 years and 42% identified as white.

A total of 71 blood-borne viral infections were detected, and 32 of these were new diagnoses.

There were 39 HCV diagnoses (15 new), 15 HBV diagnoses (eleven new) and 17 HIV diagnoses (six new). One person was newly diagnosed with HIV and HCV co-infection.

Prevalence of the three infections varied: 1.84% for HCV (0.71% newly diagnosed), 0.71% for HBV (0.51% newly diagnosed) and 0.8% for HIV (0.52% newly diagnosed).

Individuals aged 25-54 years had the highest prevalence: HCV, 2.46% (1.18% newly diagnosed), HIV, 1.36% (0.5% newly diagnosed) and HBV, 1.09% (0.5% newly diagnosed).

The investigators assumed that each test for a blood-borne virus cost £7. This meant that it cost £988 per new HCV diagnosis; each new HBV diagnosis cost £1351 and each new HIV diagnosis cost £2478.

Most of the new diagnoses would have been missed if only patients presenting with symptoms suggestive of possible HIV infection were tested.

The investigators were able to contact 23 of the 32 individuals (71%) with a newly diagnosed infection; two-thirds of these patients attended for a follow-up appointment and 59% remained in care after six months. Ten patients with a previously diagnosed infection but who were lost to follow-up were also identified. The investigators were able to contact six of these patients, five were linked to care and two were retained in care after six months.

“These pilot data on BBV need to be corroborated with longer term data and much more detailed analysis of feasibility, sustainability and acceptability to staff and patients in a longer study,” conclude the authors. “However, this snapshot of BBV testing in some UK emergency departments suggests that perhaps a year-round BBV screening policy in certain age groups and geographical locations may diagnose many more new viral hepatitis as well as new HIV infections.”