Blood-borne virus testing in emergency departments will more than double in England, first Scottish sites planned

Dr Melanie Rosenvinge at BHIVA 2024. Photo by Roger Pebody.

Last month’s British HIV Association (BHIVA) Conference in Birmingham heard that the programme of opt-out testing for the blood-borne viruses HIV, hepatitis B and hepatitis C in hospital emergency departments has now involved 4.3 million tests for the three viruses: 1.9 million for HIV, 1 million for hepatitis B and 1.4 million for hepatitis C.

This is a nearly fourfold increase on the numbers presented a year ago from the first year’s data, which started in April 2022. The conference heard that the programme is particularly uncovering a large number of people with previously undiagnosed hepatitis B.

The figures presented were from the 34 emergency departments involved in the first phase of the project – 28 in London, three in Manchester and one each in Salford, Blackpool and Brighton.

Because of the success of the programme, it has been expanded into 47 new sites in England. These are in urban areas of high HIV prevalence ranging from Newcastle to Bristol, and include all English regions, with a particular concentration of sites in Yorkshire, the West Midlands and the south coast.

In Scotland, which has a separate health service, funding has now been secured for the first three sites.

Many new cases, especially of hepatitis B

Dr Rachel Hill-Tout of NHS England said that a total of 4674 new diagnoses have now been made of the three viruses. In addition, 1173 patients who had dropped out of care were identified.

The largest number of new diagnoses were for hepatitis B virus (HBV): 3374 people tested positive for chronic infection (not counting those currently in care), of whom most (84%) were new diagnoses, the other 16% being people who had dropped out of care. There were 1165 positive tests for HIV (also discounting those currently in care) of whom 64% were new diagnoses and 36% lost to care, and 1308 for active hepatitis C virus (HCV), of whom 83% were new.

This means that the number needed to test to find one new case of HBV (excluding those lost to care) was around 300, compared with 1000 for HCV and 1600 for HIV.

The numbers of HBV diagnoses are likely to increase. HBV testing started later than the other two viruses due to funding issues, but finance has now been found. A triple test is now used, needing only one blood sample for all three viruses.

Of interest, the assay also tests for HCV antibodies, which detect previously infected people who are now cured, as well as the RNA that indicates active infection. Thirteen per cent of ED attendees tested positive for HCV antibodies; though this is evidence of spontaneous resolution of the infection in some people, it mainly attests to the existing success of direct-acting antiviral therapy for HCV.

The HIV and HBV tests consistently detected more cases than would be expected from prevalence figures derived from national surveillance. Positivity rates were 0.6% for HIV, 0.7% for HBV and 0.15% for HCV.

Dr Hill-Tout presented figures of the expected diagnosis rates in a typical emergency department (ED). While the programme has been getting established, the proportions of people offered and accepting a test have varied widely, with an average of 62% of people aged 16 or over offered a test and 70% of those accepting it.

In an ED of average size seeing 300 patients a day, the monthly number of positive tests expected would be 23 for HIV, but 20 of these would already be in care, so an ED might have on average two new diagnoses and one person who had been lost to care. There would be 27 positive tests for HBV, of whom seven would be new diagnoses and two who had been lost to care. And there would be six positive tests for active HCV, with three new diagnoses and one lost to care. These ‘yields’ are likely to increase as the ED testing becomes better established.

Of those newly diagnosed with HIV, 80% have been re-engaged in treatment, but only 39% of those lost to care have done so. For HCV, 60% of the newly diagnosed have been re-engaged, and 41% of those lost to care. Because relatively few of the HBV cases had previously been in care, only an average linkage-to-care figure was given, which was 47%.

Who is testing positive in EDs?

Focusing on a specific area and only on HIV, Dr Melanie Rosenvinge of Lewisham and Greenwich NHS Trust looked at ED testing in 10 departments across south London. These are mainly located in the south London boroughs with the highest HIV prevalence, but also include three sites in lower-incidence areas (Sutton, Bromley and Kingston) and one outside greater London (Epsom).

During the first year of the ED programme, among nearly 450,000 eligible attendees, over 75% were tested. There were 126 new diagnoses of HIV (excluding patients previously diagnosed and lost to care) – 82 men and 44 women.


erectile dysfunction (ED)

A man's inability to have or maintain an erection, also known as ED or impotence.

hepatitis B virus (HBV)

The hepatitis B virus can be spread through sexual contact, sharing of contaminated needles and syringes, needlestick injuries and during childbirth. Hepatitis B infection may be either short-lived and rapidly cleared in less than six months by the immune system (acute infection) or lifelong (chronic). The infection can lead to serious illnesses such as cirrhosis and liver cancer. A vaccine is available to prevent the infection.

blood-borne virus (BBV)

A virus transmitted through contact with infected blood. Hepatitis B, hepatitis C and HIV are BBVs. (Note that hepatitis B and HIV may also be transmitted through other body fluids).




A patient’s agreement to take a test or a treatment. In medical ethics, an adult who has mental capacity always has the right to refuse. 


A drug that acts against a virus or viruses.

Fifty-five per cent of all people diagnosed and 73% of the women were Black; 58% of the men and 71% of the women had been born outside the UK. Sixty-two per cent identified as heterosexual.

The average CD4 count was 240, with 68% below 350, and their average viral load on presentation was 63,100. Nearly a quarter of patients, and 30% of the women, presented with an AIDS-defining illness.

In terms of prevalence, the proportion of patients newly diagnosed was roughly similar to the prevalence among residents of most of the boroughs concerned. However, perhaps a better comparison is with the number of new diagnoses in the local population.

Expressed as the annual number of new cases per 100,000 people, the figures from the ED testing was far greater than from reports of new diagnoses. In the ED programme, in the borough with the highest proportion of new diagnoses – Lewisham – there were 65.9 diagnoses per 100,000 people tested in ED compared with 7.2 per 100,000 in the whole local population. Even in Kingston, the area with fewest diagnoses, there were 8.4 diagnoses per 100,000 people tested in ED, compared with 1.7 per 100,000 in the whole population. In one area, Sutton, the ED rate of 45.2 per 100,000 was over 45 times greater than the local rate of 1 per 100,000. Although this calculation does not compare like with like – people coming to EDs may not come from the local borough, and are more likely to have chronic rather than recent infection – it shows that ED testing picks up far more infections than whole-population testing would.

Testing in low-prevalence areas

Given these positive results, should ED testing be extended even further, to the whole of England? Currently England’s 295 local authorities are divided into 17 classed as having very high HIV prevalence (more than 0.5% of the population), 65 with high prevalence (0.2%-0.5%) and 213 with low prevalence (below 0.2%). EDs taking part in the first phase were all in areas of very high prevalence and the programme has now expanded into areas of high prevalence, but what about low prevalence areas?

Dr Alison Brown of the UK Health Security Agency told the conference that the proportion of diagnoses that are classed as late, with CD4 counts at diagnosis under 350, is actually higher in low-prevalence areas, at 48% of all diagnoses, than in very high-prevalence areas (36%).

Areas where more than 50% of diagnoses are classed as late include some urban areas, such as the West Midlands and the Wirral, but also rural areas such as Northumberland and Lincolnshire. People diagnosed late in low-prevalence areas are more likely to be heterosexual men than people diagnosed in other areas. They are seven times more likely to be aged over 65, though the absolute number of new diagnoses among over-65s remains low.

In areas without opt-out ED testing, the proportion of people diagnosed late who find they have HIV during an ED visit is 3%, but the ED testing programme has expanded this proportion nearly sixfold, to 17%. In low-prevalence areas, where only a minority of diagnoses are made at sexual health clinics (with the result that more recent infections get missed), a third of new diagnoses are made only at a later stage when people have already been hospitalised, whether for an HIV-related condition or another illness.

What do staff think of ED opt-out testing?

Lastly, what do ED staff think of opt-out testing for blood-borne viruses? In a survey conducted in north London’s Royal Free and North Middlesex hospitals, while 90% of staff thought the programme was “very worthwhile”, there were some dissenting voices.

One staff member thought the programme “brilliant, and so vital to the health of our local population”. Another said: “It’s just another blood test, for a disease that would have huge consequences if missed”. But another thought the programme “coercive and unnecessary,” while someone else said it was a “waste of resources for it to be done in ED”.

Although 90% thought the testing was “worthwhile” and 78% thought the posters and leaflets informing patients of the testing were sufficient to ensure consent, 52% thought patients should also be verbally informed. As concern was expressed about wasteful repeat testing for the minority of patients who are frequent ED attenders, patients will now be ‘flagged’ if they have recently had a test for blood-borne viruses.


Hill-Tout R. ED testing – challenges and lessons of a combined BBV approach. BHIVA Spring Conference, Birmingham, plenary talk, 2024.

Rosenvinge M. Opt-out HIV testing in emergency departments successfully addresses key gaps in testing. BHIVA Spring Conference, Birmingham, abstract O04, 2024.

Brown A. Current HIV testing guidelines miss areas in which one third of people diagnosed late reside. BHIVA Spring Conference, Birmingham, abstract O03, 2024.

Blakey E et al. Clinical staff attitudes to opt-out blood- borne virus screening in emergency departments. BHIVA Spring Conference, Birmingham, poster P076, 2024.