Opt-out HIV testing in the UK

Abstract

The UK has made great strides in achieving the UNAIDS 95-95-95 targets: with 95% of people diagnosed, 99% on treatment, and 98% virally suppressed. Although the epidemic is mainly concentrated among men who have sex with men (MSM), in recent years the proportion of new diagnoses among heterosexual people has surpassed that in MSM. Moreover, while HIV testing has returned to pre-COVID-19 levels among MSM, testing among other groups has not. Reaching the 5% of people living with HIV who remain undiagnosed is crucial to stopping HIV transmission and ending AIDS and HIV-related deaths by 2030. In 2021, the UK Government's Zero HIV action plan recommended switching to an opt-out HIV testing service in key areas with the highest HIV prevalence and allocated £20 million for opt-out testing over 3 years. In April, 2022, accident and emergency departments in the UK cities of Blackpool, Brighton, London, and Manchester initiated opt-out HIV testing. The results of the first 9 months’ roll-out of the programme were reported at the British HIV Association (BHIVA) Spring meeting in April. 33 accident and emergency departments participated in the programme, which includes not only testing for HIV but also for hepatitis B virus and hepatitis C virus. People with positive diagnoses are contacted by the relevant department within the hospitals to link them to care. In the first 9 months of the programme, 57% of emergency department attendances with blood tests tested for HIV, 18% for hepatitis B virus, and 24% for hepatitis C virus (fewer sites were implementing hepatitis screening). Of the HIV positive tests, 282 were new diagnoses (7·7% of 3664 positive results), 144 (3·9%) were people who were lost to care, and 3238 (88·4%) were previously diagnosed people who were engaged in care. 220 (78%) of new diagnoses were successfully linked to care, and 54 (38%) who had been lost to care were re-engaged. The number needed to test was 1562 for one new diagnosis or person lost to care. Estimates based on the current rate of testing suggest 900 000 HIV tests would be done by the end of the first 12 months of the programme, and contrasts sharply with the 114 000 tests done in emergency departments in England in 2019 before the programme. These first set of results clearly show that the opt-out strategy is working, identifying new cases and people lost to care. However, the numbers also show that not all people are being tested, which may be a result of people opting out or overworked emergency department staff not ordering the test. Surveys of emergency department staff at two opt-out sites suggest interventions are needed to help staff with the screening discussion with patients, in particular with women, older people, and Black people, all of whom were less likely to get screening. Also, the numbers presented suggest more needs to be done for linking people to care, particularly re-engagement. In England, 46% of all new diagnoses are late diagnoses (CD4 count <350 cells per μL within 91 days of diagnosis), and people diagnosed late are 13 times more likely to die within a year of their diagnosis, so the need to identify those people earlier is imperative. Opt-out testing in the UK is particularly effective at identifying those disproportionately affected by a late diagnosis, including women, older people, and those from Black African communities, all groups who are less likely to access sexual health services. Also, the long-term cost savings to the NHS of an opt-out strategy are not insignificant. The first 100 days of opt-out testing cost £2 million to the NHS but with an estimated minimum saving of £6–8 million in care costs. In a previous Editorial, we questioned the selective implementation of the opt-out programme just to areas of very high prevalence. Initial results show that the opt-out programme is not just a good public health strategy but it is also cost-effective. An opt-out approach helps to destigmatise and normalise HIV testing and to address inequalities in access to HIV care. Opt-out can find cases among people who would not consider themselves at risk of acquiring HIV, many of whom would never seek sexual health services. Also, the potential exists to get people already aware of their status who have disengaged from care back into the care system. Early detection of HIV early results in significant cost savings since the costs for care of people who present late with HIV are considerably higher. Having come so far in the fight against HIV, for the UK to go the last mile in an equitable way that leaves no-one behind, opt-out HIV testing should be expanded now to other areas in the next tier of HIV prevalence, and perhaps to all emergency departments.