Implementing routine blood-borne virus testing for HCV, HBV and HIV at a London Emergency Department – uncovering the iceberg?

Abstract

UK guidelines recommend routine HIV testing in high prevalence emergency departments (ED) and targeted testing for HBV and HCV. The 'Going Viral' campaign implemented opt-out blood-borne virus (BBV) testing in adults in a high prevalence ED, to assess seroprevalence, uptake, linkage to care (LTC) rates and staff time taken to achieve LTC. Diagnosis status (new/known/unknown), current engagement in care, and severity of disease was established. LTC was defined as patient informed plus ⩾1 clinic visit. A total of 6211/24 981 ED attendees were tested (uptake 25%); 257 (4.1%) were BBV positive (15 co-infected), 84 (33%) required LTC. 100/147 (68%) HCV positives were viraemic; 44 (30%) required LTC (13 new, 16 disengaged). 26/54 (48%) HBV required LTC (seven new, 11 disengaged). 16/71 (23%) HIV required LTC (10 new, five disengaged). 26/84 (31%) patients requiring LTC had advanced disease (CD4 1, Fibroscan F3/F4 or liver cancer), including five with AIDS-defining conditions and three hepatocellular carcinomas. There were five BBV-related deaths. BBV prevalence was high (4.1%); most were HCV (2.4%). HIV patients were more successfully and quickly LTC than HBV or HCV patients. ED testing was valuable as one-third of those requiring LTC (new, disengaged or unknown status patients) had advanced disease.

Opt-out screening for HIV, hepatitis B and hepatitis C: observational study of screening acceptance, yield and treatment outcomes

“…Only 4.0% of patients known to need follow-up were unlinked at the time of data analysis. This compares favourably with previously published studies of simultaneous screening and may reflect the long duration of our study 3 4. Unlinked patients may reattend ED, providing additional opportunities to offer linkage to care.…”

“…Our programme had over 88 000 patient visits that included opt-out screening for HIV, HBV and HCV, the largest known number of ED patients offered testing for all three infections 3–5 7–10. Screening acceptance was high, relative to previous studies 3 4 9.…”

“…However, these benefits require linkage to care and treatment of patients identified through screening. Between 6% and 13% of patients requiring follow-up in the previously published studies were not successfully linked to care 3 4. A more prolonged screening programme might provide more time and opportunities to link such patients to care.…”

“…However, only three studies of simultaneous screening of ED attendees for HIV, HBV and HCV have been published 3–5. These studies report variable test acceptance, ranging from 24% to 50%, in study populations ranging from 5931 to 10 000 ED attendees over periods of 9–13 months.…”

Seroprevalence and demographic factors associated with hepatitis B, hepatitis C and HIV infection from a hospital emergency department testing programme, London, United Kingdom, 2015 to 2016

“…As an extension of a previous week-long campaign named Going Viral [17], we carried out a 9-month prospective BBV testing programme with LTC in the ED of an east London hospital to assess the feasibility of routinely providing ED-based opt-out testing. The programme had complementary clinical and epidemiological components, the former being the focus of a separate paper [26]. Here we describe the epidemiological component, which had the following objectives: (i) to identify factors associated with the uptake of BBV testing and positive BBV serology, (ii) to estimate BBV seroprevalence and numbers needed to screen (NNS) to detect a new diagnosis and fully link a case to care and (iii) to describe the diagnostic status of BBV cases and the LTC outcomes achieved in the first 6 months after the end of testing.…”