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Opt-Out HIV, HBV, and HCV Testing in Emergency Departments Identifies Many New Infections

A week-long pilot study involving 9 U.K. 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, according to study results published in the March edition of HIV Medicine.

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Adult patients having blood tests as part of their care were offered opt-out screening for HIV, HBV, and HCV. Over a quarter of patients consented to be tested, 3% of these individuals were identified as being infected with a blood-borne virus, 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 U.K. guidance), and not for HCV or HBV, these viral hepatitis diagnoses may well have been missed."

In the U.K., 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 U.K.

The "Going Viral" campaign was conducted for 1 week between October 13-19, 2014, and involved 9 hospital emergency departments in U.K. areas with high HIV prevalence: 5 of the participating hospital emergency departments were in London, 2 were in Essex, 1 was in Leeds, and 1 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 9 emergency departments and had blood tests. Uptake of testing for blood-borne viruses was 27% (2118), but this varied between participating hospitals (from 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 (11 new), and 17 HIV diagnoses (6 new). One person was newly diagnosed with HIV and HCV coinfection.

Prevalence of the 3 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 at 2.46% (1.18% newly diagnosed), HIV at 1.36% (0.5% newly diagnosed), and HBV at 1.09% (0.5% newly diagnosed).

The investigators assumed that each test for a blood-borne virus cost £7 (about $10). This meant that it cost £988 (about $1400) per new HCV diagnosis; each new HBV diagnosis cost £1351 (about $1900) and each new HIV diagnosis cost £2478 (about $3500).

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 a follow-up appointment and 59% remained in care after 6 months. In addition, 10 patients with a previously diagnosed infection but who had been lost to follow-up were also identified. The investigators were able to contact 6 of these patients, 5 were linked to care, and 2 were retained in care after 6 months.

"These pilot data on [blood-borne viruses] 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," concluded the authors. "However, this snapshot of [blood-borne virus] testing in some U.K. emergency departments suggests that perhaps a year-round [blood-borne virus] screening policy in certain age groups and geographical locations may diagnose many more new viral hepatitis as well as new HIV infections."

4/13/16

Reference

C Orkin, S Flanagan, E Wallis, et al. Incorporating HIV/hepatitis B virus/hepatitis C virus combined testing into routine blood tests in nine UK Emergency Departments: the "Going Viral" campaign. HIV Medicine 17(3): 222-230. March 2016.