Summary
The week-long campaign offered HIV/HBV/HCV routine testing in nine UK emergency departments and investigated the uptake and yield of a combined blood-borne virus (BBV) opt-out testing strategy - the first in the UK. A partnership between the NHS, pharma (Gilead and Abbvie), and patient groups such as the Hepatitis C Trust, the campaign was endorsed by several medical societies.
Public engagement in the BBV concept was key, and celebrity patrons helped achieve high-profile media coverage. Of 7,800 patients who had bloods taken over that week across the 9 ED’s, 2,118 people were tested for BBVs (uptake was 27%). The prevalence of BBVs in the tested group was over 3% and 71 infections were found, many of which would have been missed by testing for HIV alone.
Challenge
Late diagnosis and onward transmission of asymptomatic BBVs are still global problems. Designing testing strategies to match both the prevalence and the nature of the epidemics remains challenging for HIV, HBV and HCV. While routine HIV screening in medical settings including hospitals is recommended in the UK where the prevalence, routine screening for HBV and HCV in medical settings is not recommended - irrespective of local prevalence. Yet a recent HCV seroprevalence survey in 1,000 samples derived from Royal London ED attendees revealed a HCV seroprevalence of 2.6% with 1.2% viraemic and 75% of the viraemic patients being White British. The team also showed that in males aged 35-55 the prevalence peaked at > 4%. Very little prospective work on HIV/HBV/HCV joint testing has ever been reported internationally, and the published literature refers mainly to anonymous seroprevalence studies.
Objectives
These included determining the number of ED attendees having routine bloods who were also tested for BBVs and to find whether the infections were known or newly diagnosed. Cost per test and waiting times were also to be assessed. The team also wanted to achieve media coverage, along with presenting the data in the UK and internationally, including publication in a scientific journal.
Solution
The week-long Going Viral campaign offered opt-out HIV/HBV/HCV testing to all adult (≥18 years) patients, who were already having a blood test as part of routine ED care in nine UK NHS ED departments in inner-city hospitals where local HIV prevalence was ≥0.2%. ED staff were trained to offer testing and to answer related questions by local HIV staff. Patients who had blood tests in the ED were informed that they would be tested for the 3 viral infections unless they opted out. Awareness was aided by branded posters, standing banners and hundreds of leaflets throughout each emergency department. Local laboratories tested each ‘Going Viral’ sample for: HIV antigen/antibody (HIV Ag/Ab), Hepatitis B Surface Antigen (HBS Ag) and Hepatitis C Antibody (HCV Ab). Standard operating procedures for detecting and confirming positive results were developed at each site with hospitals reporting on whether diagnoses were known (and undisclosed) infections or new infections based on clinical records. Emergency department waiting time data were taken from National Health Service England, including two weeks prior and two weeks following the Going Viral week as comparators.
Results
During the campaign, 7,807 patients had bloods taken during their ED visit - and 2,118 (27%) of these had BBV testing. Uptake differed between EDs, ranging from 9.5%- 60.5%. Of these, 71 BBV tests with were positive (3.4%) with 32 (45.1%) new diagnoses. Those aged 25-54 had the highest prevalence: HCV 2.46%, HIV 1.36%, and HBV 1.09%. There were 39 HCV infections (15 new), 17 HIV infections (six new), and 15 HBV infections (11 new). Assuming the cost per test as £7 for each virus, the cost per new case detected would be £988 for HCV, £1,351 for HBV and £2,478 for HIV. Going Viral was covered by TV and print media and had 1.5 million impressions on Twitter. Various abstracts have been accepted for international presentation at conferences.
Learnings
Of the 54 viral hepatitis infections diagnosed, nearly half were new infections: had patients only been screened for HIV as recommended by national policy in the ED setting, all would have been missed. HCV prevalence figures for the tested population were 4.5 times higher than the reported prevalence for HCV for the UK. This was most marked in 25-55 year age group with prevalence six times the National average. A peak HCV RNA positive prevalence of 4.8% (3/63) was found in males aged 35-44 years also suggesting that an age window for HCV testing may be important. This campaign shows that broadening to BBV from HIV testing only is very important.
Evaluation
Apart from the scientific interest and media coverage, the initiative’s success lies in the fact that BBV testing has not been done before and the results are striking. The campaign was endorsed on the website of the Hepatitis C Trust, NAZ, British Association of the Liver, British HIV Association and British Association for Sexual Health.
