Front door diagnostics: learning from the successes of HIV testing

It is really simple: an HIV test when people are already using the NHS. When you find yourself in A&E needing blood taken, the sample gets tested for blood borne viruses, including HIV, at the same time as whatever other tests are required. Off the back of the 2020 HIV Commission, my predecessor Ian Green made this case in a Reform pamphlet in 2021.

This approach — testing for HIV, hepatitis B and hepatitis C, unless you specifically ‘opt-out’ — is having an incredible impact in finding people with undiagnosed blood-borne viruses in England. It is also helping to diagnose people sooner and, crucially, before it is too late.

The results are better than anyone expected. The first 18 months of this proactive testing approach in just 33 A&Es in London, Manchester, Brighton and Blackpool — the areas of England classed as having ‘very high’ HIV prevalence — has been a triumph. The results should also pave the way for more conditions to be picked up through a simple, routine blood test for everyone passing through the doors of an A&E.

Which begs the question, why stop at HIV? A recent pilot where everyone attending A&E was screened for type 2 diabetes was a huge success, with results showing 10 per cent more cases could be picked up through a simple blood test. A hospital in Middlesbrough is looking at including syphilis testing in their opt-out programme. Just this year a new blood test was found to detect the earliest signs of Alzheimer’s. This is the future of public health in this country — proactive, front-footed and cost-effective.

The new opt-out blood borne virus programme has resulted in more than 1.4 million HIV tests being carried out, alongside 960,000 hepatitis C and 730,000 hepatitis B tests. This has led to almost 1,000 people being diagnosed with HIV or re-engaged in care, while 2,206 people have been diagnosed with hepatitis B and 867 with hepatitis C.

While, in an early pilot, data from Croydon University Hospital found that when they started opt-out HIV testing the average hospital stay for a newly diagnosed HIV patient was almost 35 days. Now, the average stay in just 2.4 days. The earlier we diagnose people, the better it is for their health — they can access life-saving treatment.

The evidence is crystal clear: testing everyone having a blood test in A&E for HIV and hepatitis works. It helps diagnose people who would not have been reached via any other testing route and who have often been missed before. It also saves the NHS millions, relieves pressure on our over-stretched health service and helps to address inequalities to boot, with those diagnosed in A&E more likely to be of Black ethnicity, women, those who acquired HIV through heterosexual transmission and older people.

Testing everyone as standard — whatever your gender, age, sexuality or ethnicity — also helps to tackle the stigma so closely linked to HIV and break down key barriers to testing. Those diagnosed in A&E are now able to access effective treatment, meaning they can live a healthy life and are less likely to pass on HIV to anyone else.

In fact, the programme has been such a triumph that ￡20 million funding was announced by the new Health and Social Care Secretary, Victoria Atkins, to expand opt-out testing to 47 more A&Es in an additional 33 areas in England, which will start happening from April. This includes places like Birmingham, Portsmouth, Derby and Peterborough where HIV prevalence is categorised as ‘high’. While, north of the border, the Scottish Government is funding short-term pilots on what’s worked in England across three sites.

This is the testing turbo-charge we need as we hone in on the goal of ending new HIV cases in the UK by 2030. The sheer number of tests is impressive, with the expansion meaning an additional 2 million HIV tests a year being carried out. For context, before the COVID pandemic, England was conducting around 1.4 million tests a year.

Ending new HIV cases in the UK by 2030 requires urgent action — it will not happen by accident. It requires maximising every single week, month and year between now and then. It means utilising all we have in the fight against HIV and proper long-term funding to make that life-changing goal a life-changing reality.

We have shown what is possible for HIV and other blood borne viruses by being proactive and testing everyone. Many of the people we are looking for are presenting at the front door of the NHS, especially those experiencing health inequalities, but until now we have still been missing them.

Now we want to see funding secured for this kind of front-door diagnostics for future years, as well as seeing routine HIV testing happening in others parts of the NHS to make every contact count, including pre-operation checks and in GP surgeries and abortion clinics.

It is more efficient to combine testing — in areas of London with lower HIV rates but high hepatitis ones, or vice versa, testing for these viruses has kept it cost-effective. And more importantly, saved lives in the process. Few success stories could make a stronger case for a health system geared towards prevention: better outcomes at a lower cost.