Treatment to prevention: how HIV is leading the way on early diagnosis

About half of people who pass through an A&E department on a given day will have their blood taken. But how many of us know everything we’re being tested for?

For the last three years, hospitals across England have been routinely screening everyone for HIV, hepatitis B and hepatitis C – unless they ask not to be. The results of this ‘opt-out’ approach to testing are so remarkable they should change the way we think about diagnosis across our health service.

This approach to HIV testing isn’t new. It started in maternity services in the early 2000s as part of efforts to tackle vertical (mother-to-baby) transmissions of HIV. Thanks to incredible advances in medication, people living with HIV on effective treatment can’t pass it on – including during sex or childbirth. The combined effect of this breakthrough in treatment and the introduction of routine testing during pregnancy has been the near elimination of vertical transmission in England.

Now, emergency departments across the England – and soon in Scotland – are doing the same. The approach was first piloted in 2019 in South London. The pilot proved the concept, and together HIV charities then successfully campaigned for national investment. An initial £20 million from government for HIV testing was topped up by additional money from NHS England’s Hepatitis C Elimination Fund, which meant combined opt-out testing for HIV, hepatitis B and hepatitis C could start in 34 hospitals across the four cities with the highest HIV prevalence in England. And progress will continue following today's announcement of the government's HIV Action Plan – a £170m package which includes further funding for opt-out HIV testing at A&Es and home tests available through the NHS app.

The results of the first three years are significant. The programme has delivered 2.8 million HIV tests and 7 million blood-borne virus tests in London, Brighton, Blackpool and Manchester. For context, in 2019, emergency departments across the whole country delivered 114,000 HIV tests. Crucially, more than 5,000 people have been diagnosed with blood-borne viruses and can now get the care treatment they need. Remarkably, almost three quarters of people newly diagnosed had no record of a previous test anywhere else in the health service. Half of those diagnosed with HIV were late diagnoses – only found when HIV was already severely compromising their immune system.

There are an estimated 4,500 people living with undiagnosed HIV in England, so the 719 people found by the programme is significant to national efforts to end new HIV cases by 2030. They can now access life-saving treatment that will mean they can’t pass on the virus. The 831 people diagnosed with hepatitis C can access the cure, and there have been new diagnoses of hepatitis B too.

Following the programme’s success, 46 hospitals were added in 2023, and a further nine in 2024. We at the Terrence Higgins Trust have pressed successive UK governments for this, securing a total of £67 million investment for the NHS, and successfully fought for the Scottish government to do the same in Glasgow, Edinburgh and Aberdeen – and the HIV Action Plan will build on that.

So, what do the results tell us? First, that sometimes the best place to find someone with an undiagnosed virus is at the front door of the NHS. A routine approach to testing has eliminated any bias or stigma in who is offered a test and so is helping to tackle the inequalities that run deep through the HIV epidemic. Compared to those diagnosed in other services, people found through A&E were more likely to be older, women and from an ethnic minority background – all groups otherwise more likely to be diagnosed late. In addition, men who have sex with men that are diagnosed via the programme are less likely to identify as gay and bisexual – another leap forward in diagnosing people with HIV.

This is revolutionising the way we diagnose blood-borne viruses, and we shouldn’t stop here. While acute hospitals will continue to play a vital role in prevention, there are opportunities to embed a similar approach in services closer to people’s homes and communities.

NICE guidelines recommend the same approach to HIV testing in general practices, drugs and alcohol services and termination of pregnancy services in areas with a high HIV prevalence.

We should also take this approach to other disease areas. Adding a syphilis test would make sense. A trial in Middlesborough recently found a 0.45% positivity rate over a three month period of opt-out testing in A&E. In Tameside, a different pilot found that routine screening could pick up 10% more cases of diabetes – and 30% more cases of pre-diabetes. Applying this to other conditions that can be diagnosed through a blood test could be transformative.

If we are serious about moving the health service from sickness to prevention, we must be serious about early detection. This HIV response is showing what’s possible.