Research and analysis

Public health evaluation of BBV opt-out testing in EDs in England, 33-month final report 2025

Updated 29 October 2025

Applies to England

Executive summary

This report presents the final public health evaluation of the first wave of the NHS England (NHSE) funded emergency department (ED) opt-out HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) testing programme (‘the Programme’) in 34 EDs, using data from the first 33 months (April 2022 to December 2024) of the Programme. This evaluation assesses the impact and effectiveness of the Programme over its 3-year period and complements the implementation optimisation and health economics evaluations conducted by the University of Bristol. The public health evaluation assessed the Programme against activity, outputs, outcomes and impact indicators using healthcare activity and public health surveillance data, which allowed linkage of individuals to map their care cascade.

The key findings of the evaluation are that this large-scale testing Programme has demonstrated high uptake and had a positive impact in finding people who are undiagnosed with a BBV, many of whom may not otherwise have been tested and diagnosed elsewhere. The Programme was most effective at finding people with HBV and HCV, as demonstrated by the number of people needed to be tested to newly diagnose one person (or Number Needed to Test (NNT)): 240 for HBV, 1276 for HCV and 1916 for HIV. This is not unexpected considering the high levels of unmet need for HBV. Clinical teams and peers were successful in getting most people linked to specialist care.

The scale of bloodborne virus (BBV) testing through the Programme has been substantial with over 7 million BBV tests recorded in NHSE dashboard data for the 34 sites in the Programme. In the 21 sites included in this evaluation over 1.1 million people had a BBV test at least once during the Programme. The Programme has contributed around half of BBV testing reported in surveillance data for the same geographic regions and 33-month timeframe.

Overall the Programme had a high BBV test uptake: almost 70% of eligible ED attendees (those having blood taken as part of emergency care) had a BBV test at some point during the Programme, demonstrating the effect of implementation learnings as testing uptake increased over time. However, there was still significant variation in uptake between sites, which may be influenced by differences in implementation including local systems (such as the availability of automated test ordering) as well as staff and patient factors. Operational efficiencies could be increased by improving test ‘blocking’ practices to prevent unnecessary repeat testing of individuals (over 250,000 people had a repeat BBV test within a median time of 4 months of their previous test in the Programme), and by taking a complete BBV approach at each test.

The Programme reached a population who had not previously tested for BBVs: over 60% of people who were eligible and tested for a BBV, and almost three quarters of people newly diagnosed with a BBV through the Programme had no record of a previous test in any setting. People testing through the Programme are older and from an ethnic minority group compared to people testing outside the Programme. This likely reflects the older population who attend EDs, and also those who may experience greater inequalities in health and access to care mediated through age, ethnicity and deprivation compared to the local resident population.

The Programme had the greatest impact in newly diagnosing people living with HBV (3,667) followed by new diagnoses for HCV (831) and HIV (719). Half of those diagnosed with HBV and HCV were newly diagnosed, whereas this was 8.3% for HIV. Furthermore, over 93% of all people who had a positive HIV test through the Programme and were previously diagnosed were already in HIV outpatient care. These findings suggest that an ED opt-out testing programme is likely to be most efficient if a combined BBV approach is adopted to find people living with unidentified and therefore untreated BBV, though the health economics analysis will formally assess this.

The Programme has detected newly diagnosed people with different demographics and risk factors to those diagnosed in other conventional settings where risk-based access or implementation of testing, rather than opt-out approaches, were followed. For HCV, fewer people newly diagnosed reported known social risk factors such as a history of injecting drugs or experiencing homelessness (1 in 4 people compared to 2 in 3 people newly diagnosed in other settings), and for HIV, most people newly diagnosed reported acquiring HIV through heterosexual sex (almost 2 in 3 people) in contrast to people diagnosed in other settings (almost 1 in 2 people). Reinfections with HCV were also identified through the Programme. Most had a history of injecting drug use, which reinforces the need to strengthen prevention services providing harm reduction to reduce risk from injecting.

Coinfections were also detected most commonly with HIV and HBV; those with HIV and HBV coinfection were mostly those known to be living with HIV but had no prior record of a diagnosis with HBV and the majority had been in HIV care. This potentially presents an opportunity for earlier diagnosis of coinfection in line with national testing guidance.

The proportion with late diagnoses (50.7%) was highest in those newly diagnosed with HIV, which is higher than in all other settings. Locally collected data suggests substantial late-stage HBV among those newly diagnosed. The proportion of late diagnoses (late-stage liver disease) was lower for HCV (12.5%). Almost half (47.1%) of those with late-stage HCV did not report social risk factors and would therefore not have been identified by risk-based testing in other settings. However almost 30% were from an intermediate or high HCV prevalence country and therefore eligible for testing in line with NICE guidance on hepatitis B and C testing.

The evaluation also found that some people who had been newly diagnosed during the Programme, including those with late-stage HCV, had prior attendances in EDs and could have had an opportunity to be identified for earlier engagement into care if an ED opt-out testing programme had commenced earlier. Improved awareness and implementation of existing national testing guidance could also have supported early opportunity for diagnosis in other settings.

Although surveillance data does not adequately capture the significant work of clinical teams and peers who support timely engagement, their efforts are reflected in the high proportion of people diagnosed with a BBV who were linked to care during the Programme. For people diagnosed with HCV, 81.3% were linked to care and started treatment. A national HBV care and treatment registry does not yet exist but locally collected data across 7 sites in London indicates that 97% of people diagnosed with HBV were also linked to care.

For people newly diagnosed with HIV, 97% were linked to care overall but less than half were linked within the national target of 14 days and lower than other settings within the same geographical areas and timeframe (66.3%). This likely reflects the newly established processes for onward linkage to HIV care following an ED diagnosis, including confirmatory testing, compared to HIV diagnoses in sexual health services (SHSs) which are well established and often integrated with HIV services. Furthermore, patients admitted following ED attendance may not have the same opportunities for rapid linkage to care. Peer support initiatives are being further developed in wave 2 of the Programme to strengthen timely linkages to care. Locally collected data and research have been important in reconciling and enriching the evaluation outputs.

A strength of this evaluation has been the engagement of sites to ensure that complete laboratory data, including negative results, was reported to the UK Health Security Agency (UKHSA). This enabled the evaluation to measure key public health indicators across the cascade for an individual from their ED attendance to BBV testing, diagnosis (differentiating between new and previous diagnoses) and linkage to care, and to fully assess the public health impact of the Programme compared to testing in other settings.

Main findings

The main findings from the evaluation of the programme using data from 33 months (1 April 2022 to 31 December 2024) are summarised below.

Scale of the Programme

NHSE dashboard data indicates that over 7 million tests were undertaken for a BBV in the 34 EDs in the Programme over a 33-month period: 2,781,164 HIV tests, 2,363,443 HCV tests and 1,989,161 HBV tests were completed.

The Programme contributed around 50% of all BBV testing reported in surveillance data from the same geographic regions and timeframe.

ED attendances and attendees who had a blood test

Almost 4 million people attended EDs across the 34 participating sites, of whom 2.4 million (60.6%) had a blood test and were eligible for an opt-out BBV test.

Compared to the same Integrated Care Boards (ICBs), those attending an ED were older and, in London EDs, more were from an ethnic minority group.

Uptake of BBV testing

At the 21 ED sites with complete surveillance data, 69.3% of eligible attendees were tested for any BBV, varying from 44% to 80% across sites.

9.6% of eligible attendees had a repeat BBV test within 6 months (the minimum blocking period reported across included sites) at any ED site in the Programme, which suggests scope for improved efficiency.

62.8% of eligible attendees had no record of a previous BBV test in surveillance data.

People testing in the Programme were older and a higher proportion were from an ethnic minority group, compared to the population testing outside of the Programme, which partly reflects the demographics of the population attending EDs compared to the general population.

Attendees testing positive (diagnosed) with BBVs

There were 3,667 new HBV diagnoses, 831 new HCV diagnoses and 719 new HIV diagnoses across the subset of 24 sites served by Sentinel Surveillance of Blood Borne Virus (SSBBV) laboratories.

The lowest number of people who needed to be tested to newly diagnose one person was 240 for HBV and was higher for HCV (1276) and HIV (1916).

Test positivity for newly diagnosed was highest for HBV (0.42%) followed by HCV (0.08%) and HIV (0.05%): consistent with the high undiagnosed proportion of people living with HBV.

Around 50% of all people diagnosed with HBV and HCV were newly diagnosed compared to 8.3% for HIV.

The vast majority (73.4%) of people newly diagnosed had no record of a previous BBV test in SSBBV indicating that the Programme was able to access a population who may not have had an opportunity to be diagnosed in other settings where testing is available.

People newly diagnosed through the programme reported different routes of acquisition or risk factors to people diagnosed in other settings, reflecting the success of the opt-out testing approach in diagnosing people compared to more traditional settings.

Most (93.9%) people previously diagnosed with HIV were already in care, in contrast to HCV (14.1%).

A reinfection with HCV was identified in 7.3% of people living with HCV. This included people previously diagnosed through the Programme and was higher than the estimated reinfection rate in England.

Late diagnoses

The proportion of people with a new BBV diagnosis who had late-stage disease was highest for HIV (50.7%), followed by HCV (12.5%). It is not possible to estimate the proportion of late HBV diagnoses in the absence of national HBV treatment monitoring.

Approximately 50% of people presenting with late-stage HCV liver disease did not report social risk factors and were therefore less likely to have been identified by routine risk-based testing in other settings.

Coinfections

A coinfection was diagnosed among 326 people (1.9% of all diagnoses).

Diagnoses with both HIV and HBV was the most common.

Of people diagnosed with HIV and HBV, nearly half were newly diagnosed with at least one BBV, typically a new HBV diagnosis.

Of those who are newly diagnosed with HBV, the majority had been in HIV care, potentially representing an opportunity for earlier identification of HBV in line with national guidance.

Testing opportunities outside of the Programme

The majority (79.0%) of those people newly diagnosed with a BBV were found to have attended an ED in the year prior to the Programme starting, suggesting that ED opt-out testing may have resulted in an earlier diagnosis if it was in place prior to April 2022.

Across all BBVs, there were opportunities for earlier testing and diagnosis in primary care in line with national guidance.

Linkage to care

Just under half (42.2%) of people newly diagnosed with HIV were linked to care within 14 days of the test in ED. This increased to 96.8% across the duration of the Programme.

80.0% of people newly diagnosed with HCV and 82.9% of people previously diagnosed were linked to care and started treatment which is comparable to national data for England.

In the absence of a national patient registry for HBV, locally collected data from 7 sites in London suggested that 97% of contactable patients diagnosed with HBV were linked to care.

Clinical teams and peers were integral to supporting timely linkage to care.

Introduction

The UK has made considerable progress towards achieving the World Health Organization (WHO) strategic goals to end new HIV transmissions and eliminate viral hepatitis as a public health threat by 2030. However, there are many people, disproportionately from underserved or marginalised groups, who remain undiagnosed or are diagnosed late and therefore experience the harmful yet avoidable health outcomes from these BBVs.

Opt-out testing in EDs provides a non-stigmatising and more inclusive population-based approach to newly diagnosing and re-engaging people previously diagnosed with a BBV who are not currently accessing care. It removes barriers associated with a risk-based offer of testing, which requires disclosure of risk factors, and widens testing to the broader demographic of people attending EDs.

As part of the 2021 National HIV Action Plan objective to scale up HIV testing in England, NHSE implemented a 3-year programme of HIV opt-out testing in EDs in areas of very high diagnosed HIV prevalence, starting in April 2022. This programme was expanded to include hepatitis B and C as an integrated BBV testing approach with additional funding from the NHSE Hepatitis C Elimination Programme.

NHSE commissioned the UK Health Security Agency (UKHSA), in partnership with the National Institute for Health and Care Research (NIHR) Health Protection Research Unit (HPRU) at the University of Bristol, to conduct an evaluation of the Programme, comprising public health, implementation optimisation and economic assessments. Interim public health evaluation reports were published at 12 months (November 2023) and 24 months (November 2024). The University of Bristol published a report on implementation optimisation in ED opt-out testing in April 2025. The economic evaluation report is due in Autumn 2025.

The interim public health evaluation reports of the ED BBV opt-out testing Programme at 12 months and 24 months indicated that the Programme had made a substantial contribution to all BBV testing in England, but with variable uptake across sites. Both reports highlighted success in reaching and diagnosing people who were unaware they were living with a BBV, or were not currently in care, but that linkage to care could be improved. These findings, and those from the optimisation of implementation workstream, led to interim recommendations to improve the Programme. This report presents the findings from the full public health evaluation following the completion of the 3-year Programme using 33 months of data from 1 April 2022 to 31 December 2024.

Evidence for opt-out testing in EDs

Evidence for opt-out testing for all 3 BBVs (HIV, HBV and HCV) in EDs is well documented. The National Institute for Health and Care Excellence (NICE) updated their guidance on HIV in 2025 to offer and recommend HIV testing in EDs where there is a high or very high (more than 2 per 1,000 people aged 15 to 59 years) diagnosed HIV prevalence. While the NICE guidelines do not specify EDs as a setting for viral hepatitis testing, other available evidence on BBV testing in EDs highlights EDs as a potential key setting for testing.

EDs offer open access healthcare to the entire population with over 15 million attendances in Type 1 (major) EDs every year. Opt-out testing in EDs can therefore address inequalities by reaching an underserved population with high levels of deprivation who may not be engaged by other healthcare services, in addition to people who may not self-identify as being at risk, and therefore not seek testing or be offered testing in other services. ED testing provides an opportunity for finding people living with a BBV who have not yet been diagnosed, while also providing an opportunity to re-engage people with a BBV diagnosis who are not currently accessing care. The opt-out approach normalises testing for BBVs and negates the need for a person to disclose or a healthcare worker to ask about risk factors, potentially reducing stigma and discrimination.

The ED opt-out testing programme

In April 2022, a 3-year programme of ED opt-out testing for BBVs (the Programme) was implemented in EDs within areas of very high diagnosed HIV prevalence (more than 5 per 1,000 population aged 15 to 59 years). A whole city approach was taken for London, with most London local authorities being areas with very high diagnosed HIV prevalence. The Programme provided testing for HIV, HBV and HCV for anyone aged 16 years and over (18 years and over at some sites) having a routine blood test during their ED attendance, unless they opted-out (see Figure 1).

The Programme roll out included 34 sites across all of London, Manchester, Blackpool and Brighton in Type 1 (major, 24-hour, consultant led) EDs. Sites had individual ‘go live’ dates, which refer to when an ED started testing for each BBV, with variation across both sites and start dates for each BBV (see Appendix 1). At the end of the 33 months 32 sites were testing for HIV, HBV and HCV; with 2 sites not yet testing for HBV. The 34 sites were part of ‘wave 1’ of the Programme. Expansion to ‘wave 2’ sites in areas of high HIV diagnosed prevalence (2 to 5 per 1,000 population aged 15 to 59 years) areas was announced later and is being evaluated separately.

Figure 1. Flowchart of testing process for BBV opt-out testing in EDs

NHSE good practice guidance for BBV opt-out testing in EDs recommended automated test requests, whereby the electronic ordering system automatically generated a BBV test alongside routine ED blood testing sets. The implementation optimisation report noted that not all sites were able to implement this with some choosing alternative, including manual, test ordering mechanisms. Guidance also recommended ‘blocking’ of repeat testing for individuals attending EDs more than once within a pre-specified period of time, such as 6 months. ‘Blocking’ aimed to minimise unnecessary repeat tests to reduce the costs and demand on testing laboratories and ED staff. The initiation of blocking, the period over which tests were blocked, and local implementation varied between sites and are not explored in this evaluation.

For those people who had a positive BBV test, results were reported and managed across sites and relevant specialist teams according to local policy. For people who had a negative test result, a ‘no news is good news’ approach was advised. For those who had a reactive HIV test in EDs, confirmatory testing was undertaken in outpatient SHSs or during the subsequent hospital admission.

Aggregate data for NHSE programme metrics from ED sites was available through the NHSE dashboard (accessed 24 June 2025). This data indicate the large scale of BBV testing conducted during the Programme. Between 1 April 2022 and 31 December 2024, there were 2,781,164 HIV tests, 2,363,443 HCV antibody tests and 1,989,161 HBV tests conducted over the 33-month period. The higher number of HIV tests is likely reflective of earlier ‘go-live’ dates for HIV. Laboratory surveillance data (SSBBV testing) showed the substantial contribution of the Programme to all BBV testing with the Programme accounting for approximately half of all BBV tests conducted within the same geographical regions and timeframe as the Programme.

Public health evaluation

Aims and objectives

As set out in the evaluation protocol, the public health evaluation assesses the impact and effectiveness of the (wave 1) Programme over its 3-year period.

The objectives are:

• to describe the effectiveness of the Programme in diagnosing and linking to care people who are newly diagnosed with a BBV, or previously diagnosed and not currently in care
• to describe the care pathway (cascade) for individuals who are eligible for and tested positive for BBVs through the Programme
• to describe the extent to which testing in this setting reduces health inequalities in BBV testing
• to describe the effectiveness of the Programme over time

Evaluation method

The public health evaluation uses a theory of change model as the framework for the evaluation. This is diagrammatically represented by logic models which show the relationship between Programme activities, outputs and long-term outcomes (see Appendix 2 of the 12-month report). The outputs and outcomes are monitored by a set of indicators across the care cascade. The evaluation questions and their related indicators are summarised in Evaluation questions and indicators: public health evaluation of BBV opt-out testing in EDs in England, 33-month final report 2025 and are referenced in each section of the evaluation findings.

Healthcare activity and public health surveillance data is used to monitor the indicators for activity, outputs and outcomes and impact of the Programme. The data sources are described in more detail in Appendix 2 and broadly include the following.

Attendance and activity in EDs: National Emergency Care Data Set (ECDS).

BBV testing: (SSBBV testing), a voluntary network of laboratories submitting data to UKHSA on HIV, hepatitis B and hepatitis C blood tests, established in 2002. The network covers approximately 46% of the general practice (GP) registered population in England.

Diagnoses: UKHSA Second Generation Surveillance System (SGSS) for diagnoses of HBV and HCV, with laboratory reports since 1990; HIV and AIDS Reporting System (HARS) and HIV and AIDS New Diagnosis Database (HANDD) for HIV.

Linkage to care and treatment: HARS and HANDD for HIV; Arden and GEM NHSE Hepatitis C Patient Registry and Treatment Outcome System and NHSE Blueteq System to monitor prescribing of medicines for HCV. For HBV, no national treatment monitoring data set is available, so the evaluation draws upon site-specific studies published by local clinical teams.

Routine public health surveillance data (SSBBV, SGSS, HARS and HANDD), healthcare activity (ECDS) and treatment data (NHSE Blueteq System, Hepatitis C Patient Registry and Treatment Outcome System) hold individual patient level information and identifiers (including pseudo-anonymised, or depersonalised) which allows:

• deduplication and estimation of the number of people that were tested rather than the number of tests done
• description of the characteristics of people tested
• data linkage between data sources to map the cascade for an individual, from their ED attendance to BBV testing, diagnosis (differentiating new and previous diagnoses) and linkage to care

These systems are reliant on complete data with identifiers being submitted by clinical and laboratory teams, and testing and diagnoses occurring in the timeframe and laboratories covered by the surveillance systems.

NHSE dashboard data provides aggregate counts reflecting the volume of activity (for example the number of attendances and the number of tests conducted). This data has no identifiers so cannot be deduplicated to give the number of unique individuals attending or being tested. NHSE dashboard data has not been used directly to report against the evaluation indicators but has been triangulated with surveillance and healthcare activity data to assess the quality and completeness of data used for the evaluation. Further details on the data sources, linkage and analysis methods are included in Appendix 2.

SSBBV data was available for 29 of the 34 sites participating in the Programme. After triangulation with NHSE dashboard data, 24 of the 29 sites had SSBBV data of sufficient quality to report BBV test positivity and diagnoses (Figure 2). SSBBV data was then linked to ECDS data on ED attendances with blood tests for 21 sites (3 sites had data gaps) and this data was used to report BBV test uptake (see Appendix Table 2). Data availability for reporting against each of the evaluation indicators is outlined in Evaluation questions and indicators: public health evaluation of BBV opt-out testing in EDs in England, 33-month final report 2025.

Figure 2. Flowchart showing the coverage of data sources used in the public health evaluation

Evaluation findings

ED attendances and attendees who had a blood test

People were eligible to have an opt-out BBV test in the Programme if they were already having a blood test in ED. This section presents data on the proportion of ED attendances and attendees with a blood test, therefore eligible for BBV testing. This section reports data for evaluation indicators 1a and 1b.

The main findings are:

• the Programme was able to access almost 4 million people attending EDs across the 34 participating sites, of whom 2.4 million people (60.6%) had a blood test and were therefore eligible to have an opt-out BBV test
• compared to all residents in the corresponding ICBs, those attending an ED were older and, in London EDs, more were from an ethnic minority group

There were 7,840,697 attendances across 3,895,593 attendees (adjusted for go-live dates for HIV testing at each site) during the 33-month period between April 2022 and December 2024 reported through ECDS. The number of attendances reported through ECDS was similar to the overall number of attendances reported in the NHSE dashboard data, indicating that the 2 data sources were comparable (see Appendix Table 3). NHSE dashboard data includes aggregate counts only and cannot be duplicated to estimate the number of attendees (people) to compare with ECDS.

Of the 7,840,697 attendances reported through ECDS, 4,247,489 (54.2%) included a blood test and were therefore eligible for BBV opt-out testing. Of the 3,895,593 attendees (people) reported through ECDS, 2,359,458 (60.6%) had a blood test and were therefore eligible to have an opt-out BBV test. The number of attendees (people) is lower than the number of attendances as some people had multiple attendances at a Programme ED site over the 33-month period: 33.9% (800,474) of attendees had more than one attendance with a blood test (median attendance was 1, interquartile range (IQR): 1 to 2, range: 1 to 343).

London sites (28 sites) represented 82.9% (3,519,536) of eligible attendances and 82.3% (1,941,744) of eligible attendees. Sites outside London represented 17.7% of eligible attendees.

Comparison of the population attending ED to the general population

Comparing the demographics of the population attending an ED site in the Programme to the general population within the same ICB of residence gives an indication of whether the Programme was able to access people who experience inequalities (see Appendix 2).

Compared to the general population within the same ICB of residence, a higher proportion of people attending a Programme ED site were of older age and, in London, were from an ethnic minority group. The difference in age is expected and similar to results from the Office for National Statistics (ONS) which found that a greater proportion of ED attendees are in older people (aged 80 years and over). In addition, people living in more deprived areas were more likely to attend EDs after adjusting for age, sex and ethnicity, compared to those living in less deprived areas. The ONS report suggests this association may reflect differences in health status, awareness of health system and access to primary healthcare services among those attending ED.

Uptake of BBV testing

Uptake of BBV opt-out testing among eligible people (those having blood taken as part of emergency care) estimates the effectiveness of the Programme in testing for BBVs. With the data available, it is not possible to determine whether someone did not have a BBV test because they opted out or because the test was not completed due to clinical or operational reasons. This section presents data on evaluation indicators 1c, 1d, 2 and 3 (testing).

The main findings are:

• the Programme was effective at testing eligible attendees for BBVs: overall test uptake among eligible attendees was 69.3%, which is higher than seen in smaller-scale studies in EDs
• testing uptake increased over time, particularly in the first year, likely reflecting the impact of implementation learnings: uptake varied from 43.8% to 79.8% across sites
• 9.6% of eligible attendees had a repeat BBV test within 6 months at any ED in the Programme (the minimum blocking period reported across the 21 evaluation sites), which suggests scope for improved efficiency
• the Programme was successful at testing people who had no record of a previous BBV test in surveillance data: 62.8% of eligible attendees, and this varied by virus
• the Programme tested a different population to the population being tested outside of the Programme; people testing in the Programme were older and a higher proportion were from an ethnic minority group, which partly reflects the demographics of the population attending EDs compared to the general population

Overall, in the 21 sites where SSBBV linked with ECDS data, 69.3% (1,120,329 out of 1,617,762) of eligible attendees were tested for a BBV during the Programme which is higher than test uptake reported in many smaller-scale studies. Test uptake across sites ranged from 43.8% to 79.8% overall and increased over the duration of the Programme, which may reflect implementation learnings, with the first year of the Programme showing the greatest variation (Figure 3).

There were some potential inefficiencies due to repeat testing: 16.2% of eligible attendees (261,870 out of 1,617,762) had a repeat BBV test during the Programme at any ED in the Programme, with a median time of 4 months between tests (IQR range approximately 1 to 9 months). In addition, 9.6% (155,135) of eligible attendees had a repeat BBV test within 6 months (the minimum blocking period reported across the 21 sites in the evaluation) at any ED in the Programme, although some repeat tests may have been conducted for clinical reasons and repeat testing would not be avoidable by blocking if a person attended different EDs.

Of the 1,617,762 eligible attendees, 68.0% (1,103,006 of 1,622,212) were tested for HIV, 57.9% (852,073 of 1,471,382) were tested for HCV and 56.7% (689,849 of 1,216,588) were tested for HBV accounting for different go-live date for BBV testing for each virus. Local implementation of ‘blocking’ procedures for repeat tests and variation in testing practices may also impact the number of tests conducted and differences in proportion of attendees tested for each virus. Coverage of BBV testing among all ED attendees, regardless of whether they were eligible (had a blood test) or not, was 41.3% (1,120,329 out of 2,712,792).

The Programme was successful in accessing people who did not have a previous record of a BBV test in settings reporting to SSBBV. Overall, 62.8% of eligible attendees had previously not been tested for any BBV: 68.1% for HIV, 76.3% for HCV, and 74.8% for HBV.

Figure 3. Average uptake of BBV testing by month [note 1]

Source: SSBBV data for 21 sites matched to ECDS.

Note 1: uptake by month for the 21 sites according to a person’s first visit to an ED at a particular site within the programme, indirectly accounting for blocking within a site so that test uptake is not underestimated. The IQR across sites is shown by the grey shaded area.

Comparison of eligible attendees having or not having a BBV test

497,433 of 1,617,762 eligible people did not have a BBV test. Comparing eligible people who did not have a BBV test with those who did have a test allows for any systematic differences between these groups to be identified which could impact the effectiveness of the Programme.

There was no difference in the demographics of eligible attendees who did not have a BBV test compared to those who did have a BBV test. However, among the small number of eligible people who did not have a BBV test and were found to be tested elsewhere within SSBBV (202 out of 497,433: 0.04%), 18 had a positive BBV test result after their ED attendance, of which 9 were newly diagnosed. Although there are multiple individual and provider level factors that could have contributed to people not being tested in the Programme, a high testing rate is important to support earlier diagnosis. In some instances people may have been contacted for re-test following an inadequate or indeterminate sample or signposted to further testing. At sites where testing uptake is low, the ‘no news is good news’ approach to results management recommended in the good practice guidance on BBVs opt-out testing in EDs could lead to individuals assuming they had tested negative because they had not received a positive result. This might impact on future test-seeking behaviour. The implementation optimisation workstream flagged the importance of developing procedures to mitigate this risk in the 12-month interim report which many sites have introduced.

BBV testing uptake within and outside of the Programme by demographic characteristics

Within the Programme, overall BBV testing uptake among eligible attendees increased with age, from 65.1% among people aged 16 to 24 years to 72.0% in people aged 80 years and over and varied by ethnicity, ranging from 68.8% in attendees of Asian other ethnicity to 73.1% in attendees of Black Caribbean ethnicity. Testing uptake was similar by gender and across areas with varying levels of deprivation.

The demographics of the population tested in the Programme was different to those tested outside the Programme within the same geographic region and timeframe. Compared to people who were tested outside the Programme, people testing in the Programme were older (Figure 4) and a higher proportion were from an ethnic minority group (Figure 5), which partly reflects the characteristics of the population attending EDs compared to the general population. For HBV and HCV, a higher proportion of people tested in the Programme were women. There was little difference in deprivation when comparing the populations tested for HIV in the Programme with SHSs; deprivation data was not available for people tested for HBV and HCV.

Figure 4. Proportion of eligible attendees within each age group that had any BBV test as part of the Programme and in other settings [note 2]

Source: SSBBV data for 24 sites; SSBBV data for sites outside of the Programme; SHS service data (GUMCAD).

Note 2: Testing outside of the Programme refers to testing in SHSs for HIV and testing in primary and community care settings for HBV and HCV (such as GP, SHSs, drug and prison services, and excluding antenatal screening for HBV). Data relating to people tested in SHSs and primary and community care settings has been restricted to local authorities where ED testing occurred within the Programme. SHSs are used as the comparator for HIV testing as data is more complete and this is the setting where most HIV testing activity occurs.

Figure 5. Proportion of eligible attendees within each ethnic group that had any BBV test as part of the Programme and in other settings [note 3]

Source: SSBBV data for 24 sites; SSBBV data for sites outside of the Programme; SHSs service data (GUMCAD).

Note 3: Testing outside of the Programme refers to testing in SHSs for HIV and testing in primary and community care settings for HBV and HCV (such as GP, SHSs, drug and prison services, and excluding antenatal screening for HBV). Data relating to people tested in SHSs and primary and community care settings has been restricted to local authorities where ED testing occurred within the Programme. SHSs are used as the comparator for HIV testing as data is more complete and this is the setting where most HIV testing activity occurs.

Attendees testing positive (diagnosed) with BBVs

Understanding the number and proportion of people testing positive and newly diagnosed through EDs, and those not currently in care, measures the effectiveness of the Programme in identifying new people living with a BBV. This data was compared to diagnoses in other settings such as GPs, SHSs, drug treatment and prison services within the same geographic region and timeframe and excluding antenatal screening for HBV. Test positivity is calculated from the ‘go-live’ date at each site for each of the viruses. This section reports data for evaluation indicators on diagnoses (4, 5, 6a, 6b), associated risk factors (14a, 14b), and exposure route for infection (15a, 15b).

The main findings are:

• the largest number of people newly diagnosed with a BBV through the Programme was for HBV (3,667), followed by HCV (831) and HIV (719), reflecting the higher number of people in the population living with HBV who have not yet been diagnosed
• the smallest number of people who needed to be tested to newly diagnose one person was 240 for HBV and was higher for HCV (1276) and HIV (1916)
• test positivity for newly diagnosed was highest for HBV (0.42%) followed by HCV (0.08%) and then HIV (0.05%): consistent with the high undiagnosed proportion of people living with HBV
• around 50% of people testing positive for HBV or HCV were newly diagnosed, compared to 8.3% for HIV
• the vast majority (73.4%) of people newly diagnosed had no record of a previous BBV test in SSBBV (where identifiers were available to link previous tests): this indicates that the Programme was able to access a population who may not have had an opportunity to be diagnosed in other settings where testing is offered
• people newly diagnosed through the programme reported different routes of acquisition or risk factors to people diagnosed in other settings, reflecting the success of the opt-out testing approach in diagnosing people compared to more traditional settings
• a small proportion (14.1%) of people previously diagnosed with HCV were currently engaged in care, likely reflecting the success of the NHSE hepatitis C Elimination Programme in treating people for HCV (resulting in clearance of virus and therefore no longer requiring HCV care); for HIV, the proportion of people previously diagnosed and not in care was less than 10% reflecting success in HIV services engaging people in ongoing care
• a reinfection with HCV was identified in 7.3% of people living with HCV. This included people previously diagnosed through the Programme and was higher than the estimated reinfection rate in England

Overview of BBV diagnoses and test positivity

At the 24 sites with SSBBV data, 16,929 people were diagnosed with any BBV of whom 5,185 were newly diagnosed. The largest number of new diagnoses was for HBV (3,667, 72.3%) and the highest test positivity for newly diagnosed was also for HBV (0.42%), reflecting the higher number of people living with HBV who have not yet been diagnosed (Table 1a).

The NNT to newly diagnose one person was 1,916 for HIV, 1,276 for HCV and 240 for HBV (Table 1b); a lower number indicates a higher yield or efficiency. To identify a person previously diagnosed but not in care, 2,852 people would need to be tested for HIV and 1,609 for HCV. Overall the number needed to test to identify a person newly diagnosed or previously diagnosed and not in care was 1,146 for HIV and 711 for HCV. Data is not available to calculate the NNT for these indications for HBV as there is no national care registry.

For each BBV, the proportion of people with a positive test result that were newly diagnosed was similar for HBV and HCV (52.0% and 52.0%, respectively), but lower for HIV (8.3%) (Figure 6).

Among people newly diagnosed, the vast majority (73.4%) had no record of a previous BBV test in surveillance data indicating that the Programme was able to reach a population who may not have had an opportunity to be diagnosed in other settings where routine testing is offered. The ability to link previous test results is reliant on complete data reporting with patient identifiers, such as NHS number. However, due to data de-personalisation of BBV testing in some services, such as SHSs or drug treatment services, identifiers like NHS number are not routinely collected, which limits the ability to link previous tests.

Table 1a. Number of attendees tested and testing positive (diagnosed) for HIV, HCV and HBV

Attendees tested or diagnosed	HIV	HCV	HBV
Number of attendees tested	1,377,299	1,060,035	879,724
Number (%) who tested positive	8,624 (0.63)	1,597 (0.15)	7,048 (0.80)
Number (%) who tested positive (newly diagnosed)	719 (0.052)	831 (0.078)	3,667 (0.42)
Number (%) who tested positive (previously diagnosed and not in care)	483 (0.04)	659 (0.06)	Not available

Source: ED opt-out data for 24 SSBBV sites, matched to HANDD or HARS.

Table 1b. Number of people needed to be tested for HIV, HCV and HBV to identify one person

Number of people needed to be tested to identify one person (NNT)	HIV	HCV	HBV
Newly diagnosed	1,916	1,276	240
Previously diagnosed and not in care	2,852	1,609	Not available
Newly diagnosed or previously diagnosed and not in care	1,146	711	Not available

Source: SSBBV data for 24 sites, matched to HANDD or HARS.

Figure 6. Proportion of positive test results that were new diagnoses or among people previously diagnosed, by BBV

Source: SSBBV data for 24 sites, matched to HANDD or HARS.

HIV diagnoses

For HIV, 10,658 people had a positive test within the Programme, with 8,624 (80.9%) of these being linked to routine surveillance data (see Appendix 2). Among these, 719 (8.3%) had a new diagnosis (including 64 people with HIV diagnoses before continuing care in England), and 7,905 (91.7%) had previously been diagnosed (Figure 8). It is likely that the number of new HIV diagnoses is a slight underestimate due to limitations in data quality and linkage (see Appendix 2).

The majority (93.9%, 7,422) of people previously diagnosed with HIV were already engaged in care. The remaining proportion (6.1%, 483) of people previously diagnosed with HIV had not accessed HIV care within the past 15 months. For people newly diagnosed with HIV, 668 (92.9%) had no record of a prior HIV test in SSBBV and 657 (91.4%) had no record of any BBV test.

HIV test positivity

HIV positivity for new diagnoses in the Programme was 0.052% (Table 2), which is lower than test positivity at SHSs in the same timeframe and geographical areas (0.14%) (Table 2). This likely reflects that the population attending EDs has a lower risk profile for having HIV compared to people attending SHSs.

Where postcode of residence for a person was recorded (1,031,554: 74.4%), 509,520 (49.4%) of people tested for HIV at the 24 sites were resident in a local authority of very high HIV prevalence, with 452,205 (43.8%) people resident in a local authority of high HIV prevalence and 69,829 (6.8%) resident in a local authority of low prevalence (Table 2). The distribution of HIV test positivity and the number of people needed to be tested for a new diagnosis was reflective of the diagnosed prevalence bands for postcode of residence (see Appendix 2).

Table 2. HIV positivity by testing location or diagnosed HIV prevalence band based on area of residence for the ED Programme [Note 4 and 5]

Location or diagnosed HIV prevalence band	HIV positivity (new HIV diagnoses of attendees tested for HIV)	Number needed to test to identify a newly diagnosed person (NNT)
SHSs	0.14% (1,815 of 1,279,099)	705
ED Programme overall	0.052% (719 of 1,377,299)	1,916
ED Programme: people resident in a local authority with very high HIV prevalence (more than 5 per 1,000)	0.070% (358 of 509,520)	1,423
ED Programme: people resident in a local authority with high HIV prevalence (2 to 5 per 1,000)	0.039% (177 of 452,205)	2,555
ED Programme: people resident in a local authority with low HIV prevalence (less than 2 per 1,000)	0.033% (23 of 69,829)	3,036

Source: ED opt-out data for 24 SSBBV sites, matched to HANDD or HARS. Diagnosed HIV prevalence bands grouped using Fingertips Public Health Profiles data.

Note 4: SHS data has been restricted to the same timeframe and to local authorities where ED testing occurred within the Programme.

Note 5: Diagnosed HIV prevalence band is mapped when postcode of residence of the person is available.

The majority of people who were newly diagnosed with HIV, residing in very high or high prevalence areas, were registered with a GP (92.7% and 89.8% respectively), indicating that there were potentially other opportunities for earlier diagnosis if British HIV Association (BHIVA) guidelines and NICE guidance on HIV testing were followed.

Characteristics of people with a new HIV diagnosis in EDs compared to other settings

Where recorded, most people newly diagnosed with HIV were male (463: 64.7%), of Black African ethnicity (93: 26.2%), in the 35 to 49 year age group (276: 38.4%), and born in a country of low HIV prevalence, excluding the UK (244: 44.0%) (Figure 7).

Compared to people newly diagnosed in all other settings (such as GPs, SHSs, drug services, prisons, antenatal, other secondary care and ED testing conducted outside of the Programme), in the same geographical regions and timeframe, people newly diagnosed with HIV in the Programme were older (median age 42 (IQR 33 to 53) compared to 36 years (IQR 29 to 45), a higher proportion were women (253: 35.3% versus 1,383: 30.1%), living in the most deprived area (204: 33.3% versus 1,018: 26.8%), and were of Black Caribbean (19: 5.5% versus 132: 3.4%), Black other (49: 13.8% versus 160: 4.1%) or White British (66: 18.6% versus 424: 10.9%) ethnicity (Figure 7).

Further, a higher proportion of people newly diagnosed in the Programme were born in a country of high or intermediate HIV prevalence (155: 28.0% versus 898: 24.6%) or in the UK (155: 28.0% versus 604: 16.5%) compared to people newly diagnosed in other settings.

Figure 7. Demographics of people with a new HIV diagnosis, by location of test

Source: ED opt-out data for 24 SSBBV sites (matched to HANDD or HARS), compared to HANDD data on diagnoses in all other settings such as GPs, SHSs, drug services, prisons, antenatal, other secondary care and ED testing conducted outside of the Programme. Comparator data is restricted to the same timeframe and to local authorities in England where the Programme was implemented.

Most people newly diagnosed through the Programme reported having acquired HIV through heterosexual sex compared to people diagnosed in other settings (363: 65.3% versus 1,670: 46.5%) (Figure 8). This finding reflects the success of the opt-out testing approach in diagnosing people with different risk factors compared to other settings, primarily SHSs, that have not yet fully implemented BHIVA and NICE testing guidelines on HIV.

Figure 8. Probable route of HIV acquisition for people with a new HIV diagnosis, by location of test

Source: ED opt-out data for 24 SSBBV sites (matched to HANDD or HARS), compared to HANDD data on new diagnoses in all other settings such as GPs, SHSs, drug services, prisons, antenatal, other secondary care and ED testing conducted outside of the Programme. Comparator data is restricted to the same timeframe and to local authorities in England where the Programme was implemented.

HCV diagnoses

For HCV, 9,586 (0.9%) people tested antibody positive, of whom 7,115 (74.2%) had a confirmatory ribonucleic acid (RNA) or antigen test reported to SSBBV. Of those, 6,052 (85.1%) had the confirmatory test within 7 days, a proxy marker of reflex testing (confirmatory RNA or antigen test performed on the same sample).

Of the 7,115 people who had an antibody positive result with a confirmatory test reported, 1,185 (16.7%) had a positive HCV antigen or RNA test, indicating that they were currently living with HCV. Additionally, 4,099 people had an RNA test without an antibody test recorded, of whom 413 (10.1%) were positive. Overall, 1,598 people tested HCV antigen or RNA positive.

Among the 1,598 people with a HCV diagnosis, 831 (52.0%) people were newly diagnosed and 767 (48.0%) were previously diagnosed. Nearly all (96.8%: 804) people newly diagnosed with HCV had no record of a prior HCV test and 85.2% (708) had no record of any BBV test. A small number of the people newly diagnosed (11: 1.3%) had evidence of viraemia or seroconversion indicating acquisition of infection during the Programme. These individuals had multiple ED attendances which may have allowed for their new infection to be diagnosed at an earlier stage than through other test settings.

A small proportion (14.1%, 108) of people previously diagnosed with HCV were currently engaged in care, which is expected as they are likely individuals who are awaiting or are at an early phase in treatment. This reflects the success of the HCV Elimination Programme where 83.1% of people who initiated treatment had cleared the virus (therefore RNA negative) between 2015 and 2023 in England (Hepatitis C in England 2024). The majority (86.0%, 659) of people living with HCV who were previously diagnosed were not currently engaged in care and represent people who may need additional support to engage with care to clear the virus.

Among all people who were currently living with HCV, 117 (7.3%) were diagnosed with a HCV reinfection, which is similar to the overall estimate for England (Hepatitis C in England 2024) (see Appendix 2). The majority (107: 91.5%) of people diagnosed with a reinfection had evidence of a previously cleared HCV infection prior to their first ED attendance in the Programme, and the remaining 10 people had their first and reinfection diagnosed through multiple ED attendances as part of the Programme.

HCV test positivity

Test positivity (prevalence among those tested) for HCV was 0.15% overall, and 0.08% for people newly diagnosed with HCV (Table 1a). This is comparable to the modelled prevalence estimate among the general adult population in England (0.12%, 95% confidence interval (CI): 0.10 to 0.15%) (Hepatitis C in England 2024).

Characteristics of people with a new HCV diagnosis in EDs compared to other settings

Most people newly diagnosed with HCV were male (525: 63.4%), of White other or White British ethnicity (116: 30.5% and 112: 29.5% respectively), in the 35 to 49 years or 50 to 64 years age group (257: 31.0% and 242: 29.1% respectively) and lived in the second most (238: 35.8%) or most (238: 35.8%) deprived areas (Figure 9).

Compared to people newly diagnosed in other primary and community care settings (such as GPs, SHSs, drug and prison services) in the same geographical regions and timeframe, people newly diagnosed with HCV in the Programme were older (median age 53 years (IQR 41 to 65) compared to aged 43 years (IQR 37 to 52)), a higher proportion were women (303: 36.6% versus 240: 24.8%) and living in the most deprived area (238: 35.8% versus 112: 26.5%), and a lower proportion were of white British ethnicity (112: 29.5% versus 295: 42.1%) (Figure 9).

Among those newly diagnosed through the Programme, 119 (22.8%) were born in a country of high or intermediate HCV prevalence (2% or greater) and therefore eligible for HCV testing in line with NICE guidance, of whom 108 (90.8%) had evidence of being registered with a GP. Compared to people newly diagnosed in other settings, a higher proportion of people newly diagnosed in the Programme were born in a country of low HCV prevalence (196: 37.6% versus 118: 30.4%) or in the UK (206: 39.5% versus 143: 36.9%). In addition, 74.8% (622) of people newly diagnosed through the Programme were registered with a GP, which was higher than the proportion registered with a GP among people newly diagnosed in other settings (392: 35.3%). These findings reflect the nature of the opt-out testing approach in diagnosing people with different risk factors compared to more traditional settings that have not yet fully implemented NICE testing guidelines for Hepatitis B and C.

Figure 9. Demographics of people with a new HCV diagnosis, by location of test

Source: ED opt-out testing data for 24 SSBBV sites matched to SGSS, NHSE Hepatitis C Patient Registry and Blueteq. Diagnoses outside of EDs include primary and community care settings for HCV (such as GPs, SHSs, drug and prison services, and excluding antenatal screening).

Fewer than a quarter (207: 24.9%) of people newly diagnosed through the Programme had any social risk factor recorded. This proportion was substantially higher for people who were newly diagnosed outside the Programme (761: 68.4%). Of note, 82.2% (683) of people newly diagnosed with HCV in the Programme had no record of injecting drug use. A higher proportion of people newly diagnosed through the Programme had evidence of experiencing homelessness compared with people who were newly diagnosed outside the programme (57: 7% versus 3%: 34) (Figure 10). The completeness of information on social risk factors for HCV (history of incarceration, drug use or attending a drug treatment service, or ever experiencing homelessness) is dependent on risk perception and disclosure, and this information being recorded in surveillance data.

Figure 10. Social risk factors for people with a new HCV diagnosis, by location of test

Source: ED opt-out data for 24 SSBBV sites matched to SGSS, NHSE Hepatitis C Patient Registry and Blueteq. Diagnoses outside of EDs include primary and community care settings for HCV (such as GPs, SHSs, drug and prison services).

Among people diagnosed with HCV reinfection (see Appendix 2) in the Programme the majority (79: 76.7%) were born in the UK. This likely reflects that continued risk of HCV acquisition in England is mainly through injecting drug use. Most people who were newly diagnosed with a reinfection reported currently injecting drugs (60: 51.3%) and 49 (41.9%) had experienced homelessness.

HBV diagnoses

Among people diagnosed with a current HBV infection, over half (52.0%, 3,667 out of 7,048) were newly diagnosed. This number is higher than the number of people newly diagnosed with HIV and HCV (719 and 831, respectively). 94.0% (3447) of people who were newly diagnosed with HBV had no prior HBV test reported through SSBBV, and 82.1% (3011) had no prior BBV test.

In the absence of a sentinel or national care monitoring system of people living with diagnosed HBV, it is not possible to indicate what proportion of those newly diagnosed were linked to specialist care or the proportion of those previously diagnosed who required re-engagement into care. Data from 7 London ED sites over the first 2 years of the Programme indicate that over 3 quarters of diagnoses were new or not under follow up, and 41% of those previously diagnosed who were contacted were not currently in care.

HBV test positivity

Test positivity (prevalence among those tested) for HBV was 0.80% overall, and 0.42% for people newly diagnosed with HBV (Table 1a). This is higher than the general population estimate in England of 0.58% (Hepatitis B in England 2024).

Characteristics of people with a new HBV diagnosis in EDs compared to other settings

Most people newly diagnosed with HBV were male (2,251: 61.7%), of Black African (565: 25.9%) or White other (506: 23.2%) ethnicity, in the 35 to 49 years or 50 to 64 years age groups (1288: 35.1% and 1050: 28.6% respectively), and lived in the second most (1,166: 38.6%) or most (757: 25.0%) deprived areas (Figure 11).

Data from 7 London ED sites show that where country of birth was reported, 94% of people newly diagnosed were born in a country of intermediate or high HBV prevalence and therefore eligible for HBV testing in line with NICE guidance on hepatitis B and C testing.

Compared to people newly diagnosed in other primary and community care settings in the same geographical regions and timeframe (such as GPs, SHSs, drug and prison services, and excluding antenatal screening), people newly diagnosed with HBV in the Programme were older (median age 48 years (IQR: 38 to 60) compared to 39 years (IQR: 32 to 49)), a higher proportion were women (1,396: 38.3% versus 722: 32.8%) and a higher proportion were of White other ethnicity (506: 23.2% versus 232: 15.7%) or Black ethnicity (843: 38.6% versus 490: 33.1%). There was little difference by area of deprivation. 2,982 (81.3%) were registered with a GP, which was higher compared to people newly diagnosed in other settings (1641: 74%).

Figure 11. Demographics of people with a new HBV diagnosis, by location of test

Source: ED opt-out testing data for 24 SSBBV sites. SSBBV data matched to SGSS diagnoses for outside of the Programme diagnoses. Diagnoses outside of EDs include primary and community care settings for HBV (such as GPs, SHSs, drug and prison services, and excluding antenatal screening).

Late diagnoses

Assessing the proportion of people testing at EDs who were found to have late-stage BBV measures whether existing testing services are promptly identifying people living with a BBV and linking them to treatment and care before adverse health outcomes develop. Late diagnoses were only considered for those individuals testing newly positive (newly diagnosed) through the Programme. This section presents data on the evaluation indicators for late diagnoses (12a, 12b, 13a and 13b).

The main findings are:

• the proportion of people with a new BBV diagnosis who were found to have late-stage disease was highest for HIV (50.7%), followed by HCV (12.5%): it is not possible to estimate the proportion of late HBV diagnoses in the absence of national HBV treatment monitoring
• approximately 50% of people presenting with late-stage HCV liver disease did not report social risk factors and were therefore less likely to have been identified by routine risk-based testing in other settings

HIV late diagnoses

A late HIV diagnosis is defined as having a CD4 count below 350 cells per mm3 within 91 days of diagnosis and no evidence of a recent infection (see Appendix 2).

Of the 719 new HIV diagnoses in the Programme, 475 had sufficient information to assess whether they were diagnosed late. Among these, 241 (50.7%) were diagnosed late (Figure 12). Compared to people newly diagnosed in all other settings, a higher proportion of people were diagnosed late in the Programme (832: 36.9% versus 241: 50.7%).

There was little difference in the proportion of people diagnosed late in areas of very high or high prevalence (50% and 50.8% respectively), but people residing in lower prevalence areas had a lower proportion of late diagnoses (23.5%).

Most people who were diagnosed late for HIV through the Programme were in the 35 to 49 years or 50 to 64 years age groups (99: 41.1% and 74: 30.7% respectively), of Black African ethnicity (39: 32.2%), and lived in the most deprived or second most deprived areas (145: 73%). For country of birth, 44.2% (92) of people newly diagnosed with late-stage HIV were born in a low prevalence country outside the UK, 29.3% (61) were born in a country with high or intermediate HIV prevalence, and 26.4% (55) were born in the UK. The gender distribution for people newly diagnosed with late-stage HIV was also similar to the one observed for all new HIV diagnoses in the Programme.

HCV late-stage liver disease

A late-stage HCV liver disease diagnosis is defined as a presentation with cirrhosis or hepatocellular carcinoma (HCC) (see Appendix 2).

Of 831 people newly diagnosed with HCV, 104 (12.5%) were diagnosed at a late stage (Figure 12). A national comparison is not currently available for this indicator, but a previous analysis using data in England for 2021 (Hepatitis C in England report 2022) found that 6.3% of individuals had cirrhosis with past or current decompensation or HCC at first treatment. Although these definitions differ, the higher proportion reported in the Programme suggests that ED opt-out testing has identified people who were living with undiagnosed HCV for a long period of time. 28 people who were diagnosed at a late stage in the Programme subsequently died, 15 (53.6%) of whom had End Stage Liver Disease (ESLD) or HCC noted as the underlying or contributing cause of death.

Most people with a late-stage HCV liver disease diagnosis were male (77: 74.8%), of White other ethnicity (22: 43.1%), in the 50 to 64 years or 65 to 79 years age groups (32: 30.8% and 35: 33.7% respectively), and lived in the second most (37: 36.6%) or most (38: 37.6%) deprived areas. 49 (47.1%) people had no available risk factors reported. However, 26 (28.9%) were born in a country of intermediate or high HCV prevalence (2% or greater) and therefore eligible for HCV testing in line with NICE guidance.

HBV late-stage liver disease

A late-stage HBV liver disease diagnosis is defined as a presentation with cirrhosis or HCC (see Appendix 2). As no national treatment monitoring for HBV exists it is not possible to estimate late-stage HBV liver disease among people newly diagnosed with HBV for the whole Programme using routine surveillance data, but some indication can be ascertained from other sources.

Of the 3,667 individuals newly diagnosed with HBV, 71 (1.9%) had evidence of late-stage liver disease through linkage to hospital inpatient records (Hospital Episode Statistics (HES)) or ONS mortality records. Of these 71 people, 24 died, of whom 16 had HCC or ESLD noted as the underlying cause or contributing cause of death. Clinical coding in HES may underestimate late-stage liver disease as it is only consistently reported for inpatients and will not capture people who are awaiting an assessment for liver disease or people with late-stage disease being managed as an outpatient.

Data from 3 South East London EDs reported that among the subset of people newly diagnosed with HBV and attending their first appointment (202), 32 (15.8%) were diagnosed late. Of these, 19 had advanced liver disease (13 had liver cirrhosis, 3 had HCC, and 3 died of liver related complications).

Figure 12. Proportion of people with a new BBV diagnosis who were diagnosed with late-stage disease

Source: ED opt-out data for 24 SSBBV sites matched to HANDD or HARS for HIV, to NHSE Hepatitis C Patient Registry and ONS mortality data for HCV, and to HES for HBV and HCV.

Coinfections

Shared modes of transmission and overlapping risk factors can result in some people living with more than one BBV (coinfection). Coinfection can result in treatment complications, lead to accelerated disease progression and increases the risk of morbidity and mortality. Identification of a coinfection is important to understand whether there were opportunities for earlier diagnosis to improve current BBV testing guidance and implementation. This section reports data for coinfection evaluation indicators 20, 21 and 22.

The main findings are:

• in the Programme, 326 people (1.9% of all diagnoses) had a coinfection
• diagnoses with both HIV and HBV were the most common
• of people diagnosed with HIV and HBV, nearly half were newly diagnosed with at least one BBV, typically a new HBV diagnosis
• of those who are newly diagnosed with HBV, the majority had been in HIV care with no record of a prior HBV test, potentially representing an opportunity for earlier identification of HBV in line with national guidance

Through the Programme, a small number of people were found to be living with a coinfection (326 out of 16,929 BBV diagnoses: 1.9%). The most common coinfection was HIV and HBV (293, 89.9%), followed by HIV and HCV (28, 8.6%), and HCV and HBV (9, 2.8%). Of these a small number of people were found to be living with all 3 BBVs.

Of those people with a coinfection, 200 (61.3%) people were previously diagnosed with both BBVs before the Programme, 94 (47.5%) had one BBV diagnosed previously with the other BBV newly diagnosed during the Programme, and 32 (16%) had both BBVs newly diagnosed during the Programme. This finding reflects the success of opt-out testing in newly diagnosing at least one BBV where NICE guidelines for HIV and viral hepatitis and BHIVA guidance  on hepatitis for adults with HIV have not been fully implemented in other settings.

Due to the anonymity of BBV testing in services such as SHSs or drug treatment services where identifiers such as NHS number are not recorded, there may be limitations in the ability to link to previous test results to differentiate between new and previous diagnoses.

Coinfection of HIV and HBV

Among the 293 people with HIV and HBV coinfection, the highest proportion (61.4%: 180) were previously diagnosed with both HIV and HBV, 28.0% (82) were previously diagnosed with HIV and newly diagnosed with HBV, 8.5% (25) were newly diagnosed for both HIV and HBV, and 2.0% (6) were previously diagnosed with HBV and newly diagnosed with HIV (Figure 13).

Of the 82 people with a new HBV diagnosis who were previously HIV diagnosed, the vast majority (90.7%) were known to be in HIV care suggesting there were opportunities for earlier HBV diagnosis. However, as noted earlier there are uncertainties with data linkage between services with anonymised BBV testing.

Coinfection of HIV and HCV

Among the 28 people with HIV and HCV coinfection, the highest proportion (78.6%, 22) were previously diagnosed with both HIV and HCV. The remaining proportion of people (17.9%, 5) were either previously diagnosed with HIV and newly diagnosed with HCV, or newly diagnosed with both HIV and HCV (Figure 13).

Coinfection of HBV and HCV

Among the 9 people with HBV and HCV coinfection, most 66.7% (6) were newly diagnosed with both HBV and HCV (Figure 13).

Figure 13. BBV coinfections among people diagnosed (new and previously diagnosed) through the Programme

Source: ED opt-out data for 24 SSBBV sites, matched to NHSE Hepatitis C Patient Registry and HANDD or HARS.

Testing opportunities outside of the Programme

Opt-out testing in EDs offers an opportunity for universal BBV testing, whereas other healthcare settings take different approaches to BBV testing in line with national guidance. Linked surveillance data can be used to identify whether a person newly diagnosed with a BBV in the Programme had previously attended a GP or ED (see Appendix 2). This information can be used to assess whether there were opportunities for earlier testing and diagnosis, and to support improved implementation of existing guidance in these settings. This section presents data for evaluation indicators 23 and 24.

The main findings are:

• the majority (79.0%) of those people newly diagnosed with a BBV were found to have attended an ED in the year prior to the Programme starting, suggesting that ED opt-out testing may have resulted in an earlier diagnosis if it was in place prior to April 2022
• across all BBVs, there were opportunities for earlier testing and diagnosis in primary care in line with national guidance

Testing opportunities in EDs

Across all BBVs, 79.0% of people newly diagnosed had an ED attendance in the year prior to the Programme starting in April 2022. For HIV, this was 86.4% (621 out of 719), for HCV 85.9% (713 out of 831) and HBV 84.7% (3107 out of 3667). This finding suggests that if opt-out ED testing was in place prior to April 2022, these individuals may have had the opportunity to be diagnosed earlier. Some ED sites may have implemented a pilot of opt-out testing prior to April 2022 but this has not been considered in this evaluation.

For those who were diagnosed with late-stage BBV, almost everyone (90.9%) was found to have attended an ED in the year prior to the Programme starting. For HIV, this was 85.1% (205 out of 241), for HCV 99.0% (103 out of 104) and HBV 98.6% (70 out of 71).

Testing opportunities for HIV in primary care

For those who were newly diagnosed with HIV through the Programme and had postcode of residence available, 91.8% were living in a local authority of very high or high diagnosed HIV prevalence and were registered with a GP, and for those who were diagnosed late, 87.6% were registered with a GP. This potentially presents an opportunity for earlier testing.

Testing opportunities for HCV in primary care

Of people who were newly diagnosed with HCV and born in a country of high or intermediate HCV prevalence, 90.8% (108 out of 119) were registered with a GP. These people would have been eligible for HCV testing in primary care in line with NICE guidelines and may have had an opportunity for an earlier diagnosis. This proportion was similar for people diagnosed with late-stage liver disease through the Programme (84.6%: 22 out of 26).

Testing opportunities for HBV in primary care

Country of birth is not available through national HBV surveillance systems, so it is not possible to assess prior testing opportunities in primary care based on this indication. However, 81.3% (2,982 out of 3,667) of people newly diagnosed with HBV in the Programme were registered with a GP.

Local data from 7 London sites found that 94% of people diagnosed with HBV were born in a country of intermediate or high HBV prevalence. It is not clear what proportion of these people were registered with a GP, but they would have been eligible for testing in primary care in line with NICE guidance.

Linkage to care

Describing the care cascade among people newly diagnosed in EDs and those supported to re-engage with care is important to assess the impact of the Programme on linking people to timely care and treatment to reduce morbidity and mortality. This section presents data for linkage to care evaluation indicators 7 (a to d), 8 (a to b), 9 (a to b) and 11 (a to f). The linkage to care evaluation indicator for HBV (indicator 10 a to b) is not presented using surveillance data as this is not available in the absence of a national patient registry for treatment monitoring, however, NHSE dashboard and locally collected data from sites is reported.

The main findings are:

• just under half (42.2%) of people newly diagnosed with HIV were linked to care within 14 days, increasing to 96.8% across the duration of the Programme
• 80.0% of people newly diagnosed with HCV and 82.9% of people previously diagnosed were linked to care and started treatment which is comparable to national data for England
• in the absence of a national patient registry we were unable to assess the care cascade for HBV; in a local analysis of data from 7 London ED sites, the reported proportion was as high as 97% among contactable people
• clinical teams and peers were integral to supporting timely linkage to care

HIV linkage to care

Overall, across the duration of the Programme, 96.8% (660 out of 682) of people newly diagnosed with HIV were linked to care (HIV clinic) and 66.0% (291 out of 441) of people previously diagnosed and not in care were subsequently re-engaged (Figure 14).

The definition for linkage to HIV care excludes individuals who have died of any cause (see Appendix 2). Overall, 5.1% (37) of people newly diagnosed and 13.8% (24 out of 174) of people previously diagnosed and not in care died during the Programme. Of those who were previously diagnosed, 6.3% (501 out of 7,905) died of any cause during the Programme.

Figure 14. Linkage to care for people newly and previously diagnosed with HIV and not in care in the previously 15 months

Source: ED opt-out data for 24 SSBBV sites, matched to HANDD or HARS.

BHIVA guidelines for people living with HIV recommend that people diagnosed with HIV should be linked to care within 14 days. Of those newly diagnosed, 42.2% (300 out of 708) of people were recorded as linked to care within 14 days compared to 66.3% in all other settings within the same geographical areas and timeframe as the Programme. 61.9% (434 out of 701) of people newly diagnosed were linked to care within 1 month (compared to 88% nationally and 74.6% in all other settings) and 78.8% (514 out of 652) were linked within 3 months (compared to 82.3% in all other settings) (Figure 15).

There are different factors influencing linkage to care data making comparison with linkage to care from other settings, such as SHSs, challenging. There may have been a few people whose ED HIV diagnosis was confirmed, and treatment commenced as a hospital inpatient, who may not appear to have been linked to care. This is due to linkage to care data only being available to UKHSA once the individual attends an HIV outpatient clinic. The delay also likely reflects the newly established processes for onward linkage to HIV care following an ED diagnosis, compared to HIV diagnoses in SHSs which are well established and often integrated with HIV services. Lastly, the testing context and population differs between EDs and SHSs, which could impact on the time taken to engage with specialist services as people testing in SHSs are mostly seeking a sexually transmitted infection (STI) screen.

NHSE dashboard data indicates that across the 34 sites 687 of those diagnosed with HIV were offered community support and 370 people engaged with the support. Further interventions are being put in place in wave 2 of the ED opt-out testing programme, including peer support initiatives, to improve timely linkage to care.

Figure 15. Time to linkage to care for people newly diagnosed with HIV

Source: ED opt-out data for 24 SSBBV sites, matched to HANDD or HARS.

Among people newly diagnosed with HIV at a late stage of infection, 50.2% were linked to care within 14 days, with 72.5% and 86.0% being linked within 1 month and 3 months, respectively. Overall, across the duration of the Programme, 95.5% of people newly diagnosed at a late stage were linked to care.

For those previously diagnosed but not engaged in care, 28% (98 out of 350) were re-engaged within 1 month, 38.7% (177 out of 457) were re-engaged within 3 months and 57.8% (185 out of 320) were re-engaged within 1 year (Figure 16).

Figure 16. Time to re-engagement in care for people previously diagnosed with HIV

Source: ED opt-out data for 24 SSBBV sites, matched to HANDD or HARS.

HCV linkage to care

Overall, 81.3% (1,038 out of 1,276) of people diagnosed with HCV were linked to care and started treatment, of which 55.4% (575 out of 1,038) had evidence of clearing the virus (reported sustained virologic response (SVR) or a negative RNA test). Among people newly diagnosed with HCV the proportion of people linked to care and starting treatment was 80.0% (545 out of 681) (Figure 17), and for people previously diagnosed but not engaged in care, 82.9% (493 out of 595) were relinked to care and started treatment (see Figure 18 and Appendix 2).

These proportions are comparable to national data for England between 2015 to 2023 (Hepatitis C in England 2024), which showed that the proportion of people diagnosed with HCV who were linked to specialist care was 81.4%, of whom 96.1% initiated treatment. The median time between HCV diagnosis and linkage to care in the Programme was 58 days (IQR 31 to 136 days): 51 days (IQR 31 to 106 days) for those newly diagnosed, and 63.5 days (IQR 30 to 178) for those previously diagnosed and re-engaged.

Overall, 55.4% (575 out of 1,038) of people initiating HCV treatment had evidence of clearing the virus (reported SVR or a negative RNA test). This proportion was 59.8% (326 out of 545) among those newly diagnosed (Figure 17) and 50.5% (249 out of 493) among those previously diagnosed (Figure 18). The proportions are lower than national data for England in 2023 (Hepatitis C in England report 2024) where 83.1% of people initiating treatment had evidence of clearing the virus. This may be because some people in the Programme did not have evidence of a test to confirm clearance of the virus at the time of conducting this evaluation.

Linkage to care data excludes individuals who have died during the Programme (see Appendix 2), and individuals who do not have sufficient identifiers to be able to link their information to treatment data. Overall, 7.6% (55) of people newly diagnosed and 8.1% (54) of people previously diagnosed and not in care died before they could be linked to care. 5.6% (40) of people newly diagnosed and 9.6% (64) of people previously diagnosed died after initiating treatment but before a treatment outcome was reported. This may reflect the underlying co-morbidities and acute illness among people attending EDs.

Among people newly diagnosed with HCV at a late stage of infection, 98.9% (92 out of 93) of people were linked to care and initiated treatment, of whom 59.8% (55 out of 92) had evidence of clearing the virus. Among all people diagnosed with a HCV reinfection, 66.3% (73 out of 110) were linked to care and initiated treatment, of whom 37.0% (27 out of 73) had evidence of clearing the virus.

Surveillance data cannot capture the reasons why people did not engage with care. Unpublished local analysis of data from 2 NHS Trusts suggested possible reasons including: services were unable to contact the person, the person declined care or did not attend an appointment, the person was not eligible for treatment, or the person has left the country (Brown A, Daly F, Attridge-Smith, personal communication, 19 June 2025). These reasons are similar to findings from other studies that have looked at barriers to engagement with HCV care.

The input of peers (people with lived experience), has been fundamental to engaging people into care across various elimination initiatives in England, including this Programme. Data from the Hepatitis C Trust show that an estimated 450 people diagnosed through the Programme and engaged in care were supported by a peer (Smith S, personal communication, 18 June 2025).

Figure 17. HCV linkage to care for people newly diagnosed [note 6 and 7]

Source: ED opt-out data for 24 SSBBV sites, matched to NHSE Hepatitis C Patient Registry and Blueteq.

Note 6: Other treatment outcomes include relapse, breakthrough, lost to follow up, and non-response. Those who died between initiating treatment and receiving an outcome are included in the ‘Treatment started’ bar.

Note 7: This includes a clinical report of either an SVR through NHSE Hepatitis C Patient Registry or an RNA negative result at 98 days or more after treatment initiation. Individuals are excluded where a positive result has been recorded within 28 days of the RNA negative.

Figure 18. HCV linkage to care for people previously diagnosed [notes 8 and 9]

Source: ED opt-out data for 24 SSBBV sites, matched to NHSE Hepatitis C Patient Registry and Blueteq.”

Note 8: Other treatment outcomes include relapse, breakthrough, lost to follow up, and non-response. Those who died between initiating treatment and receiving an outcome are included in the ‘Treatment started’ bar.

Note 9: This includes a clinical report of either an SVR through NHSE Hepatitis C Patient Registry or an RNA negative result at 98 days or more after treatment initiation. Individuals are excluded where a positive result has been recorded within 28 days of the RNA negative.

HBV linkage to care

In the absence of a national patient registry for treatment monitoring, linkage to care for people diagnosed with HBV through the Programme as a whole could not be assessed. Sites submitted data to the NHSE dashboard and some sites undertook their own analysis of locally collected data.

NHSE dashboard data suggests that 56.4% (3,413 out of 6,054) of people newly diagnosed or previously diagnosed and not in care were subsequently linked into care through the Programme. Across the 34 sites, 114 of those diagnosed with HBV were recorded as offered community support and 33 people engaged with community support at the first meeting.

In a study of 28 London ED sites, a median of 57% (IQR 31 to 75%)) of people who were newly diagnosed with HBV or previously diagnosed and not in care were subsequently linked to care. A separate study from 7 ED sites across North Central London (April 2022 to October 2023) and South West London (November 2022 to March 2024) reported higher linkage to care with 97.3% (660 out of 678) being assessed for treatment among people who were newly or previously diagnosed and not in care with HBV and who were contactable. Across 3 EDs in South East London (November 2022 to June 2024), 34.8% (123 out of 353) of people newly diagnosed with HBV were assessed as eligible for treatment. Among those where contact was successful (254), 202 (79.5%: 57.2% of all new diagnoses) attended a first appointment. 39.1% (79) of these individuals were eligible for treatment, of whom 55.7% (44) initiated treatment.

Data on re-engagement into specialist care was available for 1 South East London ED. 54 (73.0%) of the 74 people who were previously diagnosed and not in care were re-linked into care. 26 of these people (48.1%) were eligible for treatment, of whom 8 (30.8%) initiated treatment.

Appendix 1. ED sites go-live dates

The operational go-live date for the commencing of testing for each BBV varied at each Programme site is outlined in Appendix Table 1, alongside information on whether the site submits data to SSBBV by the end of the Programme timeframe.

Appendix Table 1. Site go-live dates by BBV

Hospital	HIV	HBV	HCV	London site	Included in SSBBV data
Blackpool Victoria Hospital	1 Nov 2020	4 Aug 2023	2 Aug 2023	No	Yes
Charing Cross Hospital	1 Apr 2022	1 Jul 2022	1 Jul 2022	Yes	Yes
Chelsea and Westminster Hospital	1 Apr 2022	1 Apr 2022	1 Apr 2022	Yes	Yes
Croydon University Hospital	1 Apr 2022	20 Mar 2023	20 Mar 2023	Yes	Yes
Ealing Hospital	19 May 2022	19 May 2022	19 May 2022	Yes	Yes
Epsom Hospital	16 May 2022	7 Mar 2023	7 Mar 2023	Yes	Yes
Hillingdon Hospital	22 Jul 2022	22 Jul 2022	22 Jul 2022	Yes	Yes
Homerton University Hospital	1 Apr 2022	12 Sep 2022	12 Sep 2022	Yes	Yes
King George Hospital	28 Jul 2022	2 Oct 2023	28 Nov 2022	Yes	Yes
King’s College Hospital	1 Apr 2022	16 Nov 2022	16 Nov 2022	Yes	Yes
Kingston Hospital	1 Apr 2022	24 Apr 2023	24 Apr 2023	Yes	Yes
Manchester Royal Infirmary	1 Dec 2021	10 July 2024	1 Dec 2021	No	Yes
Newham General Hospital	1 Apr 2022	25 Apr 2022	1 Apr 2022	Yes	Yes
North Manchester General Hospital	8 Sep 2022	10 July 2024	8 Sep 2022	No	Yes
Northwick Park Hospital	19 May 2022	19 May 2022	19 May 2022	Yes	Yes
Princess Royal University Hospital	21 Apr 2022	1 Feb 2024	1 Feb 2024	Yes	Yes
Queen Elizabeth Hospital	1 Apr 2022	9 May 2023	9 May 2023	Yes	Yes
Queen’s Hospital	1 Aug 2022	2 Oct 2023	28 Nov 2022	Yes	Yes
Royal Sussex County Hospital	6 Apr 2022	To be confirmed	6 Apr 2023	No	Yes
St George’s Hospital (Tooting)	1 Apr 2022	17 Nov 2022	17 Nov 2022	Yes	Yes
St Helier Hospital	1 Apr 2022	7 Mar 2023	7 Mar 2023	Yes	Yes
St Mary’s Hospital	1 Apr 2022	15 Aug 2022	15 Aug 2022	Yes	Yes
St Thomas’ Hospital	1 Apr 2022	1 Nov 2022	1 Nov 2022	Yes	Yes
The Royal London Hospital	1 Apr 2022	25 Apr 2022	1 Apr 2022	Yes	Yes
The Whittington Hospital	5 Sep 2022	5 Sep 2022	5 Sep 2022	Yes	Yes
University Hospital Lewisham	1 Apr 2022	9 May 2023	9 May 2023	Yes	Yes
West Middlesex University Hospital	1 Apr 2022	1 Apr 2022	1 Apr 2022	Yes	Yes
Whipps Cross University Hospital	4 Apr 2022	25 Apr 2022	4 Apr 2022	Yes	Yes
Wythenshawe Hospital	15 Mar 2022	10 July 2024	15 Mar 2022	No	Yes
Barnet Hospital	22 Apr 2022	22 Apr 2022	22 Apr 2022	Yes	No
North Middlesex Hospital	1 Apr 2022	1 Apr 2022	1 Apr 2022	Yes	No
Royal Free Hospital	22 Apr 2022	22 Apr 2022	22 Apr 2022	Yes	No
Salford Royal Hospital	8 Jan 2024	To be confirmed	8 Jan 2024	No	No
University College Hospital	1 Apr 2022	3 Apr 2023	3 Apr 2023	Yes	No

Appendix 2. Technical notes and methodology

Data sources, linkage and limitations

The public health evaluation uses data from the following sources.

NHSE dashboard data on BBV opt-out testing in EDs

The NHSE dashboard data for the ED BBV opt-out testing programme reflects the volume of activity that each site reports against the programme’s metrics. It includes numbers of attendances, attendances with blood tests, tests by BBV, diagnoses and linkage to care outcomes at site and Trust level. This is used to report data on numbers of tests completed in the Programme, and to triangulate with surveillance data.

The NHSE dashboard includes aggregate numbers at site and trust level and does not include patient identifiable information to allow deduplication across the programme or at site level. This means the NHSE dashboard data presents data on all attendances and therefore will be higher than the data presented by UKHSA. Classification of a new diagnosis may differ as UKHSA is able to cross check England level diagnoses data with SGSS that has hepatitis diagnoses recorded since the 1990s. Furthermore, the care status of a person could be recorded more than once if they were tested in more than one ED.

National ECDS

ECDS is the national data set for urgent and emergency care, managed by NHSE. Primarily a commissioning data set, it provides information on activity in EDs for a range of secondary uses. ECDS is used for data on ED attendances, ED attendances with blood tests, ED attendees, ED attendees with blood tests, and demographic information about attendees. ECDS includes individual level data on all attendances from all ED in England. Linkage between ECDS and SSBBV is used to calculate uptake of BBV testing. Tests from SSBBV that had evidence of being done in an ED (using a combination of the setting of the test, site address and record location) were linked to ECDS attendances where blood tests had been done using patient NHS number, arrival date in ED, specimen date in SSBBV, and NHS trust. BBV tests with a specimen date more than 8 days after an ED attendance were excluded from the linked data set.

SSBBV testing in England

SSBBV is a sub-national surveillance system for BBV testing activity and results in England, managed by UKHSA. Established in 2002, it includes data on all positive and negative BBV tests processed by the sentinel laboratories that participate in SSBBV. Laboratory participation in SSBBV is voluntary, and currently represents an estimated 46% of the GP registered population in England. SSBBV can be used to calculate test uptake and positivity as well as total numbers of new and previous diagnoses. 24 of the 34 participating ED sites were represented in SSBBV data for this final report for positivity and the cascade of care. A subset of 21 sites were used to present testing rates, 3 sites were excluded as linkage between SSBBV and ECDS was low. 5 sites were not included within the final report due to significant testing data incompleteness from SSBBV when comparing to NHSE dashboard data.

UKHSA SGSS

SGSS is the national laboratory reporting system used in England to capture laboratory reports of infectious diseases and antimicrobial resistance since 1997, managed by UKHSA. It is the main system through which NHS and private diagnostic laboratories submit mandatory reports of notifiable organisms (including HBV and HCV) to UKHSA, in accordance with the Health Protection (Notification) Regulations 2010. Linkage between SSBBV and SGSS is used to identify past diagnoses of HBV and HCV with individual level records going back to the 1990s.

HARS and HANDD

HARS contains pseudo-anonymised (depersonalised) data on HIV care attendances in England, and HANDD collates reports of new HIV diagnoses, AIDS and deaths of people living with HIV. Both are managed by UKHSA and are updated annually. HARS or HANDD are used for HIV diagnoses and treatment information. HIV diagnoses were obtained by linking positive HIV tests in SSBBV to diagnosis events in HARS or HANDD. This means that HIV diagnosis data is limited to the 24 sites that have SSBBV data available in the final report. Linkage between SSBBV and HARS or HANDD is used to identify new diagnoses, number of people previously diagnosed and not in care, and linkage to care and re-engagement in care. HARS or HANDD holds past diagnoses of HIV with individual level records going back to 1980s.

SSBBV data was matched to HIV surveillance data (HANDD or HARS) using probabilistic matching based on initials, soundex (a 4-letter code generated from a person’s surname), date of birth and gender. HARS and HANDD systems do not contain NHS numbers. A significant proportion (19%) of positive HIV tests in SSBBV could not be matched to HARS or HANDD, preventing confirmation of the diagnosis. It is therefore likely that confirmed diagnoses are underestimated in this report. However, based on the other data within the Programme, we would expect that only around 8% of those unmatched are likely to be new HIV diagnoses.

Reasons for not matching include wrong or missing identifiers within either data set, false identifiers given on admission to ED, a person presenting to ED but living abroad, confirmatory negative results not being reported through SSBBV and delays in data reporting.

Delays in data reporting can be assessed by comparing the number of new diagnoses reported in the 24-month evaluation with those identified in this updated evaluation. Previously, 391 new diagnoses were reported, which has now increased to 446 for the same timeframe and sites, demonstrating the lag in data reporting.

Arden and GEM NHSE Hepatitis C Patient Registry and Treatment Outcome System

The Hepatitis C Patient Registry and Treatment Outcome System hosted and managed by the Arden and GEM commissioning support unit for NHSE was established in 2016. Patient level data is made available to UKHSA. The registry contains data for people who have received an HCV diagnosis and have initiated or will be initiating treatment. Information is recorded by clinical teams on demographics, risk factors for infection, stage of liver disease at treatment initiation, liver related co-morbidities and treatment outcomes. This data is used for HCV treatment information, evidence of late diagnosis, to identify previous HCV diagnoses and demographic and risk factor information.

There are known to be delays with entering information onto the Registry as well as incomplete records. As a result, the data likely underestimates the number of treatment initiations and this data is used in combination with registered prescriptions of HCV treatments through the NHSE Blueteq system through data linkage. Linkage between SSBBV and the Hepatitis C Patient Registry and Treatment Outcome System is used to identify individuals who have been linked to care, individuals initiating HCV treatment, and treatment outcomes. Data is linked using NHS number or name and date of birth.

NHSE Blueteq system to monitor prescribing of medicines

Blueteq is a web-based system for the approval and management of high-cost medicines across a range of healthcare conditions, including HCV. All individuals who are treated must have their medicine prescription registered. Blueteq prescription is used in combination with the Hepatitis C Patient Registry and Treatment Outcome System. Linkage between SSBBV and Blueteq data is used to identify individuals who have initiated treatment.

GUMCAD STI Surveillance System

GUMCAD is the national surveillance system for STIs in England, established in 2008, and provides information on the number of HIV tests carried out in SHSs, and the demographic characteristics of those tested.

Hospital Episode Statistics (HES)

HES, managed by NHSE, is a curated data product containing details about admissions, outpatient appointments and historical ED attendances at NHS hospitals in England. HES is used to supplement data on ethnicity through linking to SSBBV. HES linked to death registrations is used to supplement data on mortality, and inpatient records were used to identify late-stage liver disease through data linkage. Clinical codes are underreported for outpatient and ED records and therefore were not included in the identification of late-stage liver disease. HES and SSBBV data is linked using NHS number or hospital number and site. Matches are verified using date of birth, sex and postcode.

Office for National Statistics (ONS) death registrations

Death registrations, managed by the ONS, were used to identify people who have died and their date of death through linkage to SSBBV. Cause of death was used to identify late-stage liver disease for those newly diagnosed using underlying or contributory cause of death. Cause of death is coded according to the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD 10). Data was linked using a stepwise deterministic approach, first using NHS number and date of birth and then combinations of soundex, day month and year of birth and finally soundex, initial and date of birth where NHS number was not available.

Surveillance, dashboard and healthcare activity data coverage of ED sites

Data availability for reporting against each of the evaluation indicators is outlined in Appendix Table 2. A full list of indicators and data sources used is available in Evaluation questions and indicators: public health evaluation of BBV opt-out testing in EDs in England, 33-month final report 2025.

Appendix Table 2. Data availability by indicator

Indicator	Coverage and data source
ED attendances, ED attendances with blood tests, tests by BBV, diagnoses and linkage to care	34 sites: NHSE dashboard data
ED attendances and attendees, attendances and attendees with a blood test	34 sites: ECDS
Diagnoses (newly or previously); Linkage to care (HIV and HCV); Test positivity	24 sites: SSBBV, HANDD, HARS, Blueteq and NHSE Hepatitis C Patient Registry and Treatment Outcome System
BBV test uptake	21 sites: SSBBV and ECDS linked

The NHSE dashboard data for the ED BBV opt-out testing programme covers the 34 participating sites and reflects the volume of activity that each site reports against the programme’s metrics.

SSBBV coverage in the Programme at 33 months was 29 out of 34 (82%) participating sites, an increase from 16 of 34 (47%) participating sites in 2022 (12 month interim report). NHSE dashboard data was used to triangulate between data sources to identify any data quality issues. BBV test positivity, diagnosis (new or previous) and linkage to care data was available for 24 of the 29 sites. Numbers of tests reported for 5 sites were lower than expected when comparing to the NHSE dashboard and were therefore excluded from the evaluation.

ECDS coverage in the Programme included all 34 participating sites and was used to present the number of ED attendances and attendees, and the number of attendances and attendees with a blood test. However, uptake was only available for a subset of 21 of the 24 sites covered by SSBBV, due to low data linkage between SSBBV and ECDS for 3 of the 24 sites. 21 sites are an increase from 5 sites in the 12-month interim report.

A full list of the data availability for each of the 34 Programme ED sites is outlined below.

The 24 sites included for diagnosis and linkage to care analysis are:

• Blackpool Victoria Hospital
• Charing Cross Hospital
• Chelsea and Westminster Hospital
• Croydon University Hospital
• Hillingdon Hospital
• Homerton University Hospital
• King George Hospital
• King’s College Hospital
• Kingston Hospital
• Manchester Royal Infirmary
• Newham General Hospital
• North Manchester General Hospital
• Northwick Park Hospital
• Queens Hospital
• Royal Sussex County Hospital
• St George’s Hospital (Tooting)
• St Mary’s Hospital
• St Thomas’ Hospital
• The Royal London Hospital
• University Hospital Lewisham
• West Middlesex University Hospital
• Whittington Hospital
• Whipps Cross University Hospital
• Wythenshawe Hospital

Of the 24 sites above, the 3 sites excluded from BBV test uptake analysis with a lower number of tests when matched with ECDS are:

• Blackpool Victoria Hospital
• Chelsea and Westminster Hospital
• Whittington Hospital

The 5 sites excluded due to significant data incompleteness recording testing data in SSBBV preventing triangulation between data sources compared to NHSE dashboard data is:

• Ealing Hospital
• Epsom District Hospital
• Princess Royal University Hospital
• Queen Elizabeth Hospital
• St Helier Hospital

The 5 sites excluded as no SSBBV data was available:

• Barnet Hospital
• North Middlesex Hospital
• Royal Free Hospital
• University College Hospital
• Salford Royal Hospital

Due to data availability and limitations highlighted above numbers will differ between data indicators and data source. NHSE dashboard data compared with ECDS attendances, and the number of attendees compared to attendances reported through ECDS is available in Appendix Table 3. Finally, the number of ECDS attendees for the 21 sites covered by SSBBV is shown in Appendix Table 3. In SSBBV sites and SSBBV ECDS linked sites 60.4% and 59.6% had a blood test respectively.

The 28 London sites represented most (84.1%, 6,592,518) of attendances and attendees (83.1%, 3,239,070). The 21 sites used for testing uptake in SSBBV data represented 66% (5,211,274) of all attendances and 69.6 % (2,712,792) of attendees, of which 82.1% (4,276,422) of attendances were London based with 81.8% (2,218,017) attendees. The 24 SSBBV sites used for positivity analysis represented 72.5% (5,681,411) of all attendances and 75.7% (2,949,241) of all attendees with 80.4% (4,566,270) attendances and 80.0% (2361445) attendees from a London based site.

Appendix Table 3. Number of tests completed in the Programme by BBV

Activity	NHS Dashboard attendances (34 sites)	ECDS attendances (34 sites)	ECDS attendees (34 sites)	ECDS attendances (21 sites)	ECDS attendees (21sites)
Visits	7,661,938	7,840,697	3,895,593	5,211,274	2,712,792
Blood test	4,481,699 (58.5%)	4,247,489	2,359,458	2,806,977	1,617,762
Any BBV test	Not available	Not available	Not available	1,570,896 (56.0%)	1,120,329 (69.3%)
HIV test	2,781,164	Not available	Not available	1,517,592 (54.1%)	1,102,647 (68.2%)
HCV test	2,363,443	Not available	Not available	1,122,653 (40.0%)	851,747 (52.7%)
HBV test	1,989,161	Not available	Not available	901,889 (32.1%)	689,656 (42.6%)

Whilst the Programme of ED opt-out testing for BBVs was implemented in EDs with very high diagnosed HIV prevalence (more than 5 per 1,000 population aged 15 to 59 years), a whole city approach was taken for London. The distribution of sites for London are as follows.

The 11 sites in London that are in a local authority of very high HIV prevalence are:

• Charing Cross Hospital
• Chelsea and Westminster Hospital
• Croydon University Hospital
• Homerton University Hospital
• King’s College Hospital
• Newham General Hospital
• St Mary’s Hospital
• St Thomas’ Hospital
• The Royal London Hospital
• University Hospital Lewisham
• Whittington Hospital
• Northwick Park Hospital

The 7 included sites in London that are in a local authority of high HIV prevalence are:

• Hillingdon Hospital
• King George Hospital
• Kingston Hospital
• Northwick Park Hospital
• Queens Hospital
• St George’s Hospital (Tooting)
• Whipps Cross University Hospital

Analysis methods

To understand Programme outcomes, a descriptive approach was taken to summarise BBV testing, positivity and referral to care for each virus, with counts and proportions provided. Indicators were stratified by site and by individual demographics including gender, age, ethnic group, Index of Multiple Deprivation (IMD) quintile and risk group information. IMD is a residential area-level measure of socioeconomic status using the person’s postcode of residence. The first quintile (Q1) represents the most deprived 20% of lower super output areas (LSOAs), small geographical areas with 1,000 to 3,000 residents) and the fifth quintile (Q5) the least deprived 20% of LSOAs. Numbers describing newly and previously diagnosed people include those who experienced more than one infection within the programme, including coinfections and reinfections, an individual is only counted once.

ED attendances and attendees who had a blood test

Data is presented for all attendances and tests, and for all attendees (unique individuals) and individuals tested during the evaluation period.

To understand whether the Programme has been able to access people who experience inequalities in health and care access, the characteristics of people attending ED sites in the programme who were eligible for inclusion has been compared to the characteristics of the population who were resident within the local ICB areas where the Programme was implemented using ONS Census 2021 data.

HIV test positivity

People tested and diagnosed with HIV have been grouped according to their local authority of residence and mapped to a corresponding HIV diagnosed prevalence band based on data within Sexual and Reproductive Health Profiles. The HIV indicator used to assign prevalence bands was the HIV diagnosed prevalence rate per 1,000 for people aged 15 to 59 years. Local authorities have been grouped as very high (more than 5 per 1,000), high (2 to 5 per 1,000) and low diagnosed prevalence areas (less than 2 per 1,000).

Across the 24 Programme sites, 74.4% people had a postcode of residence available to assign a local authority prevalence band. People who were experiencing homelessness were assigned to an area of very high prevalence. With people grouped by their local authority HIV prevalence, HIV positivity was calculated based on the number of new diagnoses identified through the Programme divided by the total number of people tested.

Attendees testing positive (diagnosed)

The characteristics of people testing newly positive within the programme has also been compared to those newly positive outside of the programme within the same geographic region and timeframe. For HIV, data was obtained from HANDD and HARS and includes people diagnosed through: GPs, SHSs, drug services, prison services, antenatal services. For HCV and HBV, data was obtained using SSBBV from:  GPs, SHSs, drug services and prison services, and excluding antenatal screening for HBV.

HCV reinfection

In England, 3 criteria have been used to identify HCV reinfection, any one of which would establish a person as experiencing reinfection. Firstly, individuals with a positive HCV RNA test at least 196 days (28 weeks) after treatment start date among those with a SVR during their first treatment period. Secondly, a positive HCV RNA test at least 196 days (28 weeks) after treatment start date where an individual has had a negative HCV RNA test after being treated (used as a proxy for SVR where this has not been reported). Thirdly, a subsequent period of treatment after an initial SVR, and where this subsequent treatment period was at least 196 days after first treatment start date. Further work will aim to integrate data from NHSE’s Blueteq system into the methodology, and to explore reinfection among people who spontaneously cleared their primary infection without treatment.

It should be noted that there is no internationally agreed definition for defining hepatitis C reinfection and a different window period may be used to confirm SVR post treatment. For example, Scotland uses a negative test between 10 weeks and 12 months post treatment to confirm SVR. As we progress towards elimination of HCV as a public health threat, ongoing work across the UK will aim to harmonise definitions of reinfection where possible and utilise multiple methods, including the use of whole genome sequencing, to better understand reinfection.

HIV late diagnoses

The definition of late HIV diagnosis currently used in the UK is a CD4 count below 350

cells per mm3 of blood within 91 days of diagnosis, excluding those with evidence of recent infection. This evidence is either a negative test within the 24 months prior to their first positive HIV test, or the result of a Recent Infection Testing Algorithm (RITA), which combines serological recency test results with clinical data. Late diagnoses could not be established or defined for those who died prior to reaching care as there was no CD4 count recorded.

HCV late diagnoses

A late-stage hepatitis C diagnosis is defined as a presentation with HCC, ESLD and or a F4 score at diagnosis using data from the Arden and GEM NHSE Hepatitis C Patient Registry and Treatment Outcome System, HES and ONS mortality data on fibrosis score, ESLD and or HCC.

HBV late diagnoses

A late-stage HBV liver disease diagnosis is defined as a presentation with HCC and or ESLD using data from HES. Data from HES is an underestimate as clinical codes are only consistently reported for inpatient records and will therefore not capture patients who have not yet been assessed for liver disease or who are being managed with late-stage disease as an out-patient.

Testing opportunities

The testing opportunities for individuals diagnosed through the programme were assessed by linkage with ECDS to identify previous attendances to an ED and through individuals’ registration with a GP. Owing to differences in go-live dates, ED attendances for the year prior to the programme start (April 2021 to April 2022) were investigated. Some sites had prior opt-out testing schemes for HIV and sometimes HCV too, but this has not been accounted for when assessing previous testing opportunities.

HIV linkage to care

Linkage to HIV care was defined as attending an HIV clinic within a set follow-up period after the ED test, excluding those who died during that period or lacked sufficient time to be linked. For instance, someone tested in October 2024 was excluded from 3-month and 1-year linkage measures, as the Programme evaluation period ended in December 2024.

HCV linkage to care

Linkage to care within the Programme for people living with HCV was assessed using SSBBV data linked to NHS Blueteq records and the Arden and GEM NHSE Hepatitis C Patient Registry and Treatment Outcome System. Linkage to care was assessed after 6 months had passed to allow time for patients to be contacted and engaged into care as well as to account for delays in data completion.

Patient identifiable data submitted by SSBBV laboratories is variable, which limits the ability to link data sets. As individuals are followed through the care pathway, the denominator is updated to exclude people who have died or who have evidence of spontaneous clearance.

Treatment outcomes for HCV could be any of:

• SVR reported
• not responding to treatment
• lost to follow-up
• did not commence treatment
• relapse (achieved clearance of virus during treatment but became HCV RNA positive again in the post-treatment period)
• breakthrough (achieved clearance of virus during treatment but became HCV RNA positive again during treatment)

Whilst surveillance data provides an opportunity to monitor the proportion of people who attend for care, it does not capture the effort made by teams, including peers, to contact a person to discuss their diagnosis and (re) engage them into care. Local data available from sites is used to bridge this gap.

Acknowledgements

Report produced by the UKHSA public health evaluation group: Tom Clare, Eloise Cross, Monica Desai, Tamara Đjuretić, James Lester, Holly Mitchell, Sema Mandal, Victoria Schoemig, Ruth Simmons.

We would like to gratefully acknowledge the expert review and advice received from colleagues in the Public Health and Implementation Evaluation group which includes colleagues from UKHSA, NHSE and University of Bristol, the ED opt-out testing Advisory Group and the ED opt-out testing Operational Group.

We would also like to thank the clinical advisory group for their expert advice and interpretation of the findings and presentation of the data: Ashley Brown, Ian Cormack, Matthew Foxton, Rachel Hill-Tout, Douglas MacDonald, Nicola Mackie, Stuart Smith, Javier Vilar, and Laura Waters. Furthermore, thank you to the teams who provided local data from site-specific studies for the evaluation in the absence of surveillance data, in particular: James Attridge-Smith, Ashley Brown, Fergus Daly, Dan Forton, Rachel Hill-Tout, Kartikeya Khanna, and Douglas MacDonald.

We are extremely grateful to all the teams involved in managing and delivering the services and programmes outlined in this report, and in evaluating the Programme. We would like to acknowledge and thank the staff who work at each of the 34 Programme sites and in the laboratories who contribute to the laboratory surveillance of each BBV and SSBBV.

Finally our thanks go to the report contributors: Alison Brown, Ashley Brown, Tom Clare, Eloise Cross, Peter Dearman, Monica Desai, Tamara Đuretić, Beatrice Emmanouil, Mark Gillyon-Powell, Rachel Hill-Tout, Matthew Hibbert, Stephen Hindle, Samreen Ijaz, Ian Jackson, David Leeman, James Lester, Kathy Lowndes, Sema Mandal, Veronique Martin, Priya Meghani, Holly Mitchell, Debbie Mou, Sarah Murdoch, Celia Penman, Annabel Powell, Rajani Raghu, Rachel Roche, Victoria Schoemig, Ruth Simmons, Nicola Spencer, Georgia Threadgold.

The project was supported by NIHR HPRU in behavioural science and evaluation at University of Bristol, with a partnership between UKHSA and the University of Bristol. The views expressed are those of the author and not necessarily those of NIHR, Department of Health and Social Care or UKHSA.

Suggested citation

Public health evaluation of BBV opt-out testing in EDs in England, 33-month final report 2025. October 2025. UKHSA, London.

For queries relating to this document, please contact: hepatitis@ukhsa.gov.uk