A groundbreaking opt-out testing programme for blood-borne viruses at the emergency department at Nottingham University Hospitals NHS Trust has uncovered dozens of previously undiagnosed cases since its launch. HIV specialist Dr Ashini Fox and colleagues explain how the initiative is improving early detection, breaking down stigma and linking patients to vital treatment – all crucial steps in the drive to end new HIV transmissions by 2030.
Early diagnosis of HIV, hepatitis B (HBV) and hepatitis C (HCV) is vital in improving health outcomes for people living with these conditions. As the infections can be asymptomatic during the early stages, testing is often the only way of detecting them before someone becomes seriously unwell or transmits the virus to others.
On World AIDS Day 2021, the UK Government agreed a £20 million investment to expand opt-out HIV testing in emergency departments (EDs) as part of their commitment to achieve zero new HIV infections by 2030. In April 2022, the programme began in areas of ‘very high’ HIV prevalence, including 34 EDs in London, Manchester, Blackpool and Brighton.
It then expanded to include HCV and HBV testing as part of the HCV Elimination programme. ED testing proved highly successful in finding those living with an undiagnosed blood-borne virus (BBV) and linking those previously diagnosed but lost to follow-up back into care.
The HIV and hepatitis clinical teams at Nottingham University Hospitals NHS Trust (NUH) were keen to implement this initiative locally and actively sought funding. In 2024, the ED testing programme was extended to an additional 47 sites across England in areas of ‘high’ HIV prevalence. NUH was the first of these ‘second wave’ sites to go live on 30 July 2024.
How does the BBV testing programme work?
Standardising testing removes the implication that someone is being singled out due to a specific identity or risky behaviour. It helps to reduce fear and fosters a more informed and supportive culture around testing. It helps to reduce stigma by making testing normal, non-judgmental and health-focused rather than targeted or judgment-based.
Every adult patient attending the ED who requires a blood test as part of their care is automatically screened for HIV, HBV and HCV unless they choose to opt out. No additional sampling is required as the screening uses the same blood being taken for other clinical purposes. Information about the testing is clearly displayed throughout the ED in multiple formats and languages, and verbal explanations are provided for partially sighted patients.
A clinical nurse specialist oversees the process, managing all results and directly contacting anyone with a positive or indeterminate result to arrange appropriate follow-up care. Patients who return to the ED within 12 months of a previous BBV screen are not retested unless there is a clinical reason to do so.
In addition to clinical nursing support, this project requires a multispecialist, multidisciplinary effort. It involves members from sexual health (HIV), hepatology, emergency medicine, research, microbiology, digital services, pathology IT and external partners. A steering group originally met weekly and now meets monthly, and education sessions were delivered to ED nurses, advanced clinical practitioners and doctors to introduce the project and increase knowledge around BBVs. Regular communication between these teams keeps the programme running smoothly and addresses any challenges that arise.
A significant success story so far
Some 151 BBV screens were carried out on the first day of the testing programme at NUH. Now, more than 43,445 BBV tests have been completed, with an average uptake of 82% among eligible patients.
As of 14 May 2025, the initiative has identified 70 new BBV diagnoses: 16 cases of HIV, 33 of HBV and 21 of HCV. Of these, 62 individuals – including all the individuals who are HIV positive – have been successfully linked to specialist care and, where appropriate, have started treatment. With earlier diagnosis comes the opportunity for earlier intervention, significantly improving long-term health outcomes. Efforts to engage the remaining eight individuals is ongoing.
Through partner notification following the 16 HIV diagnoses, a further three individuals who were previously unaware of their status have also been diagnosed and supported into specialist care. Additionally, 21 people with a prior BBV diagnosis who had been lost to follow-up have been re-identified and reconnected with care services.
Beyond individual diagnoses, the programme has helped foster a culture of prevention and awareness around BBVs across the Trust and within the wider community. Promotional efforts have opened doors to present at the board level and across various clinical specialties. This has offered the chance to challenge misconceptions and stigma commonly associated with these viruses and highlight the benefits of integrating BBV testing into routine care for all patients and their community.
The challenges of opt-out BBV testing implementation
Implementing the programme has not been without challenges. The ED operates under significant pressure, with staff working exceptionally hard to deliver patient care. Introducing a change to service in this demanding environment requires patience and a clear understanding of staff priorities. High staff turnover and reliance on agency and locum personnel could make sustained engagement and enthusiasm challenging. However, regular education sessions and support from senior ED nurses helped to address this.
Implementing a large-scale programme like this also presents the challenge of coordinating multiple teams with different priorities. The screening coordinator nurse sits centrally to ensure all teams are working towards the same objective and assists in supporting patient pathways for follow-up care. Any logistical difficulties, such as changes to IT systems, could have led to stalls in the project, but with collaborative teamwork, these have been prevented.
Implementing opt-out BBV testing in the ED requires close collaboration between specialties and secure, sustainable funding. For organisations looking to introduce similar programmes, a key first step would be fostering joint working between HIV and hepatitis teams to pool expertise and resources. At NUH, creating a dedicated coordinator role, spanning both specialties, has been particularly effective. This role not only ensures timely follow-up of results but also acts as a visible project champion within the fast-paced ED environment, helping embed the programme into routine care and drive its ongoing success.
Patient and community impact of opt-out BBV testing
The programme is well received by patients, and many have expressed gratitude for being tested. Most attended the ED for a problem unrelated to their undiagnosed BBV, and so although a new diagnosis may have come as a shock, it proved to be an opportunity to prevent ill health and for their partners to get tested, too. Any concerns or queries are directed to the screening coordinator nurse specialist, who addresses them sensitively.
Each person with a positive BBV result is followed up by a clinical nurse specialist who supports them with their diagnoses, provides essential information and rapidly links them to the appropriate specialty for full assessment, further support and treatment initiation. Ongoing support is also offered through peer support services, such as tHrIVe Support Group or the Hepatitis C Trust.
While it is a little too early to fully assess the programme’s impact on the wider community, we do know that the East Midlands has some of the highest rates of late-stage HIV diagnosis in the country. By identifying infections earlier, the programme aims to reduce the number of late diagnoses, ultimately leading to better health outcomes, lower morbidity and mortality and less pressure on primary and secondary care services.
Without early detection, many of these individuals may have progressed to becoming immunocompromised and seriously unwell, requiring more intensive treatment and support. The National Institute for Health and Care Excellence has previously estimated that the health economic costs of each subsequent year for a person with a late diagnosis of HIV are approximately 50% greater than those of someone with an early diagnosis.
The surprising number of HBV infections that we have uncovered highlights the need for improvements in national policy on how testing and treatment for these patients are coordinated and funded.
Conclusion
NUH’s ED opt-out BBV testing programme has made a measurable impact, identifying 70 people, at the time of writing, living with undiagnosed HIV, HBV and HCV, many of whom would likely not have been tested through conventional routes.
The initiative has enabled rapid access to treatment and support and helped normalise BBV testing within emergency care.
By embedding routine screening into everyday practice and reducing stigma around diagnosis, the programme is not only saving lives but also changing the culture of care. With continued support, this model holds the potential to contribute to national goals of ending new HIV transmissions and improving health outcomes for all affected by BBV.
Authors
Ashini Fox FRCP
Consultant in sexual health
Molly Hansell RN BSc
ED BBV opt-out screening coordinator and clinical nurse specialist
Sarah Montague MSc
Hepatitis C operational delivery network manager
All of Nottingham University Hospitals Trust, UK
Tommy Morton
East Midlands hepatitis C data manager
Acknowledgements
With thanks to:
The Nottingham University Hospitals ED Opt-out Steering group
Patients and staff at the Nottingham University Hospitals Trust Emergency Department
