The numbers of patients tested for BBVs during the initial nine months of this testing pathway are displayed in Fig. 1. Testing uptake for ≥ 1 BBV was 60.4%. 60.1% of eligible patients were tested for HIV, 58.2% were tested for HBV and 58.3% were tested for HCV.
Flow of patients through the BBV testing pathway within the ED testing programme.
Detection of active infections
HIV Ab/Ag prevalence was 0.41% (95% CI 0.32-0.52), HBsAg prevalence was 0.44% (95% CI 0.36-0.57) and HCV RNA-positive prevalence was 0.95% (95% CI 0.80-1.10). Coinfection prevalence was low (HIV/HBV: 0.02% (n = 3); HIV/HCV 0.01% (n = 2); HBV/HCV: 0.01% (n = 1)). For all three BBVs, the prevalence was higher in males and among individuals aged between 30 and 49 years (Table 1). BBV prevalence was significantly higher in males than females for viral hepatitis, but not HIV. The ethnicity profiles varied considerably between different BBVs but these differences were not significant, except between HCV RNA-positive and HIV Ab/Ag positive (p= < 0.01 patients). While the vast majority of HCV RNA-positive patients were White British, the majority of diagnosed HIV and HBV infections were from minority ethnic groups.
Linkage to care
There was a statistically significant difference between the proportion of patients requiring LTC across all three BBVs (p< 0.01) and when comparing each combination of BBV separately (p< 0.01 for each of HIV vs HCV, HIV vs HBV, HBV vs HCV). Almost all patients testing positive for HCV-RNA required LTC (94.9%, 95% CI 90.0–97.4%), compared to approximately one half of HBsAg-positive patients (53.4%, 95% CI 41.7–64.8%) and only one quarter of HIV Ab/Ag positive patients (24.3%, 95% CI 15.5–36.0%) (Table 2). 46.2% (95% CI 38.4–54.1%) of HCV RNA-positive patients who required LTC had been known to specialist services but were not currently in care compared to fewer than one-third of HIV Ab/Ag or HBsAg-positive patients. Eleven (7.0%, 95% CI 3.9–12.4%) HCV RNA-positive patients had previously been diagnosed with HCV but were not known to specialist services.
HIV
The majority of HIV Ab/Ag positive patients requiring LTC were male (64.7%, 95% CI 37.7–84.8%, n=11), with a median age of 46 (range: 16–64 years). Eight (47.1%, 95% CI 23.5–72.0%) were White British, 6 (35.3%, 95% CI 15.2–62.3%) were Black British or Black other and 3 (17.6%, 95% CI 5.1–46.3%) were White other (including Irish). Neither age, sex nor ethnicity were crudely associated with requiring LTC. The median CD4 count for patients requiring LTC was 99 (range 1–593) and more than two-thirds of these patients (64.7%, n = 11) were diagnosed with advanced disease (CD4 cell count < 200 cells/mm3)25. Just under two-thirds of patients requiring LTC were thought to have acquired HIV through heterosexual sex (58.8%, 95% CI 32.7–80.7%, n = 10), with approximately one-third occurring in men who have sex with men (35.3 %, 95% CI 15.2–62.3%, n=6).
HBV
Of HBsAg-positive patients requiring LTC, 71.8% (95% CI 55.1–84.1%, n=28) were male and the median age was 39 (range 19–63 years). Just 2.6% (95% CI 0.3–17.4%, n=1) were White British. Approximately half (48.7%, 95% CI 33.0–64.7%, n=19) of these individuals were White other (including Irish), 30.8% (95% CI 17.9–47.5%, n=12) were Black British or Black other , 10.3% (95% CI 3.7–25.2%, n=4) were Mixed or any other ethnicity, 7.7% (95% CI 2.4–22.2%, n=3) were Asian British or Asian other. Again, neither age, sex nor ethnicity were crudely associated with requiring LTC (all p> 0.05). Most HBsAg-positive patients requiring LTC were from an area of high prevalence (HBsAg prevalence of more than 8%26) (87.2%, 95% CI 71.8–94.8%, n = 34).
HCV
As with HIV and HBV, the majority of HCV RNA-positive patients requiring LTC were male (73.6%, 95% CI 65.9–80.2%, n = 109), with a median age of 41 (interquartile range (IQR) = 35— 48). In contrast to HIV and HBV, 87.8% (95% CI 81.4–92.2%, n=130) were White British, 9.4% (95% CI 5.6–15.4%, n=14) were White other (including Irish), 1.4 % (95% CI 0.3–5.3%, n = 2) were Black British or Black other, 0.7% (95% CI 0.1–4.7%, n = 1) were of Mixed ethnicity and a further 0.7% (95% CI 0.1 –4.7%, n = 1) were Asian British or Asian other. As with the other BBVs, neither age, sex or ethnicity were crudely associated with requiring LTC (all p> 0.05). The majority of RNA-positive patients were a current person who injected drugs (PWIDs) (56.8%, 95% CI 48.6–64.6%, n = 84), while a further quarter had previously injected drugs (25.7%, 95% CI 19.2 -33.4%, n = 38).
Linkage to care pathways
HIV
16/17 (94.1%, 95% CI 62.7-99.3%) HIV Ab/Ag positive patients were successfully linked to care (Fig. 2A). 5/17 HIV Ab/Ag positive patients diagnosed within the ED (29.4%, 95% CI 11.5–57.1%) were known to specialist services but not in care at the time of their ED visit; four of these five patients (80.0%, 95% CI 11.1–99.21%) successfully linked to care. All those newly diagnosed in ED were linked to care.
The care continuum within six months following diagnosis of (A) HIV infection, (B) HBV infection, and (C) HCV infection in the ED. Percentages shown use the number of patients requiring linkage to care as the denominator.
Twelve (70.6%, 95% CI 42.9–88.5%) patients linked to care commenced antiretroviral treatment (ARVs) within six months; of the remaining four individuals, three were known to specialist services but had previously disengaged. Eleven patients (64.7%, 95 CI 37.7–84.8%) achieved viral suppression (HIV viral load < 200 copies/mL) within six months on treatment. One patient died before completing six months on ARVs.
HBV
27 of 39 HBsAg-positive patients (69.2%, 95% CI 52.5-82.1%) were successfully linked to care (Fig. 2B). Of the twelve patients not linked, four (33.3%, 95% CI 10.9–67.1%) lived out of area, seven (58.3%, 95% CI 26.7–84.3%) were newly diagnosed with HBV for the first time within the ED and one (8.3%, 95% CI 0.8–50.1%) was known to specialist services but had previously disengaged. Three of the 27 individuals (11.1%, 95% CI 3.3–31.1%) who were successfully linked to care had previously been linked to care but had disengaged by the time of their ED attendance, and were therefore re-engaged because of their ED testing.
HCV
Only 58 of 148 patients requiring LTC (39.2%, 95% CI 31.6–47.4%) were seen in clinic or as an inpatient (Fig. 2C). In total, one quarter (25.0%, 95% CI 18.6–32.7%, n=37) of HCV RNA-positive patients requiring LTC commenced treatment within six months following ED diagnosis. LTC rates were lower for current PWIDs compared to those who did not currently inject drugs (X2 (1,148)= 4.15, p= 0.04). The only factor crudely associated with commencing treatment was PWID status, with current PWIDs being significantly less likely to start treatment than those not currently not using drugs (odds ratio = 0.11, 95% CI 0.03–0.36, p< 0.001).
Two-thirds (64%, n = 58) of those patients who did not engage with treatment within six months were current PWIDs. In contrast, current PWIDs were underrepresented within the population who successfully commenced treatment, with only 29.7% (95% CI 16.8–47.0%) of those starting treatment being current PWIDs despite 56.8% (95% CI 48.6–64.6%) of those requiring LTC having this risk factor for infection. A further 18 patients were LTC by 12 months following diagnosis, with 4 of these patients starting treatment.
Of the 37 patients who commenced treatment for active HCV within six months of their ED diagnosis, 22 (59.5%, 95% CI 42.4–74.5%) had a sustained viral response (SVR) at 12 weeks post-treatment. Just two patients (5.4%, 95% CI 1.3–20.3%) were considered to have experienced true treatment failure. The other thirteen patients (35.1%, 95% CI 21.1–52.4%) were either lost to follow-up (n = 11) or failed to comply with treatment (n = 2).
mortality
Nine BBV-positive patients died during the evaluation period: seven HCV RNA-positive and two HIV Ab/Ag positive patients, all of whom required LTC. Both HIV Ab/Ag positive patients died from HIV-related complications and were new diagnoses with CD4 < 100 at the time of their ED visit. The cause of death for all six HCV RNA-positive patients was not related to their HCV diagnosis.