Research and analysis

Appendix for emergency department bloodborne virus opt-out testing: 12-month interim report 2023

Published 9 November 2023

Applies to England

Appendix 1: site list and go live dates

Table A1. Site list and go live dates

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

Notes for table

Note 1: Ealing laboratory reports to sentinel surveillance of bloodborne virus testing (SSBBV) but does not identify the setting of test, so it was not possible to identify tests done in emergency department (ED) for this evaluation.

Note 2: data flow from Manchester laboratory has been paused due to changes to their laboratory information system (LIMS).

Appendix 2: methodology details

Logic models

Figure A1. Accident and emergency (A&E) opt out bloodborne virus (BBV) testing HIV logic model flowchart

Accessible text description of Figure A1 HIV logic model flowchart: aligning programme activities, outputs, and outcomes for long-term impact.

Programme activities:

1. Opt-out literature.

2. Performing opt-out HIV tests in A&E. Lead to programme outputs via:

• number and percentage of initial HIV tests conducted
• number and percentage of confirmatory HIV tests conducted
• HIV patients referred to treatment services

3. Dynamic system optimisation.

4. Staffing training and education. Both lead to programme outputs via:

• staff training sessions delivered

5. Partner notification and screening of contacts of HIV positive patients (limited data available). Leads to programme outputs via:

• number and percentage of initial HIV tests conducted
• contacts of diagnosed patients receiving HIV testing

Programme outputs:

1. Number and percentage of initial HIV tests conducted, and number and percentage of confirmatory HIV tests conducted. Leads to programme outcomes via:

• total confirmed HIV test results (total and new)

2. HIV patients referred to treatment services. Leads to programme outcomes via:

• total patients accessing treatment and achieving viral suppression

3. Contacts of diagnosed patients receiving HIV testing (limited data available). Leads to programme outcomes via:

• total confirmed HIV test results (total and new)
• increased provision of HIV testing and education of staff and patients on HIV

4. Staff training sessions delivered. Leads to programme outcomes via:

• increased provision of HIV testing and education of staff and patients on HIV

5. Data reporting of demographics of risk factors of patients receiving HIV tests. Leads to programme outcomes via:

• improved data on demographics and risk factors of HIV positive patients

Programme outcomes:

1. Total confirmed HIV test results (total and new). Leads to long-term outcomes (2025 HIV Action Plan):

• 80% reduction in the number of people first diagnosed in England (2,860 in 2019 to less than 600)
• 50% reduction in the number of people diagnosed with AIDS within 3 months of HIV diagnosis (219 to less than 110)

2. Total patients accessing treatment and achieving viral suppression. Leads to Long-term outcomes (2025 HIV Action Plan):

• 50% reduction in the number of people diagnosed with AIDS within 3 months of HIV diagnosis (219 to less than 110)
• 50% reduction in deaths from HIV and AIDS (230 to less than 115)

3. Increased provision of HIV testing and education of staff and patients on HIV. Leads to long-term outcomes (2025 HIV Action Plan):

• 50% reduction in deaths from HIV and AIDS (230 to less than115)
• reduce stigma

4. Improved data on demographics and risk factors of HIV positive patients. Leads to long-term outcomes (2025 HIV Action Plan):

• reduce stigma

Long-term outcomes (2025 HIV Action Plan):

1. 80% reduction in the number of people first diagnosed in England (2,860 in 2019 to less than 600). Links to long-term outcomes (2030 Joint United Nations Programme on HIV and AIDS (UNAIDS) targets): zero new HIV transmissions.

2. 50% reduction in the number of people diagnosed with AIDS within 3 months of HIV diagnosis (219 to less than 110).

3. 50% reduction in deaths from HIV or AIDS (230 to less than 115). Both link to long-term outcomes (2030 UNAIDS targets): zero AIDS-related deaths.

4. Reduce stigma. Links to long-term outcomes (2030 UNAIDS targets): zero discrimination.

Figure A2. Accident and emergency (A&E) opt out bloodborne virus (BBV) testing hepatitis C virus (HCV) logic model flowchart

Accessible text description of Figure A2 HCV logic model: aligning programme activities, outputs, and outcomes for long-term impact.

Programme activities:

1. Opt-out literature.

2. Performing opt-out HCV tests in A&E. Lead to programme outputs via:

• number and percentage of HCV antibody tests conducted
• number and percentage of HCV ribonucleic acid (RNA) tests conducted (including % reflex)
• HCV patients referred to treatment services
• data reporting of demographics and risk factors of patients receiving HCV test

3. Dynamic system optimisation.

4. Staffing training and education. Both lead to programme outputs via:

• staff training sessions delivered

5. Contact tracing and screening of contacts of HCV positive patients (limited data available). Leads to programme outputs via:

• number and percentage of HCV antibody tests conducted
• contacts of diagnosed patients screened

Programme outputs:

1. Number and percentage of HCV antibody tests conducted, and number and percentage of HCV Ribonucleic acid (RNA)  tests conducted (including % reflex). Leads to programme outcomes via:

• total HCV diagnosis made results (total, new, and reinfections)

2. HCV patients referred to treatment services. Leads to programme outcomes via:

• total patients accessing and completing treatment

3. Contacts of diagnosed patients screened (limited data available). Leads to programme outcomes via:

• total HCV diagnosis made (total, new, and reinfections)
• increased provision of HCV testing and education of staff and patients on viral hepatitis

4. Staff training sessions delivered. Leads to programme outcomes via:

• increased provision of HCV testing and education of staff and patients on viral hepatitis

5. Data reporting of demographics and risk factors of patients receiving HCV tests. Leads to programme outcomes via:

• improved data on demographics and risk factors of HCV positive patients

Programme outcomes:

1. Total HCV diagnosis made (total, new, and reinfections). Leads to long-term outcomes (HCV 2022 report recommendations) via:

• increasing case finding and the proportion diagnosed

2. Total patients accessing and completing treatment. Leads to Long-term outcomes (HCV 2022 report recommendations) via:

• increasing the numbers accessing and completing HCV treatment

3. Increased provision of HCV testing and education of staff and patients on viral hepatitis. Leads to long-term outcomes (HCV 2022 report recommendations) via:

• increasing the numbers accessing and completing HCV treatment
• strengthening a person-centred, holistic approach to hepatitis

4. Improved data on demographics and risk factors of HCV positive patients. Leads to long-term outcomes (HCV 2022 report recommendations) via:

• strengthening a person-centred, holistic approach to hepatitis
• making improvements and monitoring metrics

Long-term outcomes (HCV 2022 report recommendations):

1. Increasing the numbers accessing and completing HCV treatment. Leads to long-term outcomes (World Health Organisation (WHO) elimination targets):

• less than or equal to 5 new HCV infections per 100,000 in adult population per year
• less than or equal to 2 new HCV infections per 100 in people who inject drugs (PWID) population per year
• more than or equal to 80% of people with chronic HCV infection starting treatment in last 12 months
• less than or equal to 2 new HCV-related deaths per 100,000 population per year

2. Increasing case finding and the proportion diagnosed.

3. Strengthening a person-centred, holistic approach to hepatitis.

4. Making improvements and monitoring metrics. All lead to long-term outcomes (WHO elimination targets) via:

• more than or equal to 90% of people with chronic HCV infection diagnosed
• more than or equal to 80% of people with chronic HCV infection starting treatment in last 12 months

Figure A3. Accident and emergency (A&E) opt out bloodborne virus (BBV) testing hepatitis B virus (HBV) logic model flowchart

Accessible text description of Figure A3 HBV logic model flowchart: aligning programme activities, outputs, and outcomes for long-term impact.

Programme activities:

1. Opt-out literature.

2. Performing opt-out HBV tests in A&E. Lead to programme outputs via:

• number and percentage of HBV tests conducted
• HBV patients referred to treatment services
• data reporting of demographics and risk factors of pts receiving HBV test

3. Dynamic system optimisation.

4. Staffing training and education. Both lead to programme outputs via:

• staff training sessions delivered

5. Contact tracing and screening of contacts of HBV positive patients (limited data available). Leads to programme outputs via:

• number and percentage of HBV tests conducted
• contacts of diagnosed patients screened

Programme outputs:

1. Number and percentage of HBV tests conducted. Leads to programme outputs via:

• total HBV diagnosis made (total, new)

2. HBV patients referred to treatment services. Leads to programme outcomes via:

• total patients accessing and engaging with treatment

3. Contacts of diagnosed patients screened (limited data available). Leads to programme outcomes via:

• total HBV diagnosis made (total, new)
• increased provision of HBV testing and education of staff and patients on viral hepatitis

4. Staff training sessions delivered. Leads to programme outcomes via:

• increased provision of HBV testing and education of staff and patients on viral hepatitis

5. Data reporting of demographics and risk factors of patients receiving HBV tests. Leads to programme outcomes via:

• improved data on demographics of HBV positive patients

Programme outcomes:

1. Total HBV diagnosis made (total, new). Leads to long-term outcomes (WHO elimination targets):

• more than or equal to 90% of people with chronic HBV infection diagnosed

2. Total patients accessing and engaging with treatment. Leads to long-term outcomes (WHO elimination targets):

• less than or equal to 100 new HBV-related deaths per 100,000 live births per year
• more than or equal to 80% of people diagnosed with chronic HBV infection and eligible receiving treatment
• less than or equal to 4 HBV-related deaths per 100,000 population per year

3. Increased provision of HBV testing and education of staff and patients on viral hepatitis. Leads to long-term outcomes (WHO elimination targets):

• more than or equal to 80% of people diagnosed with chronic HBV infection and eligible receiving treatment

4. Improved data on demographics of HBV positive patients. Leads to long-term outcomes (WHO elimination targets):

• more than or equal to 90% of people with chronic HBV infection diagnosed

Appendix 2A: evaluation questions table

Table A2. Evaluation questions

Category	Number	Question
Overall effectiveness	1	What is the effectiveness of the ED opt-out BBV testing programme in detecting new HIV, HBV, HCV diagnoses?
Diagnosis	1a	What are the characteristics of individuals who are newly diagnosed with HIV, HBV, HCV?
Diagnosis	1b	What are the characteristics of individuals who are newly diagnosed with HIV, HBV, HCV through ED testing compared to those who are newly diagnosed through other case finding interventions (for example drugs services, antenatal, prisons, sexual health, primary care)?
Overall	2a	What is the contribution of ED testing to hepatitis elimination targets and HIV action plan?
Overall	2b	What is the diagnosed prevalence of HIV, HBV, HCV?
Overall	2c	What is the previously undiagnosed burden identified through ED?
Overall effectiveness	4	Is the programme equitable across different populations?
Testing	4a	What are the characteristics of the population being tested as part of the ED opt-out testing programme?
Testing	4b	Are those being tested representative of the ED attending population?
Overall	4c	What does the care cascade from ED look like and what are the reasons for drop-off at each point?
Treatment	7	Are those testing positive being appropriately and promptly linked into the treatment and care pathway?
Treatment	7a	Is the programme effective at re-engaging those previously diagnosed but not retained in care?
Treatment	7b	Is the programme effective at engaging those newly diagnosed through ED with care?
Treatment	7c	How does the time taken to link those diagnosed in ED into treatment and care compare to those diagnosed via other routes?

Appendix 2B: indicator definitions and values

Table A3. Indicator definitions and values

Indicator	Numerator	Denominator	Coverage	Evaluation data	Programme data definition	Programme data
1a. Proportion of attendances where a blood test was done as part of the ED attendance	Number of attendances to ED where a blood test was carried out (source: emergency care data set (ECDS))	Number of attendances to ED (source: ECDS)	All sites	54% (1,320,878 out of 2,464,160)	ED attendances with blood tests (denominator: adults attending ED)	53% (1,477,482 out of 2,791,968)
1b. Proportion of attendees receiving a blood test in ED	Number of patients attending ED who have a blood test (source: ECDS)	Number of patients attending ED (source: ECDS)	All sites	58% (934,466 out of 1,613,699)	Not reported	Not reported
2a. Proportion of eligible patients (attendees with a blood test) who have an HIV test	Number of patients attending ED who have an HIV (source: sentinel surveillance of bloodborne virus testing (SSBBV) linked to ECDS attendances)	Number of patients attending ED who have a blood test according to HIV go live dates (source: ECDS)	5 SSBBV sites	49% (83,574 out of 169,033)	Proportion of attendances with blood tests where an HIV test was done (denominator: ED attendances with blood tests)	58% (857,117 out of 1,477,482)
2b. Proportion of eligible patients (attendees with a blood test) who have an HCV test	Number of patients attending ED who have an HCV test (source: SSBBV linked to ECDS attendances)	Number of patients attending ED who have a blood test according to HCV go live dates (source: ECDS)	5 SSBBV sites	46% (60,275 out of 132,366)	Proportion of attendances with blood tests where an HCV test was done (denominator: ED attendances with blood tests)	32% (473,723 out of 1,477,482)
2c. Proportion of eligible patients (attendees with a blood test) who have an HBV test	Number of patients attending ED who have an HBV test (source: SSBBV linked to ECDS attendances)	Number of patients attending ED who have a blood test (source: ECDS)	5 SSBBV sites	46% (58,128 out of 127,438)	Proportion of attendances with blood tests where an HBV test was done (denominator: ED attendances with blood tests)	26% (366,722 out of 1,477,482)
3a. Proportion of all attendees who have had a HIV test	Number of patients attending ED who have a HIV test (source: SSBBV linked to ECDS attendances)	Number of patients attending ED (source: ECDS)	5 SSBBV sites	26% (85,995 out of 332,997)	Proportion of attendances where an HIV test was done (denominator: adults attending ED)	31% (857,117 out of 2,791,968)
3b. Proportion of all attendees who have had an HCV test	Number of patients attending ED who have an HCV test (source: SSBBV linked to ECDS attendances)	Number of patients attending ED (source: ECDS)	5 SSBBV sites	24% (61,719 out of 259,791)	Proportion of attendances where an HCV test was done (denominator: adults attending ED)	17% (473,723 out of 2,791,968)
3c. Proportion of all attendees who have had an HBV test	Number of patients attending ED who have an HBV test (source: SSBBV linked to ECDS attendances)	Number of patients attending ED (source: ECDS)	5 SSBBV sites	24% (59,566 out of 249,917)	Proportion of attendances where an HBV test was done (denominator: adults attending ED)	13% (366,722 out of 2,791,968)
4a. Confirmatory testing rate for HIV	Number of attendees who test positive for HIV who have a follow up confirmatory test	Number of attendees who test positive for HIV	Not currently available	Not currently available	Not reported	Not reported
6a. Proportion of attendees who have new diagnoses for HIV	Number of attendees with a positive HIV test result that was before, or within a month after the date of diagnosis in HIV and AIDS Reporting System (HARS) (source: SSBBV linked to ECDS and HARS)	Number of attendees that had an HIV test (source: SSBBV linked to ECDS)	5 SSBBV sites	0.06% (48 out of 83,574)	Proportion of new HIV diagnoses (denominator: HIV tests performed)	0.04% (341 out of 857,117)
7a. Proportion of attendees who test positive for HIV	Number of attendees with a positive HIV test result (source: SSBBV linked to ECDS and HARS)	Number of attendees that had an HIV test (source: SSBBV linked to ECDS)	5 SSBBV sites	0.9% (742 out of 83,574)	HIV total true positive tests (denominator: HIV tests performed)	0.6% (5,068 out of 857,117)
4b. HCV RNA testing for current infection	Number of patients who had an HCV RNA test (source: SSBBV)	Number of patients who had a positive HCV antibody test (source: SSBBV)	16 SSBBV sites	84% (891 out of 1,066)	HCV RNA tests performed	9850 (proportion not available)
5. Proportion of HCV RNA tests done as reflex testing	Number of patients who had an HCV RNA test within 6 days of their positive HCV antibody test (source: SSBBV)	Number of patients who had an HCV RNA test (source: SSBBV)	16 SSBBV sites	91% (814 out of 891)	Not reported	Not reported
6b. Proportion of attendees who have new diagnoses for current (RNA positive) HCV infection	Number of attendees with a positive HCV RNA test result and no recorded past positive HCV test result or past record of initiating HCV treatment (source: SSBBV linked to ECDS, Second Generation Surveillance System (SGSS) and the Arden and GEM HCV treatment register)	Number of attendees that had an HCV (antibody, antigen or RNA) test (source: SSBBV linked to ECDS)	5 SSBBV sites	0.1% (67 out of 60,275)	Patients with a positive Hepatitis C RNA (new diagnosis) (denominator: HCV tests performed)	0.1% (499 out of 473,723)
7b. Proportion of patients who are diagnosed with current (RNA positive) HCV infection	Number of attendees with a positive HCV RNA test result	Number of attendees that had an HCV (antibody, antigen or RNA) test (source: SSBBV linked to ECDS)	5 SSBBV sites	0.2% (139 out of 60,275)	Positive Hepatitis C RNA tests (denominator: HCV tests performed)	0.2% (751 out of 473,723)
6c. Proportion of attendees that have a new HBV diagnosis	Number of attendees with a positive hepatitis B surface antigen (HBsAg) test result and no recorded past positive HBsAg test result (source: SSBBV linked to ECDS and SGSS)	Number of attendees that had a HBsAg test (source: SSBBV linked to ECDS)	5 SSBBV sites	0.5% (269 out of 58,128)	HBV new diagnoses (denominator: HBV antigen tests performed)	0.3% (1,143 out of 366,722)
7c. Proportion of attendees that test positive for HBV	Number of attendees with a positive HBsAg test result (source: SSBBV linked to ECDS)	Number of attendees that had a HBsAg test (source: SSBBV linked to ECDS)	5 SSBBV sites	1.1% (633 out of 58,128)	Positive hepatitis B surface antigen (HBVsAg) (denominator: HBV antigen tests performed)	0.7% (2,454 out of 366,722)
11a. Proportion of people previously diagnosed with HIV and not currently in care who were linked to care	Number of attendees who had a positive test for HIV and were linked to a previous record in HARS and had no record of a HIV care appointment in the 15 months before their positive test in ED, who were linked to an attendance in HARS within 30 or 90 days after their positive test in ED (source: SSBBV linked to ECDS and HARS)	Number of attendees who had a positive test for HIV and were linked to a previous record in HARS and had no record of a HIV care appointment in the 15 months before their positive test in ED (source: SSBBV linked to ECDS and HARS)	16 SSBBV sites	27% (16 out of 59)	HIV previously diagnosed, not in care reengaged (denominator: HIV previously diagnosed, not in care)	35% (73 out of 208)
12a. Proportion of people newly diagnosed with HIV who were linked to care	Number of attendees who had a positive test for HIV and no previous record in HARS, who were linked to an attendance in HARS within 14 or 30 days after their positive test in ED (source: SSBBV linked to ECDS and HARS)	Number of attendees who had a positive test for HIV and no previous record in HARS (source: SSBBV linked to ECDS and HARS)	16 SSBBV sites	58% (45 out of 78)	HIV linked to care for first time (denominator: HIV number of new diagnoses)	79% (268 out of 341)
13a. Median time between HIV positive test in ED and linkage to HIV treatment	Median time between HIV positive test in ED and linkage to HIV treatment (source: SSBBV linked to HARS)	Not applicable	16 SSBBV sites	13 days (for those newly diagnosed), 42 days for relinkage to care for those previously but not currently in care)	Not reported	Not reported
11b. Proportion of people previously diagnosed with HCV and not currently receiving treatment who were linked to treatment	Number of attendees who had a positive HCV RNA test at their ED attendance and a previous positive HCV test in SSBBV or SGSS or a previous record of treatment initiation in the Arden and GEM treatment register who were linked to a treatment initiation in the Arden and GEM treatment register after their ED attendance (source: SSBBV linked to ECDS, SGSS and Arden and GEM treatment register)	Number of attendees who had a positive test for HCV RNA at their ED attendance and a previous positive HCV test in SSBBV or SGSS or a previous record of treatment initiation in the Arden and GEM treatment register (Source: SSBBV linked to ECDS, SGSS and Arden and GEM treatment register)	16 SSBBV sites	42% (28 out of 66) of people who had previously initiated treatment, 52% (71 out of 136) of people with no past evidence of treatment	Not reported	Not reported
12b. Proportion of people newly diagnosed with HCV who were linked to care	Number of attendees who had a positive HCV RNA test at their ED attendance and no previous positive HCV test in SSBBV or SGSS or previous record of treatment initiation in the Arden and GEM treatment register who were linked to a treatment initiation in the Arden and GEM treatment register after their ED attendance (source: SSBBV linked to ECDS, SGSS and Arden and GEM treatment register)	Number of attendees who had a positive test for HCV RNA at their ED attendance and no previous positive HCV test in SSBBV or SGSS or previous record of treatment initiation in the Arden and GEM treatment register (source: SSBBV linked to ECDS, SGSS and Arden and GEM treatment register)	16 SSBBV sites	45% (79 out of 175)	Proportion of people newly diagnosed, diagnosed with reinfection or previously diagnosed and not in care that complied with initial clinical contact (denominator: patients with a positive HCV RNA who had previously cleared the virus, previously been diagnosed but not in care, or were a new diagnosis)	52% (318 out of 613)
13b. Median time between HCV diagnosis and linkage to HCV treatment	Median time between HCV diagnosis and linkage to HCV treatment (Source: SSBBV linked to ECDS and Arden and GEM treatment register)	No denominator	16 SSBBV sites	58 days	Not reported	Not reported
11c. Proportion of people previously diagnosed with HBV and not currently receiving HBV care who were linked to care	No current definition	No current definition	Not available	Not available	People newly diagnosed or previously diagnosed and not in care attended a hepatology clinic (denominator: HBV previously diagnosed not in care or newly diagnosed)	38% (509 out of 1,323)
12c. Proportion of people newly diagnosed with HBV who were linked to care	No current definition	No current definition	Not available	Not available	Not reported	Not reported
13c. Median time between HBV diagnosis and linkage to HBV care	No current definition	No current definition	Not available	Not available	Not reported	Not reported

Appendix 2C: attendee demographics

Table A4. Attendee demographics by site geography and surveillance coverage

Characteristic	Number of attendees - all sites	Number of attendees who had a blood test - all sites	Percent of attendees who had a blood test - all sites	Number of attendees - 16 SSBBV sites	Number of attendees who had a blood test - 16 SSBBV sites	Percentage of attendees who had a blood test - 16 SSBBV sites	Number of attendees - London sites	Number of attendees who had a blood test - London sites	Percentage of attendees who had a blood test - London sites	Number of attendees - Manchester, Blackpool and Brighton	Number of attendees who had a blood test - Manchester, Blackpool and Brighton	Percentage of attendees who had a blood test - Manchester, Blackpool and Brighton
All	1,613,699	934,466	58%	1,044,864	598,514	57%	1,306,804	775,362	59%	313,020	161,505	52%
Age 16 to 24	236,084	100,751	43%	162,927	68,048	42%	182,139	81,792	45%	55,063	19,210	35%
Age 25 to 34	325,772	153,550	47%	222,027	104,087	47%	268,067	129,478	48%	58,815	24,406	41%
Age 35 to 49	376,893	204,293	54%	244,245	132,916	54%	311,942	173,574	56%	66,060	31,144	47%
Age 50 to 64	313,337	195,910	63%	198,342	124,631	63%	257,033	164,391	64%	57,327	31,935	56%
Age 65 to 79	217,940	160,163	73%	133,248	98,483	74%	173,573	129,631	75%	45,254	30,949	68%
Age 80 and over	143,667	119,795	83%	84,069	70,345	84%	114,045	96,493	85%	30,500	23,860	78%
Women	865,036	517,607	60%	555,064	331,082	60%	703,635	430,475	61%	164,581	88,452	54%
Men	747,900	416,540	56%	489,255	267,229	55%	602,610	344,656	57%	148,233	72,964	49%
Asian other	92,683	51,870	56%	59,763	32,863	55%	82,441	47,892	58%	10,476	4,058	39%
Black African	85,467	49,274	58%	57,335	33,244	58%	77,067	45,892	60%	8,493	3,410	40%
Black Caribbean	52,805	32,253	61%	33,308	20,987	63%	49,900	31,034	62%	2,942	1,235	42%
Black other	46,592	25,391	54%	29,118	16,095	55%	43,054	23,909	56%	3,651	1,519	42%
Indian, Pakistani or Bangladeshi	134,683	79,658	59%	97,579	53,675	55%	114,790	70,838	62%	20,082	8,874	44%
Mixed multiple	37,763	19,728	52%	25,668	13,534	53%	30,738	16,632	54%	7,159	3,148	44%
Other	142,658	76,093	53%	93,409	51,640	55%	132,466	71,610	54%	10,599	4,626	44%
White British	559,357	348,215	62%	357,335	214,658	60%	365,345	238,564	65%	197,523	111,096	56%
White other	221,858	116,080	52%	132,475	72,015	54%	206,577	109,212	53%	15,847	7,082	45%
Index of multiple deprivation (IMD) 1: most deprived	364,151	215,143	59%	234,355	138,480	59%	300,284	181,871	61%	64,988	33,735	52%
IMD 2	351,661	204,497	58%	222,541	128,893	58%	288,876	171,627	59%	64,096	33,395	52%
IMD 3	317,418	184,394	58%	204,850	117,065	57%	255,266	151,393	59%	63,242	33,405	53%
IMD 4	292,160	168,327	58%	189,577	106,911	56%	229,535	135,983	59%	63,933	32,862	51%
IMD 5: least deprived	240,094	139,426	58%	157,210	89,816	57%	192,387	114,605	60%	48,886	25,265	52%

Appendix 2D: public health evaluation data linkage methodology

Data on BBV tests and diagnoses were obtained from SSBBV. To describe the proportions of attendees that were tested for BBV and the proportions of those tested who were diagnosed, data from 5 sites identified as having satisfactory coverage of testing data (both positive and negative results) in SSBBV were linked to records of attendances with blood tests in ECDS. 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 and specimen date in SSBBV, and trust. BBV tests that were more than 8 days after an ED attendance were excluded from the linked dataset.

For HIV, HARS diagnoses were linked to HIV tests in SSBBV by a combination of probabilistic and deterministic matching as HARS contains only limited patient identifiers.

Probabilistic matching used the Splink Python package (1), and required at a minimum a matching date of birth, surname soundex and initial, or clinic ID, with overall match probability determined using a combination of these identifiers, as well as gender, and location of test. Limited fuzzy matching was used to allow for minor data entry mistakes, and frequency adjustment was used to moderate the weight of overrepresented categories. Deterministic matching was then used to match a small number of additional HIV tests, using combinations of surname soundex, initial, date of birth, area of residence, and gender.

For the analysis of data from all 16 SSBBV sites, SSBBV data were not linked to ECDS. Instead, relevant test results were identified if they had evidence of being done at one of the participating EDs using the same method as for the linked data, during the ‘go live’ period of that ED.

1. Linacre R, Lindsay S, Manassis T and others. Splink: ‘Free software for probabilistic record linkage at scale’. International Journal of Population Data Science. Volume 7 issue 3, 2022

Appendix 3: implementation optimisation evaluation standard operating procedure (SOP) review responses

A summary of the responses for SOP and guidance documents is presented in Figure A4 and Table A4.

Figure A4. ED opt-out testing SOP or guidance document flowchart

Note for Figure A4

Note 1: Total number of SOPs or guidance documents received 28 out of 33.

Accessible text description of Figure A4 ED opt-out testing SOP or guidance document flowchart:

1. NHS hospital sites 33

• Provided SOP 17 out of 33 [note 1]
• Provided guidance document or flowchart 11 out of 33 [note 1]
• SOP in development 1 out of 33
• No SOP or guidance document 4 out of 33

Note 1: Total number of SOPs or guidance documents received 28 out of 33.

Table A5. Overview of SOP review results

Topic area	Category	Sites
Type of document	SOP	17
Type of document	Guidance or flowchart	11
SOP or guidance focus	Joint BBV	7
SOP or guidance focus	HIV only	15
SOP or guidance focus	Joint HIV and HCV	6
Staff training	Training and support for staff	14
Staff training	Named ED champion or lead	18
Public facing information	Information displayed in waiting room	28
Public facing information	Translated information	10
Public facing information	Website or online material	6
Opt-out process	Opt-out process is outlined	23
Opt-out process	Unknown	5
EPR prompt	Automated	22
EPR prompt	Not automated	6
Opt-out recorded	EPR with no reason	11
Opt-out recorded	EPR with reason	4
Opt-out recorded	Unknown	13
Blocking	6 months	8
Blocking	12 months	8
Blocking	3 months	1
Blocking	Unknown	11
Insufficient sample or unable to process follow-up	Recall to hospital via tracker role	3
Insufficient sample or unable to process follow-up	Recall to GUM, GP or other setting	8
Insufficient sample or unable to process follow-up	Unknown	17
Management of non-negative results	Specialist services	28
Management of negative results	No news is good news policy	24
Management of negative results	Included on discharge summary	1
Management of negative results	Unknown	3
Data management and monitoring and evaluation	Included in SOP	15
Data management and monitoring and evaluation	Unknown	13