Should Human Immunodeficiency Virus Testing Be Replaced With Combined Blood-Borne Virus Testing?

TL;DR

The paper argues that standalone HIV testing misses other blood-borne viruses, suggesting combined testing is more effective.

Contribution

The paper highlights new evidence showing combined blood-borne virus testing improves detection beyond standalone HIV testing.

Findings

Eight cases of viral hepatitis are missed for each new HIV diagnosis with standalone testing.

A decade of research supports the added benefit of combined blood-borne virus testing.

Abstract

Standalone HIV testing is a missed opportunity- a recent systematic review showed eight cases of viral hepatitis would be missed for each new HIV diagnosis. The review builds on a decade of research demonstrating the additional benefit of BBV testing.

Full text

Globally, more than 1.1 million individuals die from hepatitis B virus (HBV) and hepatitis C virus (HCV) each year; however, only 10.5% of individuals with HBV and 21% of individuals with HCV are diagnosed [1–3]. This is in stark contrast to human immunodeficiency virus (HIV), where 85% of individuals with HIV are diagnosed [4]. Seventy-five percent of adults with HIV are on treatment, which compares very starkly with only 2.3% of those with HBV and 13% with HCV [1–4]. In 2023 the World Health Organization (WHO) pledged to eliminate the HIV, HBV, and HCV epidemics by 2030 and aligned with the United Nations General Assembly sustainable development goals [5, 6]. These important targets are yet to be achieved, which is particularly unfortunate given that HCV can be cured with antivirals for 60/year [[2](#ofad668-B2), [7](#ofad668-B7)]. HBV is treatable with antivirals costing just 29/year [1, 3].

In this issue of Open Forum Infectious Diseases, Beard and Hill present the findings of an impressive systematic review of 175 studies sampling >14 million individuals. They compare the efficacy and costs of offering triple test programs against stand-alone HIV programs to support the WHO guidelines [8]. Their findings are both clear and striking.

The authors evaluated the prevalence of HIV, HBV, and HCV across 9 different population groups: general population, hospital attendees, blood donors, people who inject drugs, people experiencing homelessness, people seeking asylum, people who are incarcerated, pregnant people, and gay and bisexual men who have sex with men (GBMSM). Apart from in GBMSM, across the 9 populations they evaluated, the combined prevalence of HBV and HCV is greater than that of HIV. By delivering combined blood-borne virus (BBV) testing, for each case of HIV identified, an additional 5 cases of HBV and 3 cases of HCV would also be diagnosed.

I read this review with great interest and asked myself the obvious question—surely BBV testing should replace HIV testing everywhere and always? However, in the Lancet HIV in 2015 I had already posed this question after leading the “Going Viral” combined BBV testing campaign a year earlier [9, 10]. “Going Viral” was the first-ever combined BBV testing week campaign. It was conducted across 9 emergency departments (EDs) in the United Kingdom. The campaign incorporated BBV testing into routine care to shed light on the prevalence of hepatitis B and C. The BBV prevalence was much higher than expected at 3.35%, 1.83% of which was HCV and 0.7% was HBV. These rates exceeded national prevalence estimates for hepatitis C and hepatitis B. Had only HIV alone been tested, as per national guidance, 54 viral hepatitis diagnoses would have been missed in the space of 1 week. As a result of our findings, we secured external funding to extend the testing period at the Royal London Hospital ED.

Over 9 months, we tested 6211 ED attendees and found that 4.1% had a BBV, mostly hepatitis C (2.4%). Half of those diagnosed with HBV required linkage to care [11]. A third of people who needed linkage to care had advanced disease, including 3 people with hepatocellular carcinoma. There were 5 BBV-related deaths. We also conducted interviews to understand whether by offering a test for BBVs rather than HIV alone, stigma in relation to HIV testing could be reduced [12]. Participant accounts indicated that the nontargeted approach of the combined BBV test seemed to be helpful. Routine opt-out BBV testing in the ED setting was viewed as an acceptable and valuable practice by the majority of patient and staff participants.

Nearly 10 years later, in January 2023, National Health Service (NHS) England reported on the achievements in the first 100 days of BBV testing between April and July 2022 [13]. A total of 250 000 HIV tests and >100 000 HCV antibody tests were delivered, resulting in identification of >500 people with previously unknown (or unrecognized or undiagnosed) BBVs. The report notes that opt-out testing in ED is an important mechanism to tackle health inequalities as it provides an inclusive approach to testing and tackling stigma associated with both HIV and viral hepatitis.

As a passionate early advocate for BBV testing, I remain surprised and disappointed that it took nearly 10 years until a cohesive national response occurred in England. Similarly, in Europe, while a combined BBV testing week took place in 2015, triple testing was not translated into routine clinical practice [14]. In contrast, in the United States, triple testing has been evaluated in an ED in Michigan as early as 2010 [15].

This strong argument made by Beard and Hill for the cost-effectiveness of BBV testing is clearly both necessary and timely. The authors acknowledge the practical barriers to implementing global testing, including adequate training of healthcare providers to deliver culturally appropriate testing to key populations. The authors highlight the central importance of combating stigma to increase uptake and acceptance of testing, regardless of test availability. They note that while $1 combination HIV/HBV/HCV triple tests are being developed, they are not yet approved by the WHO. Therefore, individual testing for HIV, HBV, and HCV is a low-cost interim solution that is only marginally costlier than HIV testing alone. In the future, this strategy also unlocks the future potential to include other infections with similar transmission routes such as syphilis.

The authors make the important points that universal access to these low-cost diagnostic tests and to antiviral treatment must be provided to avoid worsening health inequities. Curative treatment for HCV should follow a positive test and people with HIV and HBV should receive antivirals. Expanding diagnostic pathways is an opportunity that should be seized to expand preventive pathways—individuals who test negative for HBV should be offered vaccination. Individuals who test negative for HIV who would benefit from preexposure prophylaxis should receive it.

I join the authors in their recommendation that implementing BBV testing “will help to achieve the Sustainable Development Goal of elimination of these BBV epidemics by 2030.” We should not wait another moment to act on these important findings.