CEO of Terrence Higgins Trust Richard Angell talks about how Universal A&E screening can support the most marginalised and help the NHS fiscally.
This piece was originally written for the Fabia Review’s autumn 2024 edition.
When Labour was last in government, it adopted an approach that might be termed progressive universalism: it improved services for all, but prioritised services for the poorest, disadvantaged and those experiencing inequalities. Sure Start, Building Schools for the Future and city academies all started in areas of deprivation before being deployed to rebuild the public realm for all. Baby bonds gave every child a nest egg, but poorest children the most. A similar principle is now being applied in HIV prevention, in the form of comprehensive A&E testing, with great success. Starmer’s Labour government should turbocharge a new rollout of opt-out screening, not just in pursuit of ending the HIV epidemic, but to scale up diagnostics more widely and drive down inequality in the broadest sense.
HIV is a cruel epidemic. Preying on the health inequalities in our society – and the homophobia and racism which has persisted from HIV’s emergence to the present day – it initially disproportionately hit gay and bisexual men, people who used drugs, and then the African diaspora. Today, about 106,000 people are living with HIV in the UK, including 5,150 people who have the virus but do not know it. They urgently need a test. A further 14,000 people know they have HIV, but, often as a result of the wider social determinants of health, are not taking medication. They urgently need a way back into care. If we can find these two cohorts and get those at risk to take the HIV prevention drug PrEP, we can end this epidemic. The global aim of UNAIDS is to end onward transmission of HIV by 2030. This is also the longstanding policy of the UK government and something that Labour recommitted to in its manifesto. We are currently in pole position, as a country, to be the first country in the world to reach this target. If realised, it will be the first time any government has stopped the onward transmission of any virus without a vaccine or a cure.
Labour’s manifesto pledge resolved to develop an HIV action plan to make the possible probable. Keir Starmer said it would be initiated within 100 days and published within a year. Twelve months on from the election, 4 July 2025, will also mark the anniversary of Terry Higgins being the first named person to die of an AIDS-related illness.
The modern-day fight against HIV today holds new challenges. As the number of undiagnosed people gets smaller, finding each person gets harder. We need to do more to pursue approaches that go beyond white, out gay men. In particular, while there will always be the need for community testing initiatives – my charity, Terrence Higgins Trust, runs the only year-round postal home testing kit service, with 4,000 click-and-collect sites nationally – there is an increased imperative to integrate screening into patient journeys by default.
Such strategies have a long and successful track record. In the UK, we have virtually eliminated ‘vertical transmission’ – the non-stigmatising way to describe mother-to-baby transfer of the virus – with an initiative started under Tony Blair in 2000: antenatal HIV testing. Every mother is screened unless they opt out. Very few do. Opt-out testing in maternity services has been a triumph that has now inspired a similar approach in other parts of the health system.
The next frontier is accident and emergency. Since April 2022, every adult attending A&E in London, Blackpool, Brighton, Manchester and Salford is automatically tested for HIV and hepatitis if they are having their blood taken. In 24 months, we have diagnosed over 1,200 people. This cohort is more likely to include women, people of Black African heritage, and older people. Those that are men who have sex with men are more likely to identify as not being ‘out’, ‘straight’, or ‘on the down low’ and often actively avoid LGBT health messaging. Of the 1,200 people found, at least a third had already been diagnosed but were not taking their medication. Often, the untreated virus was making them ill, hence their A&E visit.
Blanket A&E testing has two key advantages. First, it is good value for money. The scheme took £2.2m to establish but, within months, had saved the NHS £8m. The scheme currently finds a positive result for every 1,500 tests, meaning the cost of negative tests is quickly paid for by savings from diagnosing people before an ICU admission. And this is without considering the savings generated by preventing onward transmission.
Second, it is diagnosing people who don’t get tested in sexual health clinics. In its first week of rollout at Lewisham Hospital, an 85-year-old was diagnosed, much to her surprise. Recently, another London hospital identified a 68-year-old with HIV who hadn’t had sex for many years. The virus was eating away at her immune system; she now takes life-saving medication that can suppress the virus so it is undetectable in her system. Women, people of Black ethnicity, heterosexual people and older people are all diagnosed with HIV in greater numbers by this approach.
And as far as health inequalities are concerned, it turns out those who experience the worst inequalities are often sitting in A&E. A&E waiting rooms tend to be disproportionately populated by the very people who are less likely to visit or have access to a sexual health service.
What’s more, blanket screening is not only working for HIV. Most of the 34 funded hospitals also test for hepatitis C and B, and have discovered even higher rates of infection than for HIV; one in every 300 tests comes back positive for hepatitis B.
Other illnesses can be screened for too. At Ashton Under-Lyne Hospital, a trial of just 4,000 ‘opt-out’ diabetes tests was done with people waiting in A&E. They found 40 previously undiagnosed people with diabetes. That’s one per every 100 tests. An expanded diabetes testing programme along these lines could be a bargain, and transformational for public health.
Wes Streeting’s three shifts for the health service are analogue to digital, buildings to community, and treatment to prevention. These screening programmes are examples of prevention at its best, but unlike many other preventative measures, they take place in hospitals. As such, there is a danger that they are overlooked as Labour seeks to move more resources into community health.
The opportunities to expand further are extensive. Blood tests are now available for bowel and prostate cancer, as well as for syphilis, which is at its highest level since the second world war. There is currently good progress on a blood test for dementia and a new drug that can stop its onset for a decade, the combination of which could help mitigate our social care crisis significantly.
The fiscal advantages are particularly clear-cut. It’s quicker to train someone in pathology than it is to train a nurse or doctor. Blood testing labs are situated near every hospital, so their expansion would create good jobs across the UK. Plus, the more tests you buy, the more the private sector is incentivised to innovate.
Situating comprehensive diagnostic testing in A&E, at the front door of the NHS, has been proven effective by its application in HIV. It improves outcomes for patients, prioritises the poorest and most disadvantaged, and creates savings, even in the short-to-medium term. After 14 years, it is time to dust down progressive universalism and put it front and centre of the Starmer-Streeting change agenda.
