Good practice guidance

In April 2025, the Scottish Government (SG) announced that opt out testing for BBVs (HIV, HCV, HBV) in Emergency Departments (EDs) will be implemented in NHS Greater Glasgow & Clyde, and NHS Lothian, with a possible further roll out in other areas in Scotland as evidence develops and supports this. Since the announcement, NHS Grampian have also expressed their intention to implement the programme, having participated in the original 2024 pilot.

To enable consistency and optimise patient engagement across sites, the Scottish Government has commissioned Public Health Scotland (PHS) to support the implementation of BBV opt-out testing in these specified EDs. PHS will therefore lead on national coordination of the programme (including streamlining of public and staff resources, a consistent approach to informed consent etc.), monitoring activity (sharing data lessons and troubleshooting), and collaborating with Glasgow Caledonian University to evaluate implementation of the intervention.

Opt-out testing for a blood borne virus (BBV) is a process where an individual is automatically tested in the context of an emergency department (ED) attendance where routine phlebotomy is being performed as part of the person’s care. The person can decline BBV testing at their attendance if they wish to do so.

Opt-out BBV testing in EDs in England has contributed to case finding and progress towards transmission elimination goals for BBVs, reducing both preventable deaths and the stigma associated with BBVs in very high prevalence areas. The epidemiological picture of BBVs in Scotland is different from England; Scotland has medium prevalence of HIV compared to the initial sites in England, two of its NHS Boards (NHS GGC & NHS Lothian) have estimated HIV prevalence which is just above the 0.2% threshold defined as ‘high prevalence’. However, it is still the case that many people living with one or more of HIV, HCV or HBV remain undiagnosed or are diagnosed at a late stage. This is despite widely available, safe, effective and free treatments. More needs to be done to expand testing to identify people living with BBVs earlier and EDs have a key role to play.

Opt-out ED testing is an effective strategy to identify people living with undiagnosed BBVs and to support previously diagnosed people not in care to re-engage. ED opt-out BBV testing supports the national HIV Transmission Elimination Delivery Plan's  commitment to end new HIV cases in Scotland by 2030 (aligned to the World Health Organisation, UNAIDS global HIV strategies), the WHO viral hepatitis elimination goals and a more inclusive and population-focused approach to elimination programmes.

Routine BBV testing in EDs builds on experience of an earlier pilot in three Scottish NHS Boards (NHS Lothian, NHS Grampian and NHS Highland) as well EDs in the UK and Ireland where an increase in detection in all three BBVs, HIV, HCV and HBV, has been observed. BBV testing in EDs is supported by Terence Higgins Trust, Waverley Care, National AIDS Trust,  National Institute of Clinical Excellence (NICE), Royal College of Emergency Medicine (RCEM), the British HIV Association (BHIVA), British Association of Sexual Health and HIV (BASHH) and British Infection Association (BIA). Inclusion of routine hepatitis B and C testing in EDs is supported by Hepatitis C Trust, and the Scottish Government Sexual health and blood borne virus action plan: 2023 to 2026.

A recent Scottish review of published literature (in similar healthcare settings to Scotland) concludes that that opt-out BBV testing is highly acceptable to patients in ED and Medical Assessment Unit (MAU) settings and is effective at increasing testing rates and identifying new cases of BBV. A further advantage of this approach is the improvement in health equity though increased access to testing, diagnosis and care for those facing barriers to accessing BBV testing.

1.1

The programme should be implemented by each of the participating Scottish NHS Boards in their respective EDs. Each Board should set up a local steering/implementation group with representation from all relevant stakeholders, including specialty teams, third sector agencies, and those providing peer support. This would include at a minimum, ED, local services for management of HIV and viral hepatitis (HIV, sexual health, hepatology, gastroenterology, infectious diseases, laboratory medicine, community organisations, IT, electronic patient record (EPR), data/business intelligence and public health). The ability to link in with Alcohol and Drug Recovery Services (ADRS) could also be useful.

1.2

A networked approach is recommended with NHS Boards taking overarching responsibility and governance for results management and delivery. At local level there should be senior management and leadership oversight at each NHS Board including a named SRO, an operational lead and named leads for each specialty area (HIV, hepatitis, emergency medicine, laboratory medicine).

1.3

Each NHS Board should develop its own standard operating procedure (SOP). SOPs should include end to end clinical pathways and data process flows with clear lines of responsibility and accountability for key elements including public facing communications, the testing process, staff training, laboratory medicine, IT, results management, linkage to care, data collection, reporting, monitoring, audit and evaluation.

2.1

Opt-out BBV testing should be normalised and considered part of routine care for people who are attending ED and having blood tests.

2.2

BBV opt-out testing should have minimal impact on ED staff efficiency and patient flow in the department and should ideally be delivered by existing ED staff.

2.3

All ED staff should be provided with training to carry out routine opt-out BBV testing, understand the rationale behind testing and how to signpost to further information.

2.4

Training should include clear and simple messaging such as "most adults are now routinely tested for HIV, hepatitis B and C unless they opt-out".

2.5

ED staff should be trained by NHS Boards using the national resources developed for staff education. NHS Boards should ensure support is available to ED staff with regards to opt-out testing.

2.6

In line with routine practice, accurate patient contact and GP details should continue to be recorded to ensure that people with non-negative (reactive or indeterminate) results can be contacted.

3.1

Routine BBV testing in EDs should be implemented using an opt-out approach.

For information on the background and rationale for opt-out HIV testing in EDs (in areas of high diagnosed HIV prevalence), please see the BHIVA, BASHH, BIA and RCEM rapid guidance on opt-out blood-borne virus testing in high-prevalence and extremely high prevalence acute medical settings and emergency departments.

Key points in the implementation of the opt-out testing strategy include:

1. All adults (16 years and over) attending ED who are having blood tests for any reason should routinely be tested for BBVs unless they opt-out.
2. People should be informed using clearly visible, translated and accessible written information which is displayed throughout the ED (see section 4) and should also be available online.
3. Clinicians should be able to take a flexible approach to opt-out depending on circumstances.
4. Pre-test counselling or specific verbal prompts or reminders is not required for routine opt-out BBV testing.
5. If a patient requires or requests further information about BBV testing, then testing should still be offered, and in addition there should be referral/signposting to relevant specialist service. This may arise if a patient indicates they have a specific risk factor for BBV.
6. If a patient is unable to see or understand the visual publicity, where feasible ED staff should provide additional verbal information or reminders about BBV testing at the point of taking bloods and in instances where the patient cannot speak or understand English, consider contacting translation services.
7. Consent for BBV testing as part of the ED attendance checks is effectively given by allowing a healthcare worker to draw blood from the patient’s arm.
8. Consent for opt-out BBV testing is based on pre-test information provided by posters, information leaflets or videos displayed in waiting rooms that BBV testing is included in routine blood testing. This does not require specific discussions about which BBVs are tested. Information should also be available online with clear instruction on how to access it i.e. QR code on posters and leaflets.

3.2

Additional considerations for BBV testing: patients presenting with BBV indicator conditions and patients lacking capacity to consent.

Routine opt-out BBV testing is intended to be an opportunistic, population level testing programme. Additional considerations regarding BBV testing will apply in the following situations:

• Where the patient's presentation to ED is thought to be BBV related and this will change management: In the event of a patient presenting to the ED with a suspected HIV, hepatitis B or C related condition including HIV seroconversion, HIV indicator conditions and acute hepatitis clinicians should follow usual clinical procedures which involve BBV testing and involvement of specialist teams as appropriate.
• If a patient is unconscious or otherwise lacks capacity to opt-out of testing: If, after taking all reasonable steps to support the patient in making their own decision, and in the absence of an appointed power of attorney, Scottish law permits BBV testing in a person who is unconscious or lacks capacity when it is necessary for that patient’s own health. Where practically feasible, clinicians should complete a Section 47 certificate under the Adults with Incapacity (Scotland) Act before testing. Reasons for not carrying out testing should be documented where possible. If a patient regains capacity after testing has been performed, the responsible clinician should, where feasible, inform the individual and signpost them to NHS Inform for further information on the ED Opt-Out Programme.  

4.1

Key messages about BBV testing, and how to opt-out, should be displayed prominently in the ED, particularly in waiting areas and phlebotomy areas as well as electronically on local NHS websites.

4.2

At the minimum public facing communications should include clear messaging on the following:

1. The purpose and context of opt out testing for BBV.
2. The opt-out nature of ED BBV testing, how it will work in terms of consent and to speak to a member of staff if they wish to opt-out or discuss testing further.
3. BBV care and treatment is safe, effective and free.
4. BBV testing and results are confidential.
5. How results will be provided (“We will only contact you if your results need any follow-up”).
6. Public facing information should state that patients will only be contacted if they have a reactive or indeterminate result.

4.3

Local SOPs should specify when the patient should expect to hear from the results team(s) in the event of a non-negative result: 14 days as a maximum is recommended.

4.4

How to seek further information.

1. Sites should provide details of local services where patients can access BBV testing and information (for example, local sexual health services) - this may be useful for people who opt-out of BBV testing in ED and for people who want to be sure that they have been tested and want to know their status regardless of whether their result is positive or negative. This will also be useful for those people who would like further information NHS Boards may wish to offer a "results phone line" or other point of contact where a patient can check their result or ask further questions about testing.

4.5

Local SOPs should be developed using appropriately cautious wording for local patient communications to reflect that while the intention is to test everyone and that where possible every effort will be made to contact patients in the event of a non-negative result, the following caveats may apply:

1. In cases where BBV tests are undertaken in ED but are not processed due to technical issues or human error.
2. In cases where the patient’s details are incorrect, contact may not be possible. Patients should ensure they have provided the correct contact details.
3. In some instances, even if blood is taken in ED, it may not be tested for BBVs for valid reasons.

4.6

Ensuring accessibility of information:

Information should be available in a range of accessible formats including posters, banners and leaflets, digital and paper options, including large print versions. Participating boards should meet service users’ interpretation and translation needs in line with national policy, which can be found on the Public Health Scotland website. There should be specific provision of accessible public facing information for people who are blind or partially sighted. A range of public facing communication materials will be made available by PHS for sites to use.

5.1

For the purposes of this guideline BBV testing refers to testing to detect current infection with HIV, Hepatitis B and Hepatitis C.

5.2

The recommended tests are as follows:

• HIV: 4th generation HIV antibody/antigen test
• Hepatitis B: Hepatitis B surface antigen
• Hepatitis C: Hepatitis C antibody with reflex RNA testing on the same sample if antibody positive.

5.3

Failsafe automatic reporting of all non-negative results should be set up to report to all relevant parties as agreed in local SOPs (e.g. HIV/hepatology/infectious diseases) with clear protocols to ensure that all non-negative results are actioned.

6.1

Trusts in England have achieved high and sustained uptake of BBV testing (>90%) in EDs through the use of automatic HIV/BBV test requesting when any blood test is ordered. Automatic blocking is applied to prevent duplicate testing in people who attend ED frequently.

Learning from Trusts in England who have achieved high and sustained uptake has informed the following recommendations. It should be noted that these are recommendations and only possible if appropriate IT functionality is in place.

1. BBV tests should be automatically added when any blood test is requested in ED. This removes the need for staff to manually add on BBV testing. An automated system message such as "Added by system as part of ED BBV Testing" may be included.
2. Sites should consider implementing automatic "blocking" of BBV testing in people who attend ED frequently to minimise unnecessary testing.
3. In practice this means that the EPR system detects a recent BBV test in ED within a given period and flags an alert to the person requesting blood tests in the ED to check whether a repeat test is indicated.
4. A blocking period of 12 months is recommended for all 3 BBVs, however sites should determine their local blocking period taking into consideration their local population, BBV epidemiology and resource constraints.
5. The opt-out triggered block on BBV testing should be automatically deleted after an appropriate time period (6 months is recommended). This means that BBV testing would automatically be blocked for 6 months following the person's initial opt-out, and if they attend the ED after 6 months, they will need to opt-out again. If this functionality is not available then by default the patient will be tested if they present to ED again (regardless of proximity of revisit) unless they choose to opt-out again.

6.2

Recording of opt-out, blocking and initial reactive BBV results

1. Where feasible, opting out of BBV testing should be recorded on the person's medical record, with the reason(s) for opting out.
2. If functionality allows recording of opt-out on the system, should automatically block ordering of BBV tests (including individual BBV tests) or generate a prompt for ED staff to deselect BBV tests from the order set (in cases where BBVs have been incorporated into the routine order set).

7.1

Delegation of results management for ED BBV testing to relevant specialist BBV services

1. ED Staff are not expected to manage non-negative results from BBV testing, nor are they expected to inform or counsel people about a reactive test result. Likewise for negative results.
2. Results management of BBV opt-out testing in EDs should be delegated to the appropriate specialist service for management of HIV, HBV and HCV in the NHS Board who will notify the individual, organise confirmatory testing and facilitate linkage to care. This will typically be the HIV/GUM/SRH service (for HIV results) as well as the relevant specialist BBV service for HCV and HBV.
3. There should be automatic failsafe reporting of all non-negative BBV results to the relevant specialist services with clear protocols to ensure that all non-negative results are actioned
4. Each NHS Board should develop a robust results management SOP which includes end-to-end processes for recall, confirmatory testing, linkage to appropriate care and support services and management of quality control issues.
5. Local SOPs should build on existing pathways for management of non-negative BBV results and should be suitable to manage the expected increased volumes of results generated by ED testing and additional considerations specific to ED testing.
6. Local Health Boards should support ED, laboratory medicine and specialist clinical services to work jointly to agree on clear lines of responsibility and accountability for management of BBV results at each site. A networked approach is recommended with local Health Boards taking overarching responsibility and governance for results management and delivery.

7.2

Informing patients of a positive or reactive BBV result

1. All positive or reactive results should be automatically reported to and managed by the relevant specialist teams who will notify the individual, organise confirmatory testing and facilitate linkage to care and support.
2. ED staff are not expected to manage results from BBV testing as this should be delegated to specialist BBV services.
3. In the event that an individual has a reactive or positive BBV test in ED and re-presents to ED before the specialist BBV team has been able to inform them, then the patient may be informed of their result by the ED team, with specialist input if appropriate. There should be local pathways to ensure that someone who receives a positive or reactive result in ED will be seen by specialist BBV services according to clinical priority. In the case of HIV this should be as soon as possible.
4. Inpatient teams should be informed if a patient has a reactive BBV test in ED and is subsequently admitted to hospital.
5. Specialist BBV services should make all reasonable efforts to contact patients with a positive or reactive result. Local SOPs should define the process for attempting to contact patients with a result.
6. In the event that it has not been possible to contact a person who has had a positive or reactive BBV test in ED using all reasonable effort, we recommend the following steps:

1. 1. In the event of a new BBV diagnosis (not known to local services) then the person's GP should be contacted to notify them of the result and to seek their support in engaging the person in care.
   2. If the person is known to be living with a BBV but is not in care and has given consent to contact their GP then the GP should be contacted.
   3. If the person is known to be living with a BBV but is not in care and has not given consent to contact their GP then a case-by-case approach should be taken including involvement of the MDT and taking relevant advice.

7.3

Management of negative results

A no contact approach for negative results is recommended. This means that the patient will only be contacted in the event of a positive or reactive result, and depending on local process, in the event of a quality control issue (e.g. under-filled sample).

7.4

Quality control issues

1. Standard protocols should be applied for quality control issues. This may be in instances where a blood sample has been taken but BBV testing cannot be performed (e.g. under-filled or unlabelled samples).
2. When there has been a quality control issue, it is recommended that the individual is notified and signposted to services where they can access a repeat test (e.g. GP, local sexual health clinic).

7.5

Local audit and quality improvement activities

NHS Boards should undertake local audit and quality improvement to monitor ED BBV testing activities: recommended metrics include laboratory turnaround time, time to patient notification of reactive or positive results and proportion of failed samples (e.g. under-filled or unlabelled).

PHS will support and help coordinate benchmarking, sharing of monitoring data, learning and troubleshooting across boards.

8.1

Adequate resources should be allocated to the following key areas: staff training in EDs, local comms, ED testing, laboratory medicine, results management (including data entry, monitoring, reporting, audit and evaluation) and follow up (including peer support).

8.2

There should be adequate resource allocation to notify and engage people identified by ED BBV testing who have a previous BBV diagnosis but who are not in care, acknowledging that this group may require additional support.

9.1

EDs should offer information on how to access local sexual health services, HIV testing, and sources of information and support around BBVs.

The following websites may be useful:

• the NHS Inform website signposts to local sexual health clinics, contraception and pregnancy services and help following a sexual assault
• information on how to book an HIV test can be found on the NHS Inform website
• free STI, including HIV and syphilis, test kits for at home self-sampling are available for some HBs from STI testing at home website on NHS Inform.  
• advice and support about HIV can be found on the Terrence Higgins Trust website and the Waverley Care website
• advice and support about hepatitis C can be found on the Hepatitis C Trust website and on the Waverley Care website
• advice and support about hepatitis B can be found on the British Liver Trust website
• peer support and information for people living with hepatitis B can be found on Hep B Companion website

10.1

Peer support is an integral part of high quality BBV care. People differ in their emotional and psychological reaction to a positive BBV diagnosis and will require a range of community and peer support services. Information should be delivered in a culturally appropriate manner and language. Peer support can be vital to adjustment to their diagnosis, as well as supporting long-term condition management and adherence, and should therefore be integrated into their care and treatment. Particular attention should be given to vulnerable groups who may be at greatest risk of being lost to follow up or not engaged in services. Similar support is necessary for people who are re-infected and who may have additional needs from services such as ADRS, housing etc.

10.2

NHS Boards should ensure that services for newly diagnosed people are available and work with local community organisations and national groups to ensure that community and peer support is offered to all individuals who have a positive BBV diagnosis identified through ED testing. This offer should be co­ produced with community organisations and integrated into the care and treatment pathway, in line with national standards for peer support, NICE guidance, BHIVA standards. NHS Boards may wish to consider the use of peer and community support to help newly engaged people engage with services for initial evaluation.

11.1

NHS Boards should work with sites to ensure robust processes and resources are in place to support data collection and reporting for the purposes of clinical care, programme assurance, audit, service evaluation and national surveillance.

11.2

Data recorded by sites should include the following minimum set of core monitoring metrics. This is not intended to be an exhaustive list and will vary according to the BBV.

Recommended core monitoring metrics for sites undertaking ED BBV opt-out testing:

• BBV testing as a proportion of people attending ED who are having blood tests
• numbers of reactive tests
• proportion of reactive tests that are true positive results
• proportion of people with a positive test who are newly diagnosed and those who had previously been diagnosed
• proportion of those previously diagnosed who are in care vs. lost to follow up.
• proportion of people with a reactive test who are contacted
• proportion of people with a reactive test who are offered peer/community support
• time to linkage to care
• time to starting treatment (acknowledging that not all people, particularly people living with HBV will start treatment)
• demographic data (age, ethnicity, gender and so on)

Qualitative data should also be collected, where possible, to ensure any learning points are taken forward to improve service provision. How and when this is done should be agreed locally and should have minimal impact on ED staff efficiency.

11.3

Data considerations for macro-level monitoring and surveillance.

1. Macro-level monitoring of the programme by Public Health Scotland will be mainly through the data captured within the PHS Electronic Communication of Surveillance Scotland (ECOSS) system. Data linkage will be undertaken by PHS in order to follow the person’s care pathway.
2. The systems include:
   • Electronic Communication of Surveillance Scotland (ECOSS) system – HCV, HBV, HIV tests and diagnoses
   • HCV diagnosis database
   • HIV diagnosis database
   • National HCV Clinical Database
   • National Sexual Health System (NaSH) – HCV, HBV HIV clinical data
3. Initial findings from the Lothian pilot show that Opt-Out BBV testing in Emergency Departments can successfully diagnose both new and re-infections among individuals not currently engaged with other clinical services. This aligns with findings from similar testing initiatives implemented in other UK Emergency Departments. Nonetheless, efforts to boost testing uptake are still needed. A more comprehensive evaluation across Scottish sites is essential to identify challenges and enhance the service for greater engagement and participation.
4. To support macro level monitoring and surveillance, data leads at sites should ensure:
   • accurate and consistent reporting in relevant systems
   • laboratories are cognisant of processes and work with PHS to ensure accurate coding of results in order to distinguish between ED and non-ED testing as well as between routine ED opt out testing and testing for clinical reasons (e.g. for patients presenting with indicator conditions, risk factors etc. who should be offered testing)
   • agreed, standardised reporting metrics should be used. In addition to core metrics, measures for audit, monitoring equity, economic evaluation and quality assurance will be considered and introduced
5. Bespoke data collection may be necessary for some indicators that are not part of existing centralised systems - for example, proportion of people contacted with their result, and method of contact - unless these can be captured through site-specific systems and reported centrally.
6. Monitoring data also feeds into the evaluation of the programme, encompassing clinical/public health, economic and implementation optimisation, led by the Scottish Government and PHS in co-production with sites and stakeholders.

Contact for queries on this guidance:

Parveen Chishti, Programme Portfolio Manager, Public Health Scotland

parveen.chishti@phs.scot

Duncan Mccormick, Consultant in Public Health Medicine, Public Health Scotland

duncan.mccormick@phs.scot