1. Yasmin Sultan 2012

2. Cambridg e East Cambs PCT Kings LynnBedfordLutonSt Edmundsb ury HIV prevalence per 1000 (15-59 years) 1.250.660.651.94.90.68 Type II diabetes prevalence /1000 (40- 70 years) 3.4% over whole of East Anglia

5.  Recommends expanded screening in areas where prevalence >2 per 1000.  Advises screen all GP registrations and medical admissions.  In 2009, this applied to 37 PCTs, 28 of which were in London.  DOH pilot study in 2009/10 ran 10,000 tests (cost £10 each). Found 50 new cases (all high prevalence areas).

6.  Numerous studies in inner city EDs (Denver, Boston).  Cost effectiveness threshold 1 per 1000.  Much higher prevalence: 2-17% (0.3% nationally – vs UK, 0.14%).  Health-seeking behaviour different.  Patient demographic different.  Less access to alternative primary care (vs UK GP screening).  Infrastructure and tradition of routine screening in USA.

7.  Lab tests ▪ Who would run them? (No 24 hour virology service). ▪ If run by Blood Services, staff training, test validation, machine time. ▪ Need to be run next day in batches to decrease cost. ▪ All positives require sending to reference lab for serial testing. ▪ Minimum cost £10.00 per test. ▪ Results will take about 1 week. ▪ Issues re follow-up and losses to follow-up  Near-patient testing kits ▪ Miss p24 antigen so less accurate ▪ Specificity lower so get 6 false positives per 7 tests done ▪ Cost was £12.00 in 2006 ▪ Needs an HCA to run test – takes about 15 minutes per test. ▪ Not recommended by BASHH for use as screening test.

8.  Counselling required for opt-in testing.  Counselling required if test is positive.  Robust follow-up systems must be in place so that test positives can be recalled.  If using near patient testing, will need 24 hour HCA to run the tests.

9.  4 hour target – one more thing to squeeze in  May encourage bleeding of more patients (especially if target-driven).  May increase attendances if patients start to perceive EDs as the place to go for an HIV test.

10.  How many new cases would we pick up?  Difficult to assess. In last 6 years, WSH Microbiologist has found 2 “unexpected” cases.  How many tests might we run?  We bleed average 100 pts/day  Cost per test:  Minimum £10.00 per (negative) test.  Cost per new HIV case detected?

11.  Screening in general practice – in UK chronic disease is managed very effectively in this setting.  Education of hospital doctors re conditions that should trigger testing

12.  Prevalence not high enough to justify screening in most parts of UK.  Screening cost very high per case diagnosed. Who is going to pay for this?  Logistically difficult to manage follow-up in ED (but easy in General Practice).  Limited resources – more cost effective to screen for diabetes, or chlamydia, or domestic violence.  Need to ask what service EDs should be, and want to be, providing.