Guidance to support opt-out blood borne virus (BBV) testing in Scottish prisons

Overview

Aim of the guidance

This guidance aims to ensure that, regardless of geographical location and prison status, all prison residents have equity of access to high quality blood-borne virus testing.

This is also in line with standard 4 of the Scottish Government MAT Standards.

This guidance provides a common definition of opt-out testing and outlines how this be delivered across the Scottish prison estate.

Guidance production

This guidance was first published in 2019 and has been updated to reflect changes in national guidance and policy.

This includes the publication of the:

• Sexual Health and Blood Borne Virus Action Plan for Scotland
• MAT standards

Background

Blood borne viruses (BBV) are a significant public health challenge in Scotland.

BBVs are preventable and treatable. If they are not diagnosed, they can cause severe illness and early death.

BBVs include:

• human immunodeficiency virus (HIV)
• hepatitis C virus (HCV)
• hepatitis B virus (HBV)

Behaviours that increase the risk of BBV transmission take place in both the community and prisons.

Find out more information on transmission in the NHS Grampian BBV leaflet.

BBVs in prisons

Prevalence of BBVs is much higher in the prison population than the general population.

A 2011 Scottish study found hepatitis C prevalence in prisons to be 19%[1], while the most recent estimate of prevalence in the UK general population is only 0.17%[2]. Recent studies estimate that the prevalence of HIV in prisons in Europe is 5%[3] and HBV 2.4%[4].

The Scottish Prison Service (SPS) prisoner survey published in 2019 found that:

• two fifths (39%) of respondents said that they had used illegal drugs at some point while in prison
• just over one quarter (28%) had used drugs in the month prior to the survey
• a minority (5%) reported having ever injected drugs in prison
• 2% stated they injected drugs in the month prior to the survey
  • of these, 78% (22) reported sharing their injecting equipment

In the Scottish Government Sexual Health and Blood Borne Virus Framework, they recommended working with NHS Boards and the Scottish Prison Service to introduce opt-out BBV testing (hepatitis B and C and HIV) for all new prison residents in Scotland during their induction period.

BBV control and elimination

Scotland’s approach to HCV prevention, treatment and care is internationally recognised. The Scottish Government has committed to HCV elimination by 2025 and eliminating new transmissions of HIV by 2030.

Prison residents have the same right to access health care as those in the community.

To eliminate HCV and HIV transmissions in Scotland and reduce the prevalence of BBVs more generally it is essential in prisons to increase:

• testing
• harm reduction
• treatment rates

Testing for BBVs needs to be:

• increased
• consistent
• embedded in routine practice

In addition to testing, harm reduction remains a critical part of preventing BBVs.

Those with a:

• negative test result should be offered harm reduction information and consistently offered testing should they still be at risk
• reactive result should be offered treatment/monitoring as appropriate in addition to harm reduction information

Hepatitis C

Hepatitis C is a virus that affects the liver and can lead to long-term liver damage if left untreated.

HCV is potentially fatal and often affects the most vulnerable in society.

It is curable with 8 to 12 weeks of treatment.

Chronic HCV progresses over a long period and frequently has no symptoms.

Up to 30% of people with chronic infection will develop advanced liver disease (cirrhosis) over a period of 20 years, with a small percentage going on to develop liver cancer each year thereafter. 

HIV

HIV is an infection that weakens the immune system making people more susceptible to other infections.

HIV is most commonly transmitted through vaginal, anal and oral sex without a condom, but it can also be transmitted through sharing injecting equipment and from mother to child during pregnancy or birth.

There is no cure for HIV, but treatment is highly effective in that most people have an undetectable viral load within 6 months of starting treatment.

People living with undetectable levels of HIV cannot pass on the virus. This is known as U=U or undetectable equals untransmissible.

Early diagnosis is important to reduce the rate of infection.

Early access to treatment enables people to live well for longer.

Hepatitis B

HBV is a virus carried in the blood and body fluids that can damage the liver and is the most widespread form of hepatitis worldwide.

HBV is usually transmitted through vaginal, anal and oral sex without a condom or through sharing injecting equipment. It can also be passed from mother to child during pregnancy or birth.

Hepatitis B can cause an acute or a chronic illness.

Chronic HBV is considered to be life-long and rarely clears. Symptoms of HBV can come and go as a slow progressing virus.

Over time, the virus can cause scarring (fibrosis) and damage to the liver. Around 20-25% of people with chronic HBV have progressive liver disease leading to cirrhosis.

HBV can be prevented with vaccination delivered over a course of three doses.

Vaccination is recommended to all prison residents and staff working in prisons. In the UK, guidance on vaccination schedules is available in the The Green Book. Offer of HBV vaccination is required to comply with the Medication Assisted Treatment (MAT) Standards.

Testing

Testing eligibility

BBV testing should be offered to everyone in custody, including individuals:

• serving a sentence
• being admitted to custody
• on remand

The legal status of the resident should not affect the offer of testing.

Opt-out testing should be offered to all people admitted to prisons and transferred from other prisons irrespective of when their previous test was done.

People serving a longer than 12-month sentence should be offered BBV testing annually in line with repeat testing recommendations.

If a person is already known to be positive or indicates they are living with a BBV, testing should be re-offered in line with ongoing risk. Referral should be made as required for treatment and continued monitoring.

Pre-test discussion

Informed consent for BBV testing is important. Prolonged counselling is rarely necessary.

The pre-test discussion should include explaining:

• the benefits of testing to the person, including
  • treatment advances for HCV and HIV
  • monitoring
  • available support
• details of how the test result will be communicated

An example pre-test discussion script is available.

Testing timing

Testing methods

Venepuncture (whole blood)

Where staff are appropriately trained, venepuncture (whole blood) should be performed as it allows for BBV testing and confirmatory testing from one sample.

Turnaround time for results from venous sampling (whole blood) is usually shorter than DBS testing.

Dry blood spot testing

Where non-clinical staff are undertaking testing or where the setting does not allow for venepuncture, dry blood spot (DBS) testing can be used to test for all three BBVs.

If a reactive result is produced, confirmatory bloods are required, and the tests should be repeated.

In some health boards DBS samples can be used to determine if someone is chronically infected with HCV using PCR testing. Please refer to local testing guidance for more information.

Point of care testing

Other point of care testing (POCT) methods exist but are not widely used at time of publication.

Local teams should consider POCT would be helpful in increasing the number of people offered a test and if they would be suitable to add to the current pathway.

Local laboratory procedures should be adhered to where POCT are used.

Who should perform the test?

Testing can be carried out by any appropriately trained member of staff.

DBS testing can be undertaken by both clinical and non-clinical staff, including:

• health care assistants
• nurses
• doctors
• pharmacists
• support workers
• prison staff
• voluntary sector staff

Ensure testing staff provide a contact number or generic email address for the nursing or medical team for laboratory staff in case they need to contact the testing team.

Details of this process can be found in local training plans and testing guidance.

Window periods

All BBV tests have a ‘window period’. This is the time after infection during which the antibody response cannot be detected by routine testing.

It is important to establish whether the person being tested is in the window period or has been at risk of exposure to infection during the window period for each virus.

If the initial test is negative but they have been at risk, they should be offered re-testing after the appropriate window period.

Window periods for BBVs

Test result interpretation and action

Positive test results or diagnosis must lead to referral and linkage to specialist services for treatment and/or monitoring.

Communicating test results

All healthcare professionals are responsible for ensuring that test results are managed appropriately. The person who conducted the test in prison is responsible for ensuring test results are given in a timely manner.

This is best done face to face. Alternative methods, such as letters, can be used to give a negative result.

Where a resident is transferred the test result should be communicated to the receiving prison healthcare team. The receiving prison is then responsible for communicating the test results and onward referral as appropriate.

When an individual is liberated prior to the result being given, alternative methods, such as letter or telephone may be appropriate to communicate negative results.

A letter should be provided to the person’s GP detailing the results of any tests undertaken. Alternatively, results can be included on a discharge summary provided to the individual.

If the result is positive, this should also be communicated to the specialist service.

Where appropriate and with consent, SPS Throughcare Support Officers and other organisations can assist those leaving custody to access services in the community.

Risk reduction advice

Testing should be used as an opportunity to give advice on reducing the risk of passing on or becoming infected with BBVs.

Recommended advice  

Safe sex

This includes:

• consistent and correct use of condoms and lubricant
• fewer partners
• non-penetrative sex
• regular testing

Avoiding sharing any drug taking equipment

This includes:

• spoons
•  filters
•  water
•  needles/syringes
• snorting equipment
•  pipes
• surfaces for drug preparation

Other advice

Such as:

• avoiding tattoos, piercings, or procedures that pierce/inject the skin using unsterile equipment
• not sharing razors, toothbrushes or hair clippers
• interventions that can reduce the risk of unborn child HIV and HBV infection
• hepatitis B vaccination
• availability of PrEP and post exposure prophylaxis (PEP) for HIV

Repeat testing

Anyone who requests a repeat test for BBVs should be accommodated.

Repeat testing should be offered to residents every 12 months.

Repeat testing should be offered every 3 months in those with high risk behaviour, including:

• gay and bisexual men and other men who have sex with men (GBMSM)
• those using substances, such as smoking, snorting or injecting drugs
• those who get tattoos or piercings in custody

For people who are at recent risk of acquiring HCV infection and either:

• have an antibody positive but PCR negative result

or

• have an antibody negative and PCR negative result

repeat PCR testing at least 3 months after the risk episode.

This is to exclude an acute infection where the PCR may not initially be positive or an acute infection in someone who had previously cleared infection.

Referral pathways

For HIV, PCR positive HCV and active HBV, refer to local specialist services.

There is no reason to delay referral as early assessment for treatment is beneficial for all BBVs.

Resources to support BBV testing

A wide range of e-learning and face to face training is available across Scotland.

This guidance includes:

• opt-out BBV testing pathway
• opt-out BBV testing algorithm
• example script to support opt-out BBV testing

Further resources for information and support, and contact details for prisons, can be found in the additional resources section.

Health improvement and awareness raising resources such as posters and patient information leaflets are available from several sources. These should be displayed in prisons.

Local public health departments can be a good source to obtain local and national resources.

Visit your local NHS board website for contact details of your local public health department or speak to specialist BBV services.

Opt-out blood borne virus testing pathway for Scottish prisons

Close

Opt-out blood borne virus testing pathway for Scottish prisons

Download a copy of the pathway

Opt-out blood borne virus (hepatitis B, C and HIV) testing algorithm

Close

Opt-out blood borne virus (hepatitis B, C and HIV) testing algorithm

Download a copy of the algorithm

Script to support opt-out testing

This script provides a template for trained and experienced health workers to construct their opt-out message around. It does not 'prescribe' the speech that should be used in every encounter.

However, untrained staff may wish to follow it more closely. 

The script provides a uniform message for the different staff delivering BBV opt-out testing in Scottish prisons. 

This script is underpinned by behavioural economic theories.

• It begins with establishing the norm.
• It then provides key information to avoid negative automatic responses.
• It includes priming words (fit and well).
• It ends with providing an opportunity to opt-out while default remains testing.

Additional resources

Blood borne viruses

Terrence Higgins Trust (THT): HIV and Sexual Health 

Terrence Higgins Trust provides information about HIV and other sexually transmitted infections. THT can support with training and education in Scotland.

Visit the Terrence Higgins Trust website.

Waverley Care 

Waverley Care provides support services for people living with BBVs in communities across Scotland, as well as prevention services for those at risk of BBVs.

With services across Scotland, Waverley Care can provide training and awareness around BBV for staff and the public. They also provide support within a number of Scottish prisons. 

Visit the Waverley Care website.

NHS inform

NHS inform is Scotland’s national health information service.

They aim to provide the people in Scotland with accurate and relevant information to help them make informed decisions about their own health and the health of the people they care for.

View their information on:

• hepatitis C 
• hepatitis B
• HIV

Hepatitis

The Hepatitis C Trust 

The Hepatitis C Trust is a national UK charity for hepatitis C. It was founded and is now led and run by people with personal experience of hepatitis C. 

A free and confidential hepatitis C helpline is available on 020 7089 6221, Monday to Friday from 10.30am to 4.30 pm.

Visit the Hepatitis C Trust website.

The British Liver Trust

The British Liver Trust is the UK’s leading liver health charity working to improve liver health for all and supporting those affected by liver disease or cancer:

Visit the British Liver Trust website.

HIV

National AIDS Trust 

The National AIDS Trust has a range of useful resources regarding HIV. 

Visit the National AIDS trust website.

National AIDS Monitor: AIDSMAP 

NAM provides information and resources on HIV and AIDS. The site also provides a range of translated materials on a variety of issues and topics. 

Visit the AIDSMAP website.

Harm reduction

Scottish Drug Forum (SDF) 

SDF promotes evidence-based best practice. It has been involved in developing innovative harm reduction approaches.

Their work encompasses:

• drug-related death prevention
• coordination and supply of Take-Home Naloxone
• prevention of and response to outbreaks of bacterial infection
• improvement of sexual and reproductive health of people who use drugs

SDF supports The Scottish Needle Exchange Workers Forum and The Scottish Naloxone Network. 

Scottish Drugs Forum delivers general and specialist training on drug-related issues for a range of agencies and through a number of approaches. They also offer a range of e-learning courses on BBVs and related topics.

Visit the Scottish Drug Forum website.

NHS Education Scotland (NES) 

NES have a range of programmes on BBV including transmission, testing, progression of infection and treatment.

Access the NES sexual health and BBV training on TURAS.

BBV/Hep C Managed Care Networks 

Each health board has a BBV/Hep C Managed Care Network (MCN), usually hosted by public health departments.

Contact your local MCN for details of their training programme.

Contact details for prisons

The Scottish Prisons Service provides contact details for the 16 publicly managed prisons and the one private sector operator under contract.

Monitoring progress

Local improvement processes will be supported by including prison testing rates in the national reporting framework that supports implementation of the Sexual Health and BBV Action Plan for Scotland 2023-2026 and the MAT standards.

Local audits of testing practice are strongly encouraged to inform implementation of this guidance. Audits should explore issues such as testing uptake in remand versus sentenced people, reasons for refusal to test, delays in accessing testing etc.

Guidance development method

Guidance development process for version 1.0 (2019)

Situation and background 

The Scottish Government updated the Sexual Health and Blood Borne Virus Framework in 2015. The update recommended the introduction of opt-out BBV testing in all Scottish Prisons.

The Health and Sport Committee commissioned a report in 2017 on the delivery of healthcare within prisons since the transfer of responsibility from Scottish Prison Service to NHS health boards.

The final report noted: 

“In particular there is an opportunity to test for blood borne viruses (BBVs) such as HIV and HCV using dried blood spot testing, but we were told testing is inconsistent and poorly managed with access to treatment not being confidential which discourages testing and treatment.”

“We recommend the opportunity is taken through the admission process to undertake dried blood spot testing on all prisoners.”

The Scottish Health Protection Network (SHPN) Sexual Health and BBV Executive Leads Network commissioned a multidisciplinary working group in 2018 to develop good practice guidance on delivering opt-out testing in prisons. The guidance was published in February 2019.

The good practice guidance was due to be updated in 2021, however, this was delayed due to the pandemic response. The purpose of the review is to ensure that all technical information is correct, and the supporting guidance and educational elements are up to date.

Methodology

Following instruction from the SHPN SHBBV Strategic Leads, a multidisciplinary Guidance Development Group (GDG) was formed in early 2018, tailored to the topic and reflecting the range of stakeholders and groups whose professional activities will be covered by the guidance. Members agreed a terms of reference, and their roles and responsibilities within the group.

The group considered and agreed the necessary actions required to update the existing guidance, including:

• reviewing current evidence and best practice in relation to BBV testing (methods, window periods, interpreting results etc) 
• signpost to resources available to support BBV testing in prisons including training to ensure the workforce is competent and confident to discuss and where relevant, deliver testing 
• develop standardised guidance and tools to support implementation across Scotland 
• agree best practice in monitoring and evaluation processes to evidence the implementation of the guidance 
• make recommendations to relevant networks to support full implementation of the guidance. 

Guidance Development Group

A multidisciplinary Guidance Development Group (GDG) was convened to produce the first version of this guidance.

The GDG had representation from:

• NHS BBV and STI services, and public health services
• Public Health Scotland
• Scottish Government
• Scottish Prison Service
• third sector organisations
• virology services.

Identification and evaluation of evidence

Most of the original good practice guidance and recommendations were based on expert opinion from GDG members, comments from stakeholders with professional experience and practical considerations (for example, resources and service user experience). The update took a similar approach.

Other sources of relevant evidence and grey literature were reviewed:

Formulation of recommendations and drafting

Members of the GDG were asked to review the content in full and provide comments on any areas that required updating or changing. Members with a particular expertise were asked to comment on technical aspects such as laboratory input into testing requirements and window periods. Expert opinion was used, and all comments and suggestions were discussed by the GDG to reach consensus.

External expert advice was sought when required from agencies such as primary care services, who did not require to be represented at the GDG.

As this was an update to existing guidance, key considerations and questions were:

• Is the data referenced throughout, the most recent?
• Are the targets referenced the most recent?
• Does the information on sample taking and processing reflect current practice?
• Are the testing algorithms up to date?
• Are the workforce development and educational resources up to date and relevant?
• Is there further resources or advice to support implementation for example, providing further advice on situations where a person refuses a test?
• Can we strengthen any of the recommendations using evidence for example citing Green Book Guidance for the delivery of hepatitis A and B vaccination?

Consultation

Following consensus by the GDG, a draft of the good practice guidance was shared with the following networks to allow for further expert consultation:

• SHPN BBV Prevention Leads Network
• SHPN Hepatitis C Clinical Leads and MCN Coordinators Network
• SHPN HIV Clinical Leads
• Justice Healthcare Managers Network

Comments and suggestions from the wider consultation were considered by the GDG before production of the final document.

Dissemination, uptake and implementation

The GDG also considered and made recommendations on best practice in monitoring and evaluation processes to evidence the implementation of the guidance and ways to support full implementation of the guidance. These recommendations are not part of the good practice guidance document but will be shared with SHPN SHBBV Strategic Leads, Scottish Government SHBBV Team and the Core Steering Group of the Scottish Prisoner Health Network.

 

 

Guidance development process for version 1.1 (2024)

The guidance published in February 2019 was due for review in 2021. This review was delayed due to pandemic response.

The purpose of the review in 2024 was to ensure that all technical information was correct, and the supporting guidance up to date. 

Version 1.0 was reviewed in 2024 to support the move from PDF publication to HTML publication. PHS approached the original authors to discuss any changes to the content before converting to html.  

As the advice contained in the guidance remains unchanged, this version did not go out for consultation and was signed off through normal PHS processes.

Equality impact assessment (EQIA)

An EQIA was undertaken to consider any unintended or differential impact or risks arising from implementing the recommendations in the guidance.

Download the EQIA

Abbreviations

Sources