A pilot project supported by the Elton John AIDS Foundation has helped transform how HIV testing is offered in England, expanding a programme first introduced in two South London hospitals to 89 emergency departments across the country. The initiative makes HIV tests a routine part of emergency care, allowing patients to be tested unless they choose to decline. The approach aims to identify people who may be living with HIV without knowing it and connect them with treatment. Its expansion follows evidence that routine testing can reach people who might otherwise miss opportunities for diagnosis and care.
The Elton John AIDS Foundation began pioneering opt-out HIV testing in South London in 2018. The initial work demonstrated how emergency departments could help identify people living with HIV who had not previously been diagnosed or who had become disconnected from treatment. According to the Foundation’s annual report, the pilot began in two South London hospitals and helped establish a model that could be extended across the NHS. The programme has since been scaled up, with government funding supporting its expansion to 89 emergency departments across England. The Foundation’s report on pilot schemes to accelerate access to pre-exposure prophylaxis, commonly known as PrEP, also highlights the wider importance of identifying HIV infections early. The initiative has reportedly led to 1,000 new HIV diagnoses through the expanded testing programme, demonstrating the potential of emergency departments to reach people who may not otherwise seek an HIV test.
Under an opt-out approach, HIV testing is offered routinely as part of a patient's hospital care rather than relying entirely on individuals to request it. Patients can decline the test, but the default offer helps make testing a normal part of healthcare. This matters because some people may not recognise their potential exposure to HIV or may feel uncomfortable asking for a test. Others may avoid testing because of stigma or assumptions about who is likely to acquire the virus. The Elton John AIDS Foundation explains that routine testing can help address these barriers by making the offer more inclusive. Its work has also shown the value of reaching people from communities that have historically faced inequalities in HIV testing and access to treatment. The Foundation’s HIV Social Impact Bond programme found that emergency departments and primary care settings were particularly effective in identifying Black African, Black Caribbean and Black Other women and girls living with HIV who might not have been tested elsewhere.
The original initiative developed through a partnership involving the Elton John AIDS Foundation, Lambeth, Southwark and Lewisham councils, the National Lottery Community Fund, ViiV Healthcare, Comic Relief and Big Issue. The Foundation’s account of its UK Social Impact Bond describes the programme as the world's first social impact bond focused on bringing people living with HIV into care. It ran for 3 years, from 2018-21, across the 3 South London boroughs. The programme combined HIV testing in hospital emergency departments, HIV clinics, GP surgeries and community settings. Providers received payments based on results, including identifying people newly diagnosed with HIV and helping those who had stopped treatment return to care. Over the three-year period, more than 265,000 people received HIV tests. More than 460 people living with HIV entered treatment, including people who received a new diagnosis and those who returned to care after previously stopping treatment. The Foundation estimated that the programme helped avoid £90 million in healthcare costs. Earlier diagnosis and timely treatment can reduce the likelihood of people becoming seriously ill, while helping prevent further HIV transmission.
The results of the South London project helped build the case for extending routine HIV testing beyond the original locations. According to the Foundation’s UK Social Impact Bond, evidence from the initiative informed the work of the HIV Commission, parliamentary inquiries into HIV testing and the impact of HIV on ethnic minority communities, and the development of the government’s HIV Action Plan. In December 2021, the government announced £20 million in funding for emergency department HIV testing in areas with particularly high rates of new infections. This marked an important step towards making the approach available to more patients across England. The Foundation’s announcement on new funding to end HIV cases in England describes opt-out testing as a way to address inequalities in diagnosis and bring people into care earlier. The wider rollout also reflects the argument that HIV testing should not depend solely on whether someone visits a specialist sexual health service.
Finding people who are already living with HIV is only one part of the effort to reduce new infections. Prevention measures, including access to PrEP, are also important. PrEP is medication taken by HIV-negative people to reduce their risk of acquiring the virus. The Elton John AIDS Foundation states that it can reduce the risk of acquiring HIV through sex by around 99% when taken as prescribed. In England, it has been available free through NHS sexual health clinics since the end of the PrEP Impact Trial in 2020. The Foundation’s pilot schemes initiative highlights the need to improve access to prevention alongside testing and treatment. Its approach recognises that people need to know their HIV status, understand their prevention options and be able to obtain appropriate support without unnecessary barriers. The Foundation has also called for public health investment that can demonstrate long-term benefits. Preventing new infections and connecting people to treatment can reduce future pressure on health services, while helping individuals receive care before their condition worsens.
The expansion to 89 emergency departments represents a significant development in England’s effort to identify undiagnosed HIV and improve access to treatment. However, the Foundation’s work also points to the need for continued investment in prevention, testing and support for people living with the virus. Its 2025 annual report records the programme’s development from a pilot in two South London hospitals into a model being scaled nationally. The report also links the wider rollout to the government’s £170 million HIV Action Plan, announced on World AIDS Day, and its commitment to ending new HIV transmissions by 2030. The Foundation has argued that proven approaches need sustained government backing if they are to reach more people.
