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Tales from opposite corners of the world: Emergency department opt-out testing: A cost-effective route to earlier HIV and Hepatitis diagnosis in Australia and Germany

Australia and Germany have both made progress toward HIV and viral hepatitis elimination targets, yet a significant share of infections remains undiagnosed.

  • HBV: 31% undiagnosed in Australia (3); 80% in Germany (4)
  • HCV: 16% undiagnosed in Australia (5); 63% in Germany (6)
  • HIV: around 8% undiagnosed in both countries (7,8)

These levels of undiagnosed infection indicate that standard blood-borne virus (BBV) testing approaches are not sufficient to meet public health goals.

Emergency department opt-out testing

European and US studies demonstrate the cost-effectiveness and improved patient outcomes of combined Emergency Department (ED) BBV opt-out testing (OOT) in high-prevalence areas (9–11).

In Australia, although several pilot programs for ED OOT for viral hepatitis have been successful (12,13), testing is notroutinely performed in EDs and is primarily indicator-based (14–16). In Germany, there are no real-world studies evaluating ED BBV OOT in practice, and no systematic testing in EDs.

Our study and what we found

To assess the potential impact in both countries, we developed a hybrid health economic model comparing ED-based combined opt-out testing with current testing practice (standard of care; SoC). The model evaluated new diagnoses, linkage to care (LTC), quality-adjusted life years (QALYs), lifetime healthcare costs, and overall cost-effectiveness from a national health system perspective.

Model results indicate that, for every 10,000 people having ED blood tests, BBV OOT resulted in 82 (Germany) and 32 (Australia) additional new BBV diagnoses and 39 (Germany) and 17 (Australia) more individuals linked to care (LTC) compared with SoC.

In both countries, ED BBV OOT was highly cost-effective (17,18) over a lifetime, with an incremental cost per QALY gained of $6,613 in Germany and $2,260 in Australia. HCV testing was estimated to be cost-saving in both countries, driven by undiagnosed disease progression and high treatment cure rates for those LTC.

Why this matters

Our findings suggest that ED BBV OOT in high-prevalence areas in Germany and Australia could enhance earlier diagnosis of viral hepatitis and HIV, facilitate engagement in care, and prove cost-effective in both countries.

The evidence supports expanding national conversations on ED testing and underscores the need for real-world pilot programmes to validate these results and address implementation challenges.

The findings of this research were presented at the American Association for the Study of Liver Disease (AASLD) in Washington, DC, in November 2025.

Link to AASLD poster

Citation: Doyle JS, Rockstroh JK, Keen P, et al. Cost-effectiveness of Emergency Department opt-out BBV testing to advance elimination targets for Viral Hepatitis and HIV transmission: Tales from opposite corners of the world. Poster presented at AASLD Conference; 7-11th November 2025, Washington DC, USA.

References:

  1. WHO-HIV-2016.06-eng.pdf;jsessionid=976B0B9DC832661A16ABF997E03B8FC2 [Internet]. [cited 2025 Sept 17]. Available from: https://iris.who.int/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf;jsessionid=976B0B9DC832661A16ABF997E03B8FC2?sequence=1
  2. Understanding measures of progress towards the 95–95–95 HIV testing, treatment and viral suppression targets | UNAIDS [Internet]. [cited 2025 Sept 17]. Available from: https://www.unaids.org/en/resources/documents/2024/progress-towards-95-95-95
  3. Viral Hepatitis Mapping Project: Hepatitis B: Geographic diversity in chronic hepatitis B prevalence, management and treatment: National Report 2022. Sydney, New South Wales: ASHM; 2024.
  4. Wolffram I, Petroff D, Bätz O, Jedrysiak K, Kramer J, Tenckhoff H, et al. Prevalence of elevated ALT values, HBsAg, and anti-HCV in the primary care setting and evaluation of guideline defined hepatitis risk scenarios. J Hepatol. 2015 June;62(6):1256–64.
  5. Hepatitis C in Australia more than halved in less than a decade [Internet]. 2024 [cited 2025 Sept 17]. Available from: https://www.kirby.unsw.edu.au/news/hepatitis-c-australia-more-halved-less-decade
  6. Tergast TL, Blach S, Tacke F, Berg T, Cornberg M, Kautz A, et al. Updated epidemiology of hepatitis C virus infections and implications for hepatitis C virus elimination in Germany. J Viral Hepat. 2022;29(7):536–42.
  7. Kirby Institute U. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2024: HIV. Available from: https://www.kirby.unsw.edu.au/sites/default/files/documents/Annual_Surveillance_Report_2024_HIV.pdf
  8. Robert Koch Institut. Epidemiologisches Bulletin 28/2024. 2024; Available from: https://www.rki.de/DE/Aktuelles/Publikationen/Epidemiologisches-Bulletin/2024/28_24.pdf?__blob=publicationFile&v=2
  9. Mwachofi A, Fadul NA, Dortche C, Collins C. Cost-effectiveness of HIV screening in emergency departments: a systematic review. AIDS Care. 2021 Oct 3;33(10):1243–54.
  10. Williams J, Vickerman P, Douthwaite S, Nebbia G, Hunter L, Wong T, et al. An Economic Evaluation of the Cost-Effectiveness of Opt-Out Hepatitis B and Hepatitis C Testing in an Emergency Department Setting in the United Kingdom. Value Health J Int Soc Pharmacoeconomics Outcomes Res. 2020 Aug;23(8):1003–11.
  11. d’Arminio Monforte A, d’Ettorre G, Galardo G, Lani E, Kagenaar E, Huntington S, et al. Estimating the potential health economic value of introducing universal opt-out testing for HIV in emergency departments in Italy. Eur J Public Health. 2025 Apr 23;ckaf057.
  12. Jacob R, Prince DS, Pipicella JL, Nguyen A, Bagatella M, Alvaro F, et al. Routine screening of emergency admissions at risk of chronic hepatitis (SEARCH) identifies and links hepatitis B cases to care. Liver Int Off J Int Assoc Study Liver. 2023 Jan;43(1):60–8.
  13. Prince DS, Pipicella JL, Fraser M, Alvaro F, Maley M, Foo H, et al. Screening Emergency Admissions at Risk of Chronic Hepatitis C (SEARCH) to diagnose or ‘re-diagnose’ infections is effective in Australia. J Viral Hepat. 2021;28(1):121–8.
  14. INDICATIONS FOR HBV TESTING [Internet]. Testing Portal. [cited 2025 Sept 17]. Available from: https://testingportal.ashm.org.au/national-hbv-testing-policy/indications-for-hbv-testing/
  15. INDICATIONS FOR HCV TESTING [Internet]. Testing Portal. [cited 2025 Sept 17]. Available from: https://testingportal.ashm.org.au/national-hcv-testing-policy/indications-for-hcv-testing/
  16. Indications for HIV Testing [Internet]. Testing Portal. [cited 2025 Sept 17]. Available from: https://testingportal.ashm.org.au/national-hiv-testing-policy/indications-for-hiv-testing/
  17. Gandjour A. A Model-Based Estimate of the Cost-Effectiveness Threshold in Germany. Appl Health Econ Health Policy. 2023;21(4):627–35.
  18. Chen W, Howell M, Cass A, Gorham G, Howard K. Understanding modelled economic evaluations: a reader’s guide for clinicians. Med J Aust [Internet]. 2024 Aug 26 [cited 2025 Sept 17];Online first. Available from: https://www.mja.com.au/journal/2024/221/6/understanding-modelled-economic-evaluations-readers-guide-clinicians
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