Phillip Keen

Barriers to HIV testing among Australian gay men

OBJECTIVE To investigate the barriers to HIV testing among Australian gay men. METHODS An online survey was conducted to explore reasons for avoiding and delaying testing for HIV; 519 non-HIV-positive men completed the online survey. RESULTS Most non-HIV-positive men (92.9%) had been tested for HIV, with 75.4% indicating they had been tested in the previous year. The most common reasons for avoiding or delaying testing were a belief that they had not done anything risky (41.2%) and the need to return for a second clinic visit to receive results (40.3%). Among men who engaged in unprotected anal intercourse with casual partners (UAIC), those who had not been recently tested were more likely to cite the lack of any symptoms as reasons for not having tested (adjusted odds ratio: 2.34; 95% confidence interval: 1.03-5.31; P=0.041). CONCLUSIONS For men who do not engage in risky sex, the decision not to test is probably reasonable, but those who engage in non condom-based risk reduction may be at some increased risk and should be encouraged to test relatively often. Changes to Australias national HIV testing policy may ameliorate some of the need to return for second clinic visits to receive results, but the policy still requires full implementation, including the introduction of rapid point-of-care HIV testing to Australia. Among men who engage in UAIC, there appears to be a particular need for information about the benefits of early treatment after HIV diagnosis and about the relative likelihood of experiencing HIV seroconversion illness.

Multi-Centre Evaluation of the Determine HIV Combo Assay when Used for Point of Care Testing in a High Risk Clinic-Based Population

Background Determine HIV Combo (DHC) is the first point of care assay designed to increase sensitivity in early infection by detecting both HIV antibody and antigen. We conducted a large multi-centre evaluation of DHC performance in Sydney sexual health clinics. Methods We compared DHC performance (overall, by test component and in early infection) with conventional laboratory HIV serology (fourth generation screening immunoassay, supplementary HIV antibody, p24 antigen and Western blot tests) when testing gay and bisexual men attending four clinic sites. Early infection was defined as either acute or recent HIV infection acquired within the last six months. Results Of 3,190 evaluation specimens, 39 were confirmed as HIV-positive (12 with early infection) and 3,133 were HIV-negative by reference testing. DHC sensitivity was 87.2% overall and 94.4% and 0% for the antibody and antigen components, respectively. Sensitivity in early infection was 66.7% (all DHC antibody reactive) and the DHC antigen component detected none of nine HIV p24 antigen positive specimens. Median HIV RNA was higher in false negative than true positive cases (238,025 vs. 37,591 copies/ml; p = 0.022). Specificity overall was 99.4% with the antigen component contributing to 33% of false positives. Conclusions The DHC antibody component detected two thirds of those with early infection, while the DHC antigen component did not enhance performance during point of care HIV testing in a high risk clinic-based population.

Effect of availability of HIV self-testing on HIV testing frequency in gay and bisexual men at high risk of infection (FORTH): a waiting-list randomised controlled trial

BACKGROUND Frequent testing of individuals at high risk of HIV is central to current prevention strategies. We aimed to determine if HIV self-testing would increase frequency of testing in high-risk gay and bisexual men, with a particular focus on men who delayed testing or had never been tested before. METHODS In this randomised trial, HIV-negative high-risk gay and bisexual men who reported condomless anal intercourse or more than five male sexual partners in the past 3 months were recruited at three clinical and two community-based sites in Australia. Enrolled participants were randomly assigned (1:1) to the intervention (free HIV self-testing plus facility-based testing) or standard care (facility-based testing only). Participants completed a brief online questionnaire every 3 months, which collected the number of self-tests used and the number and location of facility-based tests, and HIV testing was subsequently sourced from clinical records. The primary outcome of number of HIV tests over 12 months was assessed overall and in two strata: recent (last test ≤2 years ago) and non-recent (>2 years ago or never tested) testers. A statistician who was masked to group allocation analysed the data; analyses included all participants who completed at least one follow-up questionnaire. After the 12 month follow-up, men in the standard care group were offered free self-testing kits for a year. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613001236785. FINDINGS Between Dec 1, 2013, and Feb 5, 2015, 182 men were randomly assigned to self-testing, and 180 to standard care. The analysis population included 178 (98%) men in the self-testing group (174 person-years) and 165 (92%) in the standard care group (162 person-years). Overall, men in the self-testing group had 701 HIV tests (410 self-tests; mean 4·0 tests per year), and men in the standard care group had 313 HIV tests (mean 1·9 tests per year); rate ratio (RR) 2·08 (95% CI 1·82-2·38; p<0·0001). Among recent testers, men in the self-testing group had 627 tests (356 self-tests; mean 4·2 per year), and men in the standard care group had 297 tests (mean 2·1 per year); RR 1·99 (1·73-2·29; p<0·0001). Among non-recent testers, men in the self-testing group had 74 tests (54 self-tests; mean 2·8 per year), and men in the standard care group had 16 tests (mean 0·7 per year); RR 3·95 (2·30-6·78; p<0·0001). The mean number of facility-based HIV tests per year was similar in the self-testing and standard care groups (mean 1·7 vs 1·9 per year, respectively; RR 0·86, 0·74-1·01; p=0·074). No serious adverse events were reported during follow-up. INTERPRETATION HIV self-testing resulted in a two times increase in frequency of testing in gay and bisexual men at high risk of infection, and a nearly four times increase in non-recent testers, compared with standard care, without reducing the frequency of facility-based HIV testing. HIV self-testing should be made more widely available to help increase testing and earlier diagnosis. FUNDING The National Health and Medical Research Council, Australia.

Barriers to HIV testing and characteristics associated with never testing among gay and bisexual men attending sexual health clinics in Sydney

HIV diagnoses among gay and bisexual men have increased over the past decade in Australia. HIV point‐of‐care testing (POCT) was introduced in Australia in 2011 as a strategy to increase HIV testing by making the testing process more convenient. We surveyed gay and bisexual men undergoing POCT to assess barriers to HIV testing and characteristics associated with not having previously tested for HIV (never testing).

Rapid HIV Testing Is Highly Acceptable and Preferred among High-Risk Gay And Bisexual Men after Implementation in Sydney Sexual Health Clinics

Background Rapid HIV testing (RHT) is well established in many countries, but it is new in Australia. We assessed the acceptability of RHT and its associations among gay, bisexual and other men who have sex with men (GBM) after implementation of RHT in Sydney sexual health clinics. Methods GBM were invited to complete an acceptability questionnaire before and after provision of the result of finger-prick blood RHT, comparing their experience of RHT with conventional HIV testing (CHT) involving venipuncture. Logistic regression was used to assess associations between patient characteristics and the preference for RHT over CHT next time they tested for HIV. Results Of 1061 GBM who received non-reactive RHT results, 59% found RHT less stressful than CHT and 34% reported no difference, and 61% found RHT more comfortable than CHT and 26% reported no difference. Nearly all men were satisfied with RHT result delivery (99%) and the RHT process overall (99%). Most men (79%) preferred RHT for their next HIV test and this preference was stronger in men who were aged 35-44 years (adjusted odds ratio [AOR] 2.49, p<0.01), reported they would test more often if RHT was available (AOR 1.66, p=0.01), found returning for results annoying (AOR 1.67, p=0.01), and found RHT less stressful (AOR 2.37, p<0.01) and more comfortable (AOR 1.62, p=0.02) than CHT. Men concerned about the reliability of RHT were less than half as likely to prefer RHT for their next HIV test (AOR 0.44, p<0.01). Conclusions Most GBM preferred RHT to CHT next time and this preference was associated with finding RHT more convenient, more comfortable and less stressful than CHT. These findings suggest that in a clinic setting RHT should be considered to improve the patient experience and may potentially increase uptake and frequency of HIV testing.

Implementation and Operational Research: Convenient HIV Testing Service Models Are Attracting Previously Untested Gay and Bisexual Men: A Cross-sectional Study.

Introduction:HIV testing is a cornerstone of the treatment as prevention approach. We assessed which HIV testing service delivery models were more likely to attract untested or infrequent tested gay, bisexual and other men who have sex with men (GBM). Methods:We compared demographics, risk behavior, and HIV testing history among new GBM clients attending 3 different HIV testing service models (fast-track Xpress clinic, fixed-site community-based service, and time-limited community-based shopfront) between August 2013 and May 2014. We used bivariate and multivariate regression to assess factors (including service model) associated with being untested or infrequent testers (not tested within the past 12 months). Results:Overall, 1704 new GBM attended the services; 19% were untested and 41% were infrequent testers. Across the services, there were significant differences in demographics, risk behavior, and HIV testing history. The overall HIV seropositivity was 1.2% (95% confidence interval: 0.8% to 1.9%) and sexually transmitted infection positivity was 12.4% (95% confidence interval: 11.6 to 17.2) with no significant differences across services. Factors independently associated with being untested were attendance at the 2 community sites, younger age, being born in Asia, living in North Sydney, being bisexual and reporting fewer male sexual partners. Factors independently associated with infrequent testers were attending the fast track Xpress clinic, being older, being born in Asia, and reporting fewer male partners. Conclusions:The findings suggest both community and fast track testing service models are important to increase HIV testing among GBM with a similar yield of HIV diagnoses at the 3 services. The community models reached more untested men and the fast track model more infrequent testers.

The acceptability of different HIV testing approaches: cross-sectional study among GMSM in Australia

Background We explored the attitudes of Australian gay and other men who have sex with men (GMSM) about the current standard-of-care (non-rapid tests at healthcare settings) and alternative approaches (rapid tests and testing in non-healthcare settings) to better understand the acceptability of alternative testing approaches. Methods The Contemporary Norms in Networks and Communities of GMSM study enrolled GMSM in Sydney, Melbourne and Perth in 2011–2012 using peer referrals. We explored the self-reported preferences for testing: rapid versus non-rapid and in non-healthcare settings (community-based or home-based testing) versus in healthcare settings, and examined factors associated with preferences for these approaches. Analyses of associations used standard univariate and age-adjusted logistic regression models. Results Among 827 sexually active non-HIV-positive participants, 89% had been tested for HIV. Most preferred by participants was home rapid testing (46%), followed by standard-of-care (23%) and rapid testing in healthcare (20%) or community settings (7%). About 73% of participants preferred rapid over non-rapid testing, and 56% preferred testing in non-healthcare settings rather than in healthcare settings. Preference for rapid testing was associated with being fully employed (adjusted OR (aOR): 1.81; 95% CI 1.16 to 2.82), managerial/professional occupation (aOR: 2.03; 95% CI 1.19 to 3.46) and engaging in unprotected anal intercourse with casual partners (aOR: 1.89; 95% CI 1.29 to 2.78). The same factors were associated with preference for testing in non-healthcare settings. Conclusions Australian GMSM prefer alternative testing approaches, possibly due to their convenience. The availability of new testing approaches may provide more options for GMSM at risk for HIV infection, improve access to HIV testing and potentially increase HIV testing rates.

Potential public health benefits of HIV testing occurring at home in Australia.

In many countries, including Australia, policies have recently changed to support HIV self‐testing. The decision has created much debate about the public health benefits of the strategy versus the risks. Self‐testing for HIV was approved in the US on the basis that it would facilitate greater HIV testing uptake, despite having a lower sensitivity than laboratory HIV immunoassays. We calculated the frequency of self‐testing that would be required among Australian gay and bisexual men at high‐risk for there to be a public health benefit (detection of HIV infections that would have otherwise remained undiagnosed). At a population level, if access to HIV self‐testing led to men supplementing their usual sexual health check‐ups (involving a laboratory HIV immunoassay) with one or more self‐tests at home, or self‐tests led to untested gay and bisexual men having an HIV test for the first time, there would be a public health benefit. If men replaced their average of one laboratory HIV immunoassay per year with self‐testing at home, then three self‐tests would be needed to counteract the lower sensitivity of the self‐test (so zero infections would be missed). If four self‐tests were undertaken then additional infections would be detected (ie, there would be a public health benefit). Additional public health benefits include a reduction in the period of undiagnosed infection, which is known to be a period of relatively high infectiousness.

Replacement of conventional HIV testing with rapid testing: mathematical modelling to predict the impact on further HIV transmission between men

Background Rapid HIV testing is not permitted in Australia at the point of care. The authors evaluate the expected net effect of rapid HIV testing compared with standard serology diagnostic tests in terms of onward HIV transmission. Methods The authors used data for 174 men who had sex with men testing HIV-positive at the Melbourne Sexual Health Centre, Australia, in an agent-based mathematical model. Time of diagnosis is simulated according to conventional enzyme immunoassays or rapid HIV tests, with different window periods. The authors calculated the expected number of additional/averted transmissions due to missed or earlier diagnoses. Results Fourth generation rapid tests were simulated to miss ∼2–3% of diagnoses compared with conventional fourth generation enzyme immunoassay tests. However, in the remaining 97–98% of cases the rapid test would result in earlier detection of HIV. Overall, the rapid test would reduce time to patients receiving results by a median of ∼12 days. Assuming no changes in testing rates, the introduction of rapid testing diagnostic technologies would prevent one in every 2000–5000 HIV transmissions compared with the conventional diagnostic test. Conclusions Rapid tests would have a marginal benefit in reducing HIV transmission between men compared with conventional tests under assumptions of no changes in testing frequencies.

The 2016 HIV diagnosis and care cascade in New South Wales, Australia: meeting the UNAIDS 90-90-90 targets

The HIV Strategy in New South Wales (NSW) Australia aims to virtually eliminate HIV transmission by 2020. We estimated the 2016 HIV diagnosis and care cascade for the state of NSW, with a focus on introducing population‐based data to improve data quality and assess progress towards the UNAIDS 90‐90‐90 targets.