Abstract
In the UK the uptake of HIV testing among sexual health clinic attendees is high (∼90%) among men who have sex with men (MSM), although data suggest that people still leave clinic with undiagnosed HIV infection, having declined the offer of an HIV test. 1,2 This missed opportunity to diagnose HIV is important as late diagnosis is the major factor contributing to HIV-related death. 3 Reasons for declining HIV testing include low personal risk perception and lack of preparedness for testing. 4,5 The aim of this study was to determine why MSM at high risk of HIV infection decline HIV testing.
The setting was two sexual health clinics with large numbers of MSM attending: in London (Mortimer Market Centre, MMC) and in Brighton (Claude Nicol Centre, CNC). Between April 2008 and December 2009, MSM who attended the sexual health clinic at CNC (April 2008–October 2009) or MMC (May 2009–December 2009) and declined HIV testing but were assessed as high risk for HIV were invited to participate. High risk for HIV was defined as participating in unprotected anal intercourse (UAI) since their last HIV test and not tested for HIV in the last three months, or ever participating in UAI and never tested for HIV. Participants were given a detailed anonymous questionnaire about their sexual practices, self-assessed HIV risk and knowledge of HIV.
Nineteen men were recruited (9 MMC, 10 CNC). Although MSM who declined the questionnaire were not recorded, using data from a previous audit of clinic attendees, we estimate the questionnaire uptake in eligible MSM who declined HIV testing to be 11%. In the previous three months, 13 (68%) had had UAI. Nine (47%) reported having a regular male partner, of whom two were known to be HIV-infected. All men were aware that treatment for HIV was available. Eighteen (95%) were aware of prosecutions for HIV transmission. The majority (15; 79%) considered themselves to be low risk of HIV infection. Reasons for perceiving themselves at low risk included UAI without ejaculation, small numbers of sexual partners and UAI with a HIV-negative regular male partner. As factors contributing to their decision to decline HIV testing, respondents commonly cited being emotionally unprepared for a positive result (15; 79%) and, less commonly, awareness of prosecution for HIV transmission (4; 21%) and concerns over confidentiality (3; 16%). The principal perceived benefits of HIV testing were ‘peace of mind’ (16; 84%) and the ability to access timely HIV treatment (16; 84%). Most respondents indicated that the major disincentive to HIV testing was that they found it stressful (17; 89%).
Knowledge about HIV was high and most respondents perceived themselves to be at low risk, in contrast to the clinician's assessment. This may reflect risk reduction strategies such as negotiated safety – serosorting. 6 In any event, if men considered their HIV risk to be low, it remains unclear why a lack of emotional preparation for a positive HIV result was given as an important reason to decline testing. The study was small and low uptake may have introduced bias into the results. Further qualitative research may elucidate why there is a strong emotional response underlying declining an HIV test. This could lead to enhanced strategies for encouraging HIV testing which will be essential to identify a higher proportion of HIV infections at an early stage.