Provision of HIV test results by telephone is both safe and efficient for men who have sex with men

Abstract

The aim of this study was to assess the impact of delivering HIV test results by telephone on HIV testing and subsequent risk behaviour of men, as well as saving on clinic consultation time. It was conducted at the Melbourne Sexual Health Centre, the main public sexual health clinic servicing Victoria, Australia. In 2013, a policy change was introduced so men could obtain their HIV test result via telephone. We compared the proportion of men testing for HIV and receiving results in the 24 months before (2011–2012) and the 24 months after (2013–2014) the policy change. There was a modest increase in the proportion of men having a HIV test of 3.2% (p < 0.001) after the policy change. The provision of HIV results by telephone more than halved the number of men re-attending (74.4% vs. 33.1%) which freed up 516 hours of clinic time and had no adverse outcome on subsequent risk behaviour, nor changed the proportion of men who obtained their HIV results (p = 0.058), or the period of time between testing and obtaining results for HIV-negative (p = 0.007) and HIV-positive results (p = 0.198). Telephone notification of HIV test results is a useful option given the potential beneficial effects shown.

Keywords

Testing rates risk profile HIV

Introduction

Early detection of HIV can improve the prognosis of HIV through the timely administration of antiretroviral therapy and can reduce onward transmission of HIV through an individual’s awareness of their infection and changes in sexual behaviour.^1,2 Various approaches such as home HIV testing,³ opt out testing for HIV⁴ and elimination of written consents for HIV testing,⁵ have shown to reduce barriers and HIV testing among men who have sex with men (MSM). International guidelines for regular and frequent HIV testing^6,7 have underscored the importance of early diagnosis of HIV. While the rates of HIV testing among MSM in Australia are higher than among MSM in some other industrialised countries,⁸ data from published studies of MSM in Australian cities suggest that about 20–30%^9,10 of HIV-positive MSM in the community are not aware of their HIV status due to low testing rates of HIV. Moreover, mathematical modelling suggests that increased frequency of HIV testing among Australian MSM could have a substantial impact on the control of HIV in Australia through the identification of early HIV infection and reduced onward transmission.¹¹ A change in policy for providing HIV test results was therefore introduced at our clinic whereby men were given the option to telephone the clinic to obtain their HIV test result. This policy change was aimed at increasing HIV testing uptake of MSM by removing the constraints of a return visit for HIV test results.^8,12 This study primarily aimed to determine whether the rate of HIV testing and detection was different before and after telephone HIV results were introduced. We also sought to determine the change in proportion of men receiving their HIV result as well as the impact of telephone post-test discussion following a HIV-negative result, on any subsequent risk behaviour of men and compared their risk profile to those men who received face-to-face post-test discussion.

Methods

This study was conducted at the Melbourne Sexual Health Centre, the main public sexual health clinic servicing Victoria, Australia. On 1 January 2013, a change in policy for providing HIV test results was introduced whereby men were permitted to telephone the clinic to obtain their HIV test result. All HIV-positive test results are still provided at a face-to-face consultation usually after clients are called by a clinician and asked to return for their results. Prior to 2013, men were told to re-attend the clinic at least seven days after a HIV test for a face-to-face consultation to obtain their result. Seven days between testing and obtaining results was chosen so as to include more time for extra testing for HIV that may be conducted by the laboratory on those samples which return positive or indeterminate results on screening for HIV.

Men who had male partners in the last 12 months were included if they attended the clinic for the first time from 1 January 2011 to 31 December 2013, and repeat attendances were excluded. We compared the proportion testing for HIV in the 24 months before (2011–2012) and the 24 months after (2013–2014) the introduction of the policy change to obtain HIV antibody test results by telephone. Data on serological testing for HIV was obtained from the Victorian Infectious Diseases Laboratory. Information regarding the method men used to obtain their HIV results by telephone within 30 days (hereon referred to as ‘telephone result consultation’) or clinic re-attendance within 30 days (hereon referred to as ‘attendance result consultation’) was ascertained from their electronic medical patient record (CPMS).

Prior to the introduction of telephone results for HIV for MSM, all health personnel at MSHC were trained to ensure safe and effective telephone consultations. Clients were advised to ring the clinic seven days after they had a HIV test and were asked to confirm their identity before receiving their result. Post-test discussion was conducted using the Australian HIV testing guidelines¹³ and covered the same issues as would be covered in a face-to-face consultation, with clients being advised to re-attend for further discussion or any additional testing required to cover any potential HIV window period.

As per national guidelines¹³ and in keeping with Victorian legislation governing HIV testing, the provision of HIV-positive results is conducted by face-to-face consultation only. For those men who tested positive for HIV, we telephoned them and advised them to return to the clinic to obtain their results. We did not wait for men to telephone the clinic if their HIV test returned a positive result as it is critical to reduce onward transmission.

Consultation time spent in each visit is collected automatically within the practice software. Where men elected to return to the clinic to obtain their HIV result, the mean time for this attendance result consultation was calculated from CPMS, and compared to the mean time for a telephone result consultation for an HIV result. We only included consultations that occurred for the provision of ‘results only’ which is a special diagnostic code used within our clinic software for patients who are attending solely to obtain their STI screening results.

We examined the risk profile data (i.e. number of sexual partners and condom use) of the men who attended the clinic for a second time at least 3–12 months after their first HIV test for repeat STI screening to determine if there was any difference in subsequent risk behaviour of men who received telephone post-test discussion for HIV as compared to men who received face-to-face post-test discussion for HIV.

Data were analysed using SPSS version 22. Proportions with 95% confidence intervals (CI) of men who tested for HIV and men who had received the test results within 30 days via different methods were calculated. The chi squared test was used to compare the change in proportion between two periods (2011–2012 vs. 2013–2014). The paired t-test was used to compare the changes in sexual behaviour among men before and after receiving the HIV test results via the two different methods. Ethical approval for this study was granted by the Alfred Hospital Human Research Ethics Committee (number 450/14).

Results

There were 3338 men who attended the clinic for the first time between 2011 and 2012, and 3942 men between 2013 and 2014. The median age range of these men was 31 years (IQR 18–56 years). Of these men, 2866 (85.9%; 95% CI: 84.6–87.0) had a HIV test done in the first time period (2011–2012) and 3511 (89.1%; 95% CI: 88.1–90.0) in the second time period (2013–2014), (difference in proportion = 3.2%; 95% CI: 1.7–4.7, p < 0.001; Table 1).

Table 1.

The proportion of men who had a HIV test and who obtained their results either by telephone or attendance within 30 days.

	Pre-period (2011–2012)	Post-period (2013–2014)	Difference in proportion (95% CI, p value)
Total number of 1st consultations	3338	3942
Number of 1st consultation and had a HIV test done	2866 (85.9%)	3511 (89.1%)	3.2% (1.7–4.7, p < 0.001)
Result by phone within 30 days^a	49 (1.7%)	1580 (45.0%)	43.3% (41.3 to 45.3, p < 0.001
Result by visit within 30 days	2131 (74.4%)	1161 (33.1%)	41.3% (38.7 to 43.3, p < 0.001)
Result by phone OR visit within 30 days	2180 (76.1%)	2741 (78.1%)	2% (−0.07 to 4.0, p = 0.058)
Time to obtain result by phone OR visit within 30 days (mean ± SD)	8.76 (±4.54)	8.24 ± 4.15	p < 0.001
Number of men diagnosed with HIV	106 (3.1%)	128 (3.2%)	0.1% (−0.7 to 0.9, p = 0.807)
Time to obtain HIV result (mean ± SD)	11.1 ( ± 24.1)	7.8 (±4.7)	p = 0.198

In the 2011–2012 study period, the proportion of men who received their result within 30 days either by telephone or by attendance increased non-significantly from 76.1% (2180/2866, 95% CI: 74.5–77.7) in 2011–2012 to 78.1% (2741/3511, 95% CI: 76.7–79.5) in 2013–2014 (difference in proportions = 2%, 95% CI:−0.07 to 4.0%, p = 0.058). The mean time between testing for HIV and obtaining the HIV result in 2011–2012 was 8.76 days (SD: ±4.56 days) and in 2013–2014 was 8.30 days (SD: ±4.83 days, p = 0.007; Table 1).

The proportion of men who had a telephone result consultation was 1.7% and 45.0% in 2011–2012 and 2013–2014, respectively. The proportion of men who had an attendance result consultation decreased from 74.4% in 2011–2012 to 33.1% in 2013–2014 (p < 0.001).

The proportion of men diagnosed with HIV in 2011–2012 was 3.1% (106/2866, 95% CI: 3.0–4.4) and in 2013–2014 was 3.2% (128/3511, 95% CI: 3.0–4.4) (difference in proportion = 0.1%, 95% CI: −0.7 to 0.9, p = 0.807). The mean time between testing for HIV and receiving a positive HIV test result was 11.1 (SD:±24.1) days for 2011–2012 and for 2013–2014 was 7.18 days (SD: ±4.8 days, p = 0.198). There was only one man in each of the two time periods who was not able to be contacted to advise him of his positive HIV result despite multiple attempts to make contact as per the clinic’s protocols.

The mean time spent by men on an attendance result consultation in 2013–2014 was 22.1 min. In contrast, the mean time spent by men on a telephone result consultation was 2.5 min – a saving of 19.6 min per consultation. A total saving of 516 hr of consultation time for the 1580 men who had a telephone result consultation rather than an attendance result consultation in 2013–2014.

There was no difference in the baseline (day of screening) risk profile of men who tested in 2011–2012 and 2013–2014 with regard to age (p = 0.504), always condom use (p = 0.203) and number of partners in the last 12 months (p = 0.061). Additionally, in the 2013–2014 period, there was no difference in the risk profile between men who had a telephone result consultation or attendance result consultation for age (p = 0.423); condom use (p = 0.104) and number of partners in the last 12 months (p = 0.052).

Of the 1746 men who attended for the first time in 2013 and had an HIV test, 549 (31%) returned within 3–12 months for repeat STI testing. Of these 31% of men, 262 (48%) had a telephone result consultation after their first HIV test and 287 (53%) men had an attendance result consultation to obtain their result in 2013. We examined the risk profile of the men from these two groups when they attended for repeat STI testing. There was no significant change in the mean number of partners reported in the 12 months preceding their second STI screening visit within the telephone result consultation group (from 9.1 to 10.8, p = 0.255) as well as within the attendance result consultation group (from 10.6 to 10.1, p = 0.577), and the changes were not significant between both groups (p = 0.196). There was also no significant change in condom use reported in the 12 months preceding their second visit within the telephone result consultation group (from 53.5 to 51.9%, p = 0.734) and within the attendance result consultation group (from 43.4 to 43.3%, p = 0.991), and this reduction in condom use between both groups was not statistically significant (p = 0.06; Table 2).

Table 2.

Comparison of risk profile of men who received their HIV results by telephone or face to face within 30 days including attendance consultation time in 2013.

	Received results via telephone (N = 262)			Received results via return visit (N = 287)			Comparison between results received via telephone and via return visit (p-value)^a
	Baseline	Follow-up at 3–12 months	p value^b	Baseline	Follow-up at 3–12 months	p value^b	Differences between groups	p value
Number of man partners in the last 12 months (mean ± SD)	9.1 ± 12.2	10.8 ± 28.6	p = 0.255	10.6 ± 14.6	10.1 ± 13.5	p = 0.577	2.2	p = 0.196
Always condom use with man in the last 12 months (%)	53.5%	51.9%	p = 0.734	43.4%	43.3%	p = 0.991	1.5	p = 0.06

p Value calculated from independent t-test comparing the difference in number of partners, and p value calculated from Chi square test comparing the difference in condom use between MSM received results via phone and return visit at baseline and at 3–12 months follow-up, respectively.

p Value calculated from paired t-test comparing the changes in sexual behaviour at baseline and at 3–12 months follow-up.

Discussion

In our study, we found a modest increase in the proportion of men having an HIV test of 3.2% after the introduction of delivering HIV test results by telephone. We also showed that provision of HIV test results by telephone did not compromise the proportion of men who obtained their HIV results (76.1% vs. 78.1%), nor the period of time between testing for HIV and obtaining the result for both HIV negative results (p = 0.007) and HIV positive results (p = 0.198). The provision of HIV results by telephone more than halved the number of men re-attending to the clinic (74.4% vs. 33.1%) which freed up 516 hr of clinic time for other clinical tasks. We also showed that provision of post-test discussion for HIV by telephone rather than face to face had no adverse outcome on risk behaviour.

By simplifying the provision of HIV test results through use of the telephone, it removes the need for a second clinic visit, just to obtain results. A study done in Hamilton New Zealand¹⁴ published in 2005 showed an increase in the uptake of HIV testing of 7.7% (from 36.9%) in the first six months following the introduction of telephone results for HIV. We had a smaller increase in testing for HIV of 3.2% which may at least in part reflect high baseline testing (85.9%) rates of men in our clinic compared to international standards⁸ making additional gains more difficult to achieve.

Several studies have examined the impact of offering HIV results over the telephone on the proportion of those tested who obtain their HIV test result.^14–17 The study by McKinstry et al.¹⁵ conducted in King County, Washington from 1995 to 2002 showed that for men and women who test positive for HIV, overall rates of receiving results before and after telephone results were offered, increased from 85 to 94% (p = 0.07). The individuals in the group who were offered telephone results were 2.5 times more likely to obtain their HIV results compared to persons in the group not offered telephone results. A study conducted in Portland, Oregon¹⁵ in 2002 showed that more homeless youth in the telephone option group (58%) received their HIV test results than those in the face-to-face notification group (37%). A more recent study by Conway et al.¹⁷ in 2010 in Sydney, Australia showed that amongst low risk MSM¹⁷ and heterosexual clients, 86% received their results by telephone within 30 days (median seven days). A previous study in Sydney¹⁸ reported 20% of all those tested for HIV failed to attend for their HIV results in person. Our study proved that provision of HIV test results by telephone slightly increased the proportion of men who obtained their HIV results, although this was not statistically significant, and did not change the period of time between testing for HIV and obtaining the result for both HIV negative and positive results.

Reducing the number of return clinic visits for HIV results is both feasible and cost saving. Fewer clinic visits free up clinic resources and facilitates the better use of clinic time to test more MSM for HIV. Taylor et al.¹⁹ in their evaluation of offering HIV test results telephonically in Vancouver, Canada found that the average number of clinic visits per month decreased from 410 to 160 after the change was introduced. Other studies looking at re-distribution of services at our clinic^20,21 following a change in the frequency of STI testing of another patient risk group, from monthly to quarterly, showed a reduction in clinic consultations of 40%. This created additional clinic capacity to screen more patients and to see more symptomatic patients who are more likely to have a diagnosed STI. Our study too showed that by providing HIV test results over the telephone, a reduction in clinic visits of 40% was achieved; this translated to 516 hours saved in 2013–2014 which facilitated a re-distribution of clinic resources.

Point of care testing for HIV has the potential to improve the uptake of testing because of the immediacy of test results. When surveyed, most MSM in Melbourne anticipated they would test more frequently if oral fluid rapid HIV tests were available.⁹ However, in a recent randomised controlled trial at our clinic by Read et al.²² which randomised men to either on-going access to rapid HIV testing or to conventional HIV serology showed that rapid testing for HIV did not result in a sustained increase in HIV testing over time. However, the men in the conventional HIV testing arm were required to return the clinic to obtain their HIV result.²²

Our study has a few limitations. We cannot be certain that the modest increase in testing rate of 3% is at all or in part due to the provision of HIV results by telephone. Other factors such as robust advertising campaigns to promote STI/HIV may have contributed.²³ We also did not conduct any patient evaluation outcomes, including acceptability of service, ease and timeliness in obtaining the result and perceived confidentiality and privacy. Further rigorous qualitative data evaluating patient outcomes are prudent.

The collective evidence from our study suggests that providing HIV test results by telephone is safe and at least as effective as face-to-face attendance for HIV results. Given the potential effect that the provision of telephone results for HIV can have on the uptake of HIV testing and obtaining results with no adverse change in risk behaviour, telephone notification of HIV test results is a useful option for some patients and should be considered as one of many alternative HIV testing strategies for HIV prevention programmes.

Footnotes

Acknowledgements

We wish to thank Jun Kit Sze and Afrizal for data extraction and laboratory staff at the Victorian Infectious Disease Research Laboratory for handling specimens and performing HIV serology. We also wish to thank staff at the Melbourne Sexual Health centre who supported the study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: MB was supported by National Health and Medical Research Council postgraduate scholarship (ID 1038734). EPFC was supported by the Early Career Fellowships from the Australian NHMRC (1091226).

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