Abstract
This study examined the views of 172 community-based Australian men who have sex with men (MSM) on the acceptability and potential uptake of rapid oral testing for HIV in clinic and home-based settings. Men were asked to complete a questionnaire that sought their views on rapid testing for HIV. When asked about which HIV test they would prefer in a clinic setting, 64% indicated a preference for rapid oral HIV testing and 74% indicated that if rapid oral HIV testing was available at a clinic they would test for HIV more frequently. If rapid oral HIV testing was available for home testing, 63% of men indicated it would be likely they would test themselves for HIV and 61% indicated they would test more frequently. Overall, MSM expressed a preference for rapid oral HIV testing and would test more frequently if testing was available for clinic or home use in Australia.
Introduction
In many countries men who have sex with men (MSM) remain one of the major risk groups for HIV acquisition. HIV testing is an important component of HIV control as diagnosis typically leads to changes in sexual practice that reduce the risk of further HIV transmission to sexual partners. 1 For example, HIV-infected men may seek sex with other HIV-infected men rather than with HIV-negative men.
Mathematical modelling suggests that increasing the coverage and frequency of HIV testing of MSM in Australia would result in reduced HIV incidence. 2 More frequent HIV testing would also be expected to reduce the reproductive rate for HIV infection. 3 It has been estimated that 19% of all new HIV infections are transmitted from the 3% of Australian HIV-infected MSM who have primary HIV infection and that 31% of new HIV infections are transmitted from the 9% of MSM with undiagnosed HIV infection. 2 In the USA, the proportion of MSM attending STD clinics who have never been tested for HIV and the frequency of HIV testing among MSM has been monitored as an index of prevention programme success. 4 Innovative ways to increase HIV, testing rates among MSM, including the use of rapid testing for HIV, are required.5,6
In eastern Australia, the proportion of MSM who reported HIV testing in the previous year has increased. By 2006, approximately 60% of Australian MSM tested for HIV each year. 7 However, modelling suggests that further increases in the proportion tested would contribute to further reductions in HIV incidence. 2 Across the same region, about 20% of MSM aged less than 30 had never been tested for HIV before. 7
While point of care testing for HIV has been used in a wide number of countries including the USA and the UK, none are currently approved for use in Australia. Furthermore, there are few published empirical data showing that access to rapid HIV testing results in more frequent HIV testing of MSM. We sought the views of Australian MSM on the acceptability and potential uptake of rapid oral testing for HIV in clinic and home-based settings.
Methods
MSM attending two gay community events in Victoria in 2009 were invited to take part in a project where they received rapid testing for syphilis.
The two events, Midsumma carnival (www.midsumma.org.au) and the ChillOut festival (www.chilloutfestival.com.au) are the major annual gay and lesbian community events in Victoria. Over 25,000 people attended the ChillOut festival in rural Victoria in 2009 with nearly 100 stallholders, while approximately 12,000–16,000 people attended the Midsumma carnival in metropolitan Melbourne.
The project received widespread media coverage prior to the events through the gay and mainstream press. As a result, men attending the two events presented to the site voluntarily without the need for recruitment. Marquees were set up at each event and staffed by sexual health doctors and nurses from the Melbourne Sexual Health Centre. As men interested in testing approached the marquee of their own accord, a participation rate was not applicable.
Men were asked to complete an anonymous questionnaire that sought their views on rapid testing for syphilis and HIV. Men were shown images and given information on the OraQuick ADVANCE® Rapid HIV 1/2 Antibody Test (OraSure Technologies, Bethlehem, PA, USA) and informed that the test is similar in its ability to detect HIV compared with conventional blood testing. Men were asked about their preferred method of HIV testing, their likelihood of using rapid testing in a clinical or home-based setting and if they would be likely to test more frequently if such testing was available. Responses were presented on 5–point Likert scales and men were asked to provide a reason for their preferences using free text.
Data from the questionnaire were entered into SPSS version 15. Descriptive analysis was conducted on quantitative data and the chi-square test was used to analyse categorical data. Men who reported being HIV positive were excluded from the analysis. Qualitative responses were analysed and themes grouped independently and then agreement reached on common themes.
The project received a waiver from the Alfred Hospital Research Ethics Committee as it was considered to be a clinical improvement activity.
Results
Of the 183 men who received rapid testing for syphilis, 176 men completed the questionnaire, four of whom reported being HIV positive. Data were analysed for the remaining 172 men. Fifteen per cent of men (n = 26) reported never being tested for HIV previously. Of the 126 who provided the time since they were last tested for HIV, the median time since their last HIV test was 12 months (range 1–228 months).
The median age of the men was 32 years (range 15–71 years). They reported a mean of 11 (range 1–200) male sex partners in the previous 12 months with 68 (48%) of the 141 men who reported anal sex reporting inconsistent or no condom use.
Clinic-based rapid HIV testing
When asked about which HIV test they would prefer in a clinic setting, 103 of the 160 (64%) men reporting a test preference indicated they would prefer rapid oral HIV testing with 29 (18%) preferring conventional blood testing and 28 (18%) expressing no preference. Of the 25 men who had never been tested for HIV and who reported a preference, 23 (92%) indicated they would prefer rapid oral HIV testing over conventional testing. Overall, 118 of 159 men (74%) indicated that if rapid oral HIV testing was available at a clinic they would test for HIV more frequently while 19 (12%) indicated they would not test more frequently and 22 (14%) were unsure.
Men reported (86/172) they would prefer rapid oral HIV testing for a range of reasons, including: because it would provide immediate and accurate results; the test was easy, simple and convenient to use; it was private and confidential; and would be less painful and invasive than conventional blood testing:
… convenience and peace of mind. (C10)
… quicker results, less stress in waiting to know. (C29)
The main reason men felt they would prefer conventional blood testing was because of the reliability of results:
… belief that usual blood test may be more accurate. (M47)
Home-based rapid testing
If rapid oral HIV testing was available for home testing, 104 of 166 men (63%) indicated it would be likely they would test themselves for HIV at home while 33 (20%) indicated they would be unlikely to self-test at home and 29 (17%) were unsure. Of the 26 men who had never been tested for HIV and reported on their likelihood of home-based testing, 22 (85%) indicated they would be ‘very likely’ or ‘likely’ to test themselves for HIV at home if tests were available. Furthermore, 100 of 165 men (61%) reporting on the frequency of home-based testing, indicated they would test more frequently if home HIV testing was available while 29 (18%) indicated they would not test more frequently and 36 (22%) were unsure.
Men reported (41/105) it likely they would test themselves at home because: it would give them confidentiality, privacy and discretion; immediacy of results; because it was easy, painless, safe and reliable; and because there was no waiting time to see a doctor or receive test results:
… just to have the security of knowing and not getting through the waiting game. (M52)
… quick, easy, confidential. (M121)
The main reasons men reported (18/33) they would be unlikely to test at home was because they would: prefer a health professional to administer the test; be concerned about the reliability of the test; and because of concern about receiving an HIV-positive result at home without any professional support:
… I would prefer to have a professional do it so I could discuss the results, especially if it came back positive. (M45)
Responses to these questions were compared between men who reported testing for HIV within the previous 12 months and those who last tested more than 12 months previously. There was no significant difference in the proportion who preferred rapid testing in either a clinic (P = 0.2) or home setting when the two groups of men were compared (P = 0.6). No difference was evident between how likely men would be to test at home and whether they had ever tested for HIV before (P = 0.4) or whether they had tested for HIV in the previous 12 months or not (P = 0.9). Furthermore, there was no difference in the proportion who indicated they would test more frequently with rapid testing either in a clinic (P = 0.2) or home setting (P = 0.4).
Overall, 83% of men felt that it would be helpful, if rapid oral HIV testing was available in Australia, to have access to medical advice and counselling support over the telephone and if this number was listed in the test kit.
Discussion
In this community-based sample of Australian MSM, men expressed a preference for rapid oral HIV testing and would test more frequently for HIV if testing was available for clinic or home use in Australia. The main reasons men stated they would prefer rapid oral HIV testing was because they felt it would be: easy; provide immediate results; and would be less invasive than conventional blood testing. Men who indicated a willingness to test themselves at home for HIV did so because they could be assured of privacy and confidentiality and because it would save them time in waiting to see a doctor and receive test results.
Limitations
There are some strengths and limitations to this study. Men were recruited from a non-clinical setting so as to capture men who had not previously been tested for HIV or who had not tested frequently for HIV in the past. It is this group of men who stand to gain the most from HIV testing. A limitation of the study is that the findings may not be generalizable to other populations of MSM. As men in this study volunteered for rapid oral syphilis testing, it is possible this may have biased their views in favour of rapid oral HIV testing.
A further limitation was that men were asked hypothetically about rapid HIV testing without actual experience of testing themselves. As the questionnaire was self-administered, information on the test was kept brief, with men informed that the OraQuick test is similar in its ability to detect HIV as conventional blood testing. The window period for point of care HIV tests is generally longer than for later generation immunoassays, resulting in non-reactive results during early HIV infection. 6 It is possible that men's preference for rapid testing and their likelihood of testing more frequently may have differed if they had experienced testing or been informed of the possibility of a longer window period.
While to our knowledge, rapid self-testing for HIV has not been approved, approval for such testing has been sought. 4 Of note, in a recent US study in which men and women attending an emergency department undertook self-HIV testing, a strong preference was shown for rapid oral HIV test over finger-stick blood testing, with 97% of patients who experienced rapid oral HIV testing reporting they would ‘definitely or probably recommend’ testing to a friend and would ‘probably or definitely’ perform a self-test at home if testing was available. 8 An almost 100% concordance was found in reading of the test results between patients and healthcare workers. 8
The preferences and reasons expressed by MSM in favour of rapid testing for HIV in this study in both clinic and home-based settings support the evaluation of rapid testing as a means of increasing HIV testing of MSM in Australia. Prospective studies are required to determine if access to rapid HIV testing increases the frequency of HIV testing among MSM. Studies should determine whether any of the benefits derived from rapid oral HIV testing are offset by possible harms, one of which may be the longer window period associated with rapid oral HIV testing compared with later generation HIV immunoassays.
Footnotes
Acknowledgements
We wish to thank the following people for their support of this study: the men who kindly agreed to the study, doctors and nurses from the Melbourne Sexual Health Centre who distributed the questionnaires, the organizers of the Midsumma carnival and ChillOut festival and the Alfred Health Public Relations Unit. Quoc Pham (Orasure, USA) for providing consent to the use of images of the Oraquick Advance® Test.