By Caroline Park, Paul Flowers (Glasgow Caledonian University)
Last week’s report from Public Health England shows that 100,000 people in the UK are living with HIV. New diagnoses amongst gay men remain high with 3250 in 2013 alone. It is estimated there are 7200 undiagnosed gay men living with HIV. This is a key population which maintains the rate of new HIV infections and shows no decline across the last few years. Understanding this group of men and enabling them to seek testing and treatment represents a vital way forwards in controlling HIV in the UK and beyond. Access to and uptake of HIV testing has increased significantly over the past few years. In Scotland, for example, the percentage of gay men who have never tested has reduced dramatically from 50% in 2000, to 20% in 2010 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3561706/). This is a trend which is also reflected in the wider population. There has been a 5% increase in HIV tests since 2012 with over one million being performed in sexually transmitted infection (STI) clinics in 2013 (ow.ly/Etwkb). Despite this, research suggests only 20% of gay men and other MSM at high risk of infection had tested within the last six months (Frankis et al, 2014).
The need for a wider testing tool Kit
There is a need to find ways of increasing HIV testing amongst those at high risk of infection. Several new approaches to the testing tool kit are available, including home sampling (http://www.haus.org.uk/) and self-testing (HIVST). The latter became legal within the UK on 6th April 2014 although they have still to be made commercially available (Hayes, 2014). In The USA however they are already being distributed and utilised (Myers et al, 2014). HIVST offers an alternative to HTC by facilitating testing in private, at a suitable time and within one’s home or other preferred surroundings. So in anticipation of self-testing in the UK – what is known about self-testing and how should we preparing for its arrival? (see, http://www.hivscotland.com/our-policy-work/testing/instant-result-self-testing-for-hiv/ ).
‘As soon as these are available they’re going to want to speak to someone straight away. There actually needs to be planning in advice for additional support, online and on the phone. There are people waiting to receive phone calls from somebody who’s just got that test result’. Community Leader, Glasgow, 2014
Benefits of HIV self-testing
There is a wealth of literature investigating attitudes and perceptions towards HIVST and in particular the benefits they offer. Those listed include: they are convenient (Pant Pai et al., 2013; Young et al., 2014), quick and easy to use (Bilardi et al., 2013; Lee et al., 2007), offer privacy and discretion (Bilardi et al., 2013; Cambiano et al., 2014), are accurate and trustworthy (Wood et al., 2014), have the ability to increase knowledge of ones HIV status in resource limited settings (Cambiano et al., 2014), could potentially encourage communication about HIV among potential partners (Carballo-Dieguez(1) et al., 2012), are acceptable to high risk groups (Katz et al., 2012; Carballo-Dieguez(2) et al., 2012), potentially encourage more frequent testing among men with high risk behaviours (Carballo-Dieguez(1) et al., 2012) and offer immediate results (Bilardi et al., 2013; Bavinton et al., 2013).
The power to change behaviour?
To date there is no consensus within the literature as to whether HIVST would change sexual behaviours. This finding resonates with the wider deeply ambivalent literature on the effectiveness of HIV testing as a means of reducing risk behaviour. Studies can, and do, show that testing both increases and decreases condom -less sex. In one study the majority of men reported that availability of HIVST would not change their current protected anal intercourse. A minority however stated they may have unprotected sex if both they and their partners tested negative (Bilardi et al., 2013). In contrast, results from a study where HIVST were actually used, condoms were still used in many encounters where both parties tested negative (Balán et al., 2014). This suggests that when faced with the reality of a sexual encounter, the predominant determinant in condom usage remains personal judgement rather than the HIVST results. Some men reported they would not use rapid tests with casual partners. They felt it would be too inconvenient, uncomfortable and a mood killer (Bilardi et al., 2013).
The ETTISH project
In the ETTISH project (led by the team at Glasgow Caledonian University), we are currently exploring the potential of using HIVST amongst gay men in the future. We are seeking to understand and anticipate the barriers and facilitators of its use with a wide range of UK stake holders. One of the challenges with HIVST is conceptualising how it might be used and how it could be optimised. How can we make best use of the technology to reach the undiagnosed? Will the worried well be picking up tests kits in Boots? Are there health economic arguments that support its targeted delivery to men at particular high risk? What are the ethical dilemmas associated with HIVST? Which networks of new stake holders may pick up those who have positive results? Are optimal services for gay men and routes into HIV Care and support in place? Our current participants include community organisations, business partners, and -NHS R&D willing – a range of NHS professionals who may be involved in emerging patient pathways.
A shifting focus
Arguably, it is time to invoke a major new focus upon HIV testing over and above a focus upon understanding condomless sex. New technological developments such as pre-exposure prophylaxis (http://bmjopen.bmj.com/cgi/content/long/4/11/e005717) or treatment as prevention are increasingly eroding the value and meaning of measuring and promoting condom use per se. Moreover, it is not only a renewed interest in HIV testing that is needed, but a direct focus upon the HIV testing tool kit. This includes pushing the limits of what technologies like self-testing could do. We should look above and beyond charting the impact of their commercial implementation. This includes developing a deep understanding of the difference between annual testing and testing every three months (quite distinct health behaviours). Also, a revitalised focus on the barriers to testing in an era of multiple opportunities to test in a variety of contexts is needed. Finally, we require an in-depth focus on the meaning and duration of negative test results.
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