HIV Australia | Vol. 9 No. 3 | November 2011

ALISA PEDRANA and MARK STOOVÉ present a range of findings from their research into community-based testing in Australia and discuss new strategies to improve access through community-based testing.

In Australia, men who have sex with men (MSM) account for more than 65% of newly diagnosed and 85% of newly acquired cases of HIV each year.¹ Despite high self-reported annual testing rates (around 60%)² and a reduction in viral loads among those on antiretroviral therapy (ART)³, Australia has witnessed substantial increases in newly diagnosed HIV infections over the past decade⁴.

This rise has been attributed to factors including moderate increases in sexual risk behaviours among gay men and dramatic increases in other sexually transmitted infections (STIs) including syphilis, gonorrhoea and chlamydia^{5, 6, 7, 8}, which are known to increase HIV transmission risk.^{9, 10, 11}

Regular HIV testing is one of the key HIV prevention strategies for gay and homosexually active men in Australia. Frequent testing decreases the number of people who are unaware of their HIV status and reduces cases of late diagnoses. Timely diagnosis of HIV provides opportunities for optimal commencement of treatment, which in turn suppresses viral load, thereby reducing transmission risk and enhancing long-term health outcomes for individuals^{12, 13}. Frequent testing and timely diagnosis also provides opportunities for risk assessment and allows for discussion of risk reduction strategies and behaviour modification to reduce the risk of onward transmission.¹⁴

HIV testing patterns among men who have sex with men in Australia

Although annual Australian HIV testing rates among MSM are generally considered to be high, national behavioural data and a recent national online survey of 3,457 MSM paint a different picture: only about 20% of men deemed to be in the ‘high-risk’ category tested regularly for HIV; 20% of the men surveyed reported two or more HIV tests per year; while between 6–24% said that they had never been tested.^{15, 16, 17} Non-adherence to the recommended HIV testing guidelines among many gay and other MSM is also concerning.

A recent study assessing compliance with recommended HIV testing frequency guidelines among MSM attending primary care clinics in Melbourne reported re-testing rates as low as 35% in one year, indicating that self-reported annual testing rates among MSM could be over-estimated.¹⁸

So why, despite extensive health promotion activities designed to highlight the importance of HIV testing¹⁹, are so many men not testing as frequently as recommended?

Structural, personal and policy barriers to frequent HIV testing are commonly reported.^{20, 21, 22} These include not knowing where to get tested, difficulties in getting an appointment, difficulties finding a gay-friendly doctor and the need to return for a test result. A number of study findings indicate that many MSM prefer HIV testing options that provide more timely results and greater convenience.²³ These men report not having enough time to get tested, citing inconveniences such as the return visit required to receive results when being tested at GP clinics and sexual health services (where the majority of HIV testing is conducted).²⁴ Current testing guidelines recommend annual testing for sexually active gay men and more frequent testing (3–6 monthly) for men at ‘high risk’.²⁵

Current models of HIV testing in Australia

In Australia, HIV testing involves conventional testing of venous blood samples using enzyme-linked immunoassay (EIA) followed by confirmatory Western blot at a laboratory. Test results usually take at a few days (but sometimes a week) because testing is often batched. Conventional HIV testing requires a return visit to the testing site to receive results and post-test counselling. Thus, the process from testing to receipt of results can be 1–2 weeks and multiple appointments per test means that ‘high risk’ men, may need 4–8 clinic appointments per year.

Technical advances in rapid HIV testing have resulted in test performance comparable to conventional testing. Rapid HIV tests therefore provide a potentially valuable alternative to current testing models. Advantages of rapid testing include specimen collection processes that are less invasive, results are available within 30 minutes and provided back to clients in the same visit, testing can be conducted almost anywhere including by non-clinically trained staff in community-based settings, and individuals are only required to return for another visit if their rapid test is ‘preliminary positive’ or indeterminate, which accounts for a small proportion of tests.²⁶

Review of community-based models of HIV testing

Community models of HIV testing for MSM, often using HIV rapid tests, have been used widely in the United States^{27, 28, 29} and throughout Europe^{30, 31} for over 10 years, and more recently in New Zealand³². The primary goal of community based HIV testing models is to increase opportunities for people at risk of HIV to get tested. The Centers for Disease Control and Prevention (CDC) in the United States recommend that community-based organisations test all at-risk clients³³; while the European Centre for Disease Prevention and Control recommends offering HIV testing in medical and non-medical settings, in cooperation with non-governmental organisations to facilitate access and uptake³⁴.

However, to date there has been limited uptake of community-based HIV testing models in Australia and current HIV testing policies and other regulatory restrictions in Australia preclude the use of rapid tests, except under very restricted circumstances.³⁵ In response, ACON recently commissioned the Burnet Institute to undertake a systematic review of published literature in relation to community-based testing and rapid HIV testing for MSM.³⁶ This review examined 32 published papers between 2000 and 2010 that described 44 community-based HIV testing services accessed by MSM (mostly located in the US (n=28) and Europe (n=11)).

HIV testing outcomes

The review demonstrated that on average a third of MSM who were tested at services had never been tested previously for HIV. In addition, services were generally successful in attracting men who were at high risk; most services identified a high number of new HIV infections, with the median HIV positivity of 3.9% among services that catered for MSM only. The highest positivity rates were reported at community-based organisations/community clinics. These data suggest that rapid testing services, particularly those based in community sites, are providing an alternative HIV testing option for populations at risk of HIV who may not routinely access other HIV testing services.

Uptake of rapid HIV tests

Rapid testing at the services was common, with three quarters of services included in the review offering rapid testing for HIV antibodies (24 finger-prick, 10 oral-fluid). Where rapid testing was provided onsite, clients received the results of their rapid test on the same day, usually in the same session, at the point-of-care. In most services, only ‘preliminary’ positives and indeterminate results were confirmed by conventional confirmatory testing. Provision of more timely HIV results by these services could potentially reduce onward HIV transmission rates because clients are immediately aware of their HIV status and receive post-test counselling. Rapid tests also enable testing to be conducted by non-medically trained staff, without the need for the space and privacy needed for traditional blood draw procedures; 65% of these services were therefore able to provide outreach rapid testing services.

Rapid HIV tests

Test results at these services were provided to clients within 15–60 minutes of the specimen being collected. In most services (30 out of 34), a single rapid test algorithm was used followed by whole blood collection for confirmatory testing if the rapid test was reactive or indeterminate. Clients were usually offered the opportunity to return to the test site in person to receive their confirmatory test results or given alternative options such as attending a local partnering community-based organisation or sexual health clinic. Most reports in the review did not aim to formally evaluate test performance. However from the information reported, often based on a small number of positive tests, the rapid HIV tests showed very high positive-predictive values, meaning that when a rapid HIV test was positive it was extremely likely to indicate a true infection.

Testing Protocols, Testing Outcomes and Communicating Results

Universal pre-and post-test counselling was provided at all the community-based services. Pre-test counselling for rapid testing included additional information regarding the meaning of a rapid test result. In many outreach services and community-based organisations, one agency provided the testing services and another agency provided care and treatment for referred positives, highlighting the importance of developing prompt and durable linkages to ongoing medical care.

Location, operating hours and procedures for accessing testing at community-based testing services were considered key to reducing barriers to HIV testing among MSM, and to have implications for the cost and feasibility of various staffing models. Most of the 44 services reviewed (33 out of the 44 services reviewed) offered a walk-in HIV testing service, five offered both walk-in and by appointment services, and three by appointment only. The majority of services (63%) offered testing at no cost to clients.

Staffing models and staff training

Involvement of a wide range of staff (e.g. peer/outreach workers, nurses, physicians, social workers, phlebotomists, volunteers) was reported by the services reviewed, with staffing profiles varying by service type, size and by region. Most services utilised non-medically trained staff to undertake rapid HIV testing, including pre/post-test discussions, risk assessment and referral.

A number of studies in the review demonstrated the feasibility and reliability of non-medically trained staff in conducting HIV counselling and testing when specific rapid testing training and quality assurance processes were in place. The use of non-medically trained staff also provided a substantial reduction in costs compared to physician-led testing services.

The studies reporting on acceptability also highlighted the importance of providing client-friendly services and the key role of peer and welfare oriented testing staff in achieving this outcome. Ongoing staff training and supervision were considered important, particularly to increase acceptability and effectiveness of rapid testing within community-based services.

Community-based testing (with and without the provision of rapid testing) has been shown to be feasible and to provide a model of HIV testing that attracts a significant proportion of MSM who have never tested before, and men who are at high risk of HIV. With the rest of the world making progress in further reducing barriers to testing and providing greater access to health services, can Australia afford to be left behind?

References

1 National Centre in HIV Epidemiology and Clinical Research. (2010). HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2010. National Centre in HIV Epidemiology and Clinical Research, the university of New South Wales, Sydney.

2 Holt, M., Mao, L., Prestage, G., Zablotska, I., de Wit, J. (2010). Gay Community Periodic Surveys National Report 2010. National Centre in HIV Social Research, National Centre in HIV Epidemiology and Clinical Research. the university of New South Wales, Sydney.

3 Law, M., Woolley, I., templeton, D., Roth, N., Chuah, J., Mulhall, B., et al. (2011). Trends in detectable viral load by calendar year in the Australian HIV observational database. J Int AIDS Soc, 14, 10.

4 National Centre in HIV Epidemiology and Clinical Research op. cit. 2010.

5 Middleton, M., Grulich, A., McDonald, A., Donovan, B., Hocking, J., Kaldor, J. (2008). Could sexually transmissible infections be contributing to the increase in HIV infections among men who have sex with men in Australia? Sex Health, 5(2), 131–140.

6 National Centre in HIV Epidemiology and Clinical Research. (2009). HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2008. National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney.

7 National Centre in HIV Epidemiology and Clinical Research op. cit. 2010.

8 Teague, R., Mijch, A., Fairley, C. K., Sidat, M., Watson, K., Boyd, K., et al. (2008). Testing rates for sexually transmitted infections among HIV-infected men who have sex with men attending two different HIV services. Int J STD AIDS, 19(3), 200–202.

9 Buchacz, K., Patel, P., Taylor, M., Kerndt, P., Byers, R., Holmberg, S., et al. (2004). Syphilis increases HIV viral load and decreases CD4 cell counts in HIV-infected patients with new syphilis infections. AIDS, 18(15), 2075–2079.

10 Wasserheit, J. (1992). Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis, 19(2), 61–77.

11 Wilson, D., Hoare, A., Regan, D., Law, M. (2009). Importance of promoting HIV testing for preventing secondary transmissions: modelling the Australian HIV epidemic among men who have sex with men. Sex Health, 6(1), 19–33.

12 Attia, S., Egger, M., Muller, M., Zwahlen, M., Low, N. (2009). Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS, 23(11), 1397– 1404.

13 Cohen, M., Chen, Y., McCauley, M., Gamble, T., Hosseinipour, M., Kumarasamy, N., et al. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med, 365(6), 493–505.

14 Marks, G., Crepaz, N., Senterfitt, J., Janssen, R. (2005). Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes, 39(4), 446–453.

15 Holt et. al. op. cit.

16 Rawstorne, P., Holt, M., Kippax, S., Worth, H., Wilkinson, J., and Bittman, M. (2009) . E-male survey 2008: key findings from a national online survey of men who have sex with men in Australia. National Centre in HIV Social Research, The University of NSW, Sydney.

17 Zablotska, I., Imrie, J., Bourne, C., Grulich,  A., Frankland, A., Prestage, G. (2008). Improvements in sexual health testing among gay men in Sydney, Australia, 2003-2007. Int J STD AIDS, 19(11), 758–760.

18 Guy, R., Goller, J., Spelman, T., El-Hayek, C., Gold, J., Lim, M., et al. (2010). Does the frequency of HIV and STI testing among MSM in primary care adhere with Australian guidelines? Sex Transm Infect.

19 Guy, R., Goller, J., Leslie, D., Thorpe, R., Grierson, J., Batrouney, C., et al. (2009). No increase in HIV or sexually transmissible infection testing following a social marketing campaign among men who have sex with men. J Epidemiol Community Health, 63(5), 391–396.

20 Chen, M., Bilardi, J., Lee, D., Cummings, R., Bush, M., Fairley, C. (2010). Australian men who have sex with men prefer rapid oral HIV testing over conventional blood testing for HIV. Int J STD AIDS, 21(6), 428–430.

21 Pedrana, A., Hellard, M., Guy, R., Wilson, K., Stoové, M. (2011). High rates of undiagnosed HIV infections in a community sample of gay men in Melbourne, Australia. (accepted). JAIDS Journal of Acquired Immune Deficiency Syndromes.

22 Prestage, G., McCann, P., Hurley, M., Bradley, J., Down, I., Brown, G. (2009). Pleasure and Sexual Health: The PASH Study, National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney.

23 Chen et al. op. cit.

24 Prestage et al. op. cit.

25 STIGMA (2010). Sexually Transmitted Infection Testing Guidelines For Men Who Have Sex With Men 2010. Sydney Australasian Chapter of Sexual Health Medicine/Royal Australasian College of Physicians, Royal Australian College of General Practitioners, Australasian Society of Infectious Diseases and the Australasian Society for HIV Medicine.

26 Bennett, A. (2009, June 22, 2009). Point of care rapid HIV testing: considerations for service provision. HIV Nursing.

27 Aguirre, D., Mares-Del Grasso, A., Emerson, C., Tsang, J., Pincus, J., Calhoun, C., et al. (2007). Rapid HIV testing in outreach and other community settings – United States, 2004–2006. (Table). Morbidity and Mortality Weekly Report, 56(47), 1233(1235).

28 Bogart, L., Howerton, D., Lange, J., Becker, K., Setodji, C., Asch, S. (2008). Scope of Rapid HIV testing in Private Nonprofit urban Community Health Settings in the united States. Am J Public Health, 98(4), 736–742.

29 Bowles, K., Clark, H., tai, E., Sullivan, P., Song, B., tsang, J., et al. (2008). Implementing rapid HIV testing in outreach and community settings: results from an advancing HIV prevention demonstration project conducted in seven u.S. cities. Public Health Rep, 123 Suppl 3, 78–85.

30 De La Fuente, L., Delgado, J., Hoyos, J., Belza, M., Alvarez, J., Gutierrez, J., et al. (2009). Increasing early diagnosis of HIV through rapid testing in a street outreach program in Spain. AIDS Patient Care and STDs, 23 (8), 625–629.

31 Koevoets, W., van Loon, S. (2004). Rapid HIV testing in a one-hour procedure motivates MSM in the Netherlands to take the test. Paper presented at the Access for All: 15th International AIDS Conference.

32 Smythe, E. (2007). Evaluation of 3 month Auckland based rapid test pilot. Auckland: New Zealand AIDS Foundation.

33 Branson, B., Handsfield, H., Lampe, M., Janssen, R., taylor, A., Lyss, S., et al. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity & Mortality Weekly Report Recommendations & Reports, 55(RR-14), 1–17; quiz CE11–14.

34 European Centre for Disease Prevention and Control [ECDC]. (2010). HIV testing: increasing uptake and effectiveness in the European Union. ECDC, Stockholm.

35 Australia Government Department of Health and Ageing. (2006). 2006 National HIV testing Policy. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-bbvs-hiv-testing-policy.

36 Pedrana, A., Guy, R., Bowring, A., Hellard, M., Stoové, M. (2011). Community models of HIV testing for men who have sex with men (MSM): Systematic Review 2011. Burnet Institute, Melbourne.

Alisa Pedrana is a PhD candidate and research assistant at the Centre for Population Health, Burnet Institute. Mark Stoové is head of the HIV/STI Research Group at the Centre for Population Health, Burnet Institute.

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