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

The revised National HIV Testing Policy was launched at the 2011 ASHM Conference by Levinia Crooks, ASHM CEO, and Co-Chair of the Expert Reference Committee responsible for developing the new policy (see article by Levinia Crooks describing key features of this policy). The revised policy supports the use of rapid HIV testing in some circumstances.

Phillip Keen discusses some next steps, now that the policy support for rapid HIV testing is in place.

Introduction

Policy support for use of rapid HIV testing kits at the point of care has been welcomed by AFAO and our member organisations as a significant achievement towards the roll-out of rapid testing technology in Australia.

However, there are still no rapid tests licensed by the Therapeutic Goods Administration (TGA) for use at the point of care in this country. AFAO understands that at least one rapid test kit has been submitted for licensing to the TGA, but it is not clear how long the TGA assessment process will take.

While we await the outcome of this process, there are other important tasks that require our attention. The next steps should involve planning for the introduction of rapid testing services in Australia; this should include the involvement of policymakers, community-based organisations, educators, researchers and clinical staff.

This article, while not intending to be too proscriptive, suggests some key areas of work relevant to these various groups.

Policymakers

Although support for rapid testing in the National HIV Testing Policy and TGA licensing of rapid test kits are both major steps forward, a significant barrier to the uptake of rapid testing will remain unless payment for their use is provided under Medicare. Without Medicare support, a GP offering rapid tests would have to absorb the cost of the test kits, or else pass the cost on to their patients.

Similarly, if rapid tests were offered by a publicly funded sexual health clinic service providing testing services free to patients, equipment costs would have to be covered by the clinic’s funding; any new community-based testing services run by non-government organisations would face an additional funding hurdle while unable to recoup costs from Medicare.

The Sixth National HIV Strategy has identified priority actions in HIV testing, including:

More than half of gay men in a recent study indicated that they would test, or test more often if rapid HIV testing were available free at a community organisation.² Additionally, there is strong evidence many countries that offering rapid HIV testing services and community based testing to gay and other men who have sex with men has increased testing volumes, achieved outstanding results in the ratio of positive tests to total tests, and attracted a high proportion of men who have never previously tested.³

Although there have been no cost-effectiveness studies in relation to rapid HIV testing undertaken in Australia to date, it is likely that rapid testing will be very cost effective as the National HIV Testing Policy has a number of mechanisms in place which will limit the use of rapid HIV tests to people at increased risk of HIV infection.⁴

In order to achieve the benefits that are likely to accrue from rapid HIV testing and community-based testing, policymakers should consider funding trials, and (subsequent to TGA licensing) targeted clinical and community-based testing services. Under the National HIV Testing Policy, community organisations providing rapid HIV testing services will require endorsement from state and territory health departments.

Health officers and community organisations should commence dialogue regarding the appropriateness of community-based testing services in their jurisdictions and the necessary planning and resourcing needed to build any new services.

Community-based HIV organisations

AIDS Councils and related community-based organisations should be working now to identify and engage with public and private clinical services that are well placed to introduce rapid HIV testing. Commencing dialogue now to identify barriers and necessary preparatory work will expedite the delivery of rapid testing following TGA licensing.

Another area for action is in relation to developing models for community-based testing. Although the Western Australian AIDS Council has built successful community-based HIV and STI testing services, participating in or managing testing services would be new areas of work for most community-based HIV organisations.

Community organisations will need to consider the mix of testing services currently available in their area, as well as what new services should be put in place to make testing more accessible and acceptable to their constituents.

Where community organisations develop new partnerships with existing clinical services, or new community-based testing services, they will need to carefully assess their current competencies and plan how to build new competencies. The mix of clinical and peer-based experience in staffing models for new community based services will need attention, and issues of medical indemnity will require investigation.

HIV Educators

HIV educators will need to plan for the arrival of rapid HIV testing by preparing information resources and community awareness campaigns. Rapid HIV tests have specific limitations and benefits. The limitations of rapid tests include a longer window period following exposure to HIV to detect an infection, compared to the best currently available laboratory tests (approximately one to two weeks longer, depending on the rapid test) and that reactive results on rapid tests require further testing to confirm an HIV diagnosis.

The benefits of rapid tests include a less invasive method for collecting the specimen (usually blood from a finger-prick or an oral sample),and a rapid result; rapid HIV tests take between one minute and approximately twenty minutes to process the specimen.

Building community knowledge and informed, realistic expectations among gay men regarding rapid tests will be crucial to achieving successes from their introduction.

Clinical staff

Introducing rapid HIV testing into clinical settings will require the development of new skills, clinical guidelines and quality control protocols and processes. Administering rapid tests at the point of care requires careful set-up, specific equipment and careful attention to specific processes performed at precise intervals, which are particular to the test kit being used.

Staff involved in administering and interpreting rapid tests will require specific training, and periodic assessment and skills updates (AFAO understands that ASHM is currently developing a curriculum for a training program for health workers who will administer rapid HIV tests).

Guidelines for providing information to clients regarding some of the limitations of rapid tests will need to be developed.

There are currently two trials of rapid HIV testing already underway in Australia, and a third about to commence. In the absence of TGA licensed rapid tests being available, clinical trials are the only way to legally provide rapid HIV tests.

Trials also offer valuable opportunities for developing and documenting local experience in delivering rapid HIV testing, to guide future practice. Trials have commenced at the Melbourne Sexual Health Centre, and a trial in Brisbane is being conducted through the Brisbane Sexual Health Clinic and AIDS Medical Unit. A third trial will commence in October 2011 in Sydney; four sexual health clinics will participate. All the current trials are targeted to gay and other men who have sex with men.

These three trials have a range of objectives, and between them will produce valuable knowledge in relation to assessing test performance, the acceptability of rapid testing to clinical staff and testing clients, and the impact of rapid testing on gay men’s testing frequency.

A gap exists in relation to trials in private General Practice settings. HIV testing in GP settings is a critical component of HIV testing in Australia, so developing appropriate models for providing rapid testing within them requires urgent attention. As stated earlier in this article, the current lack of Medicare funding for rapid HIV tests presents an additional barrier to the introduction of rapid testing in private settings.

Researchers

Australian researchers have generated valuable knowledge regarding gay men’s attitudes to HIV testing, barriers to testing and the acceptability of rapid testing. As we move towards a context where rapid testing is routinely offered, researchers will need to consider how to understand the impact of rapid testing on gay men’s testing behaviour and risk practices.

References

1 Department of Health and Ageing [DoHA]. (2010). Sixth National HIV Strategy 2010–2013. DoHA, Canberra.

2 Prestage, G., McCann, P., Hurley, M., Bradley, J., Down, I., Brown, G. (2010). Pleasure and Sexual Health: The PASH Study, 2009. Monograph. National Centre in HIV Epidemiology and Clinical Research, university of NSW, Sydney.

3 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. Report commissioned by ACON.

4 Department of Health and Ageing [DoHA]. (2011). National HIV testing Policy. DoHA, Canberra. Available online at: http:// testingportal.ashm.org.au/hiv (accessed 11 October 2011).

Phillip Keen is an AFAO HIV Health Promotion Officer in the AFAO-NAPWA Education Team. Phillip has led AFAO’s recent advocacy work in relation to ensuring that rapid HIV testing at the point of care can be made available in Australia. He is a member of the Expert Reference Committee overseeing the revision of Australia’s National HIV Testing Policy.

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