Factors impacting HIV testing: a review--perspectives from Australia, Canada, and the UK

What drives older men who have sex with men in China away from AIDS information?

A worrying phenomenon has emerged recently: more people are deliberately avoiding rather than seeking information regarding acquired immunodeficiency syndrome (AIDS). This is the first study to explore behaviors related to AIDS information avoidance and the potential influential factors among older men who have sex with men (MSM). We enrolled 11 older MSM from Wuhan, the largest city in central China, from January to March 2023 using a phenomenological method. This qualitative research was conducted using face-to-face semi-structured interviews. AIDS information avoidance was commonly observed among the respondents. Behaviors related to AIDS information avoidance included avoiding AIDS-related information, ignoring known AIDS information, and avoiding medical care. The main factors associated with AIDS information avoidance included information overload, high-risk sexual behaviors, over-optimism, fear of disclosure, and age. China should provide AIDS information in a manner suitable for older MSM, pay more attention to MSM over the age of 70 years, those who are not open about their sexual orientation and those who are too optimistic, and strengthen the censorship of AIDS information.

Methodologies used in studies examining substance abuse, violence and HIV/AIDS (SAVA) constructs using a syndemic framework: a scoping review

The syndemic theoretical framework has been used in health disparities research to explain several co-occurring epidemics, particularly in populations facing disparate health conditions. A prominent example of this is seen in Singer's Substance Abuse, Violence and HIV/AIDS (SAVA) syndemic theory. However, even though numerous studies support some of the theoretical underpinnings of the SAVA syndemic, the empirical applications of the theory remain methodologically underdeveloped. The current review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review (PRISMA-ScR), to present the state of the science of methodologies examining SAVA constructs using the syndemic framework. Seven bibliographic databases were searched with no language or date restrictions. Studies were synthesized by author, year of publication, study location, total sample size, study population, SAVA outcomes, analytic method of SAVA measurement, intervention type, level of influence, disease interaction and concentration, main findings of the study, and possible future areas of research. Our search yielded a total of 967 articles, and 123 were included in the review. Methodologic and statistical innovation is needed to elevate the impact of syndemic theory for elucidating the synergistic effects of determinants leading to health disparities.

Community-based HIV testing through a general health check event in a high HIV-prevalent multicultural area in Rotterdam, The Netherlands: a pilot study on feasibility and acceptance

BACKGROUND

HIV testing is crucial for finding the remaining cases in a declining HIV epidemic in The Netherlands; providing HIV testing in non-traditional settings may be warranted. We conducted a pilot study to determine the feasibility and acceptability of a community-based HIV testing (CBHT) approach with general health checks to improve HIV test uptake.

METHODS

CBHT's main conditions were low-threshold, free-of-charge, general health check, and HIV education. We interviewed 6 community leaders, 25 residents, and 12 professionals/volunteers from local organizations to outline these main conditions. Walk-in test events were piloted at community organizations, providing HIV testing along with body mass index (BMI), blood pressure, blood glucose screening, and HIV education (October 2019 to February 2020). Demographics, HIV testing history, risk perception, and sexual contact were collected via questionnaires. To evaluate the pilots' feasibility and acceptance, we utilized the RE-AIM framework and predefined goals, incorporating quantitative data from the test events and qualitative input from participants, organizations, and staff.

RESULTS

A total of 140 individuals participated (74% women, 85% non-Western, median age 49 years old). The number of participants during the seven 4-h test events ranged from 10 to 31. We tested 134 participants for HIV, and one was found positive (positivity 0.75%). Almost 90% of the participants were never tested or > 1 year ago, and 90% perceived no HIV risk. One-third of the participants had one or more abnormal test results on BMI, blood pressure, or blood glucose. The pilot was well-rated and accepted by all parties. The staff had concerns about waiting time, language problems, and privacy. Participants hardly indicated these concerns.

CONCLUSIONS

This CBHT approach is feasible, acceptable, and well-suited for testing not (recently) tested individuals and detecting new cases. Besides reducing HIV-associated stigma and increasing HIV test acceptance, offering multiple health tests may be appropriate as we frequently observed multiple health problems. Whether this laborious approach is sustainable in the micro-elimination of HIV and should be deployed on a large scale is questionable. CBHT like ours may be suitable as a supplement to more sustainable and cost-effective methods, e.g., proactive HIV testing by general practitioners and partner notification.

Knowledge of Australia's My Health Record and factors associated with opting out: Results from a national survey of the Australian general population and communities affected by HIV and sexually transmissible infections

My Health Record is Australia's national, digital, personal health record system. All Australians have a record in the system unless they choose to opt out of it. Concerns about privacy, security and unwanted sharing of data, particularly in marginalised populations, may impede its use. We conducted a national, online survey of Australians' attitudes to digital health in April-June 2020. The sample (N = 2,240) was recruited from the general population and four priority populations affected by HIV and other sexually transmissible infections: gay and bisexual men, people living with HIV, sex workers, and trans and gender diverse people. This analysis assesses factors associated with greater knowledge of My Health Record and the likelihood of opting out of the system. Due to increased concerns about data privacy and misuse, we hypothesised that priority population members would know more about and be more likely to opt out of the system. We found that most of the sample (71.2%) knew little about My Health Record and 29.4% had opted out of the system. Greater knowledge of My Health Record was associated with younger age, having a university degree, having one or more health conditions, and being trans or gender diverse. Being a student, unemployed, receiving government benefits, or having poor self-reported health, were associated with less knowledge. Opting out of My Health Record was associated with having a university degree, one or more health conditions, and being a priority population member. The likelihood of opting out was lower among people born overseas, residents of Queensland, and people who were students, unemployed, or receiving government benefits. We recommend additional investment in community-based education to address people's concerns about My Health Record and support people to use the system without compromising their health care, privacy, or security. Opting out may be a legitimate choice for people who perceive more risks than benefits from the system.

Factors Influencing the Acceptability of Nominal, Non-nominal, and Anonymous HIV Testing Options Among Young Men Living in Vancouver, Canada: A Qualitative Study

ABSTRACT

Individuals unaware of their HIV seropositive status continue to represent a key "driver" of the HIV epidemic. Strategies to improve initiation into the HIV treatment cascade, including among young men, are required. This study assesses the acceptability of three HIV testing options among young cisgender men living in Vancouver, British Columbia. Using a modified grounded theory approach, we conducted semi-structured interviews with 45 young cisgender men ages 18-30 years to identify the factors influencing the acceptability of diverse HIV testing approaches. Participants ascribed value to non-nominal testing as a means of providing a secure pathway to HIV-related care for those who test positive while also safeguarding privacy. Anonymous HIV testing was problematized by participants as potentially creating difficulty in accessing ongoing HIV-related care. Most participants preferred non-nominal testing. Nevertheless, based on principles of equity, we argue that anonymous access to one's serostatus should be available, especially within a criminalized context.

Denys R, Lund C, Worthington C. Assessing the acceptability of dried blood spot testing for HIV and STBBI among Métis people in a community driven pilot project in Alberta, Canada

BACKGROUND

Little literature exists on culturally grounded approaches for addressing human immunodeficiency virus (HIV) and sexually transmitted and blood-borne infections (STBBI) among Métis people. The goal of this mixed-methods research was to explore the experiences of Métis community members participating in a dried blood spot testing (DBST) for HIV/STBBI pilot for Métis communities in Alberta, Canada, with the aim of assessing the acceptability of this testing method.

METHODS

Grounded in community-based and Indigenous research approaches and working in partnership with a Métis community-based organization, data collection included a survey and four gathering circles with Métis DBST recipients at one of two community events, and semi-structured interviews with three DBST providers.

RESULTS

Twenty-six of the 30 DBST recipients completed surveys, and 19 DBST recipients participated in gathering circles. Survey results suggest DBST is a highly acceptable STBBI testing method to Métis community members. Thematic analysis of gathering circle and interview transcripts revealed four broad themes related to the participants' experiences with DBST related to its acceptability (i. ease of DBST process, ii. overcoming logistical challenges associated with existing STBBI testing, iii. Reducing stigma through health role models and event-based, and iv. Métis-specific services).

CONCLUSIONS

These findings illustrate the potential for DBST to be part of a culturally grounded, Métis-specific response to HIV and STBBI.

Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol

INTRODUCTION

There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.

METHODS AND ANALYSIS

Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common 'critical factors for success or failure' can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply . A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma.

PROSPERO REGISTRATION NUMBER

CRD42021249348.

Acceptability and facilitators of and barriers to point-of-care HIV testing in a homeless-focused service in Gloucestershire: a qualitative evaluation

OBJECTIVES

Late HIV diagnosis increases the risks of onward transmission, morbidity and mortality. Rapid point-of-care testing (POCT) reaches people who have never been tested and people living with HIV who are undiagnosed. This study explored the acceptability and feasibility of HIV POCT from the perspectives of service providers and users.

METHODS

A pilot study introduced HIV POCT to one service in Gloucestershire, England. Eleven semi-structured interviews with service users and a focus group with three service providers were conducted. The Theoretical Framework of Acceptability and the Theoretical Domains Framework were used to design the topic guide and analysis.

RESULTS

Acceptability of HIV POCT was high. Seven facilitators were identified (e.g. understanding the test purpose and process), alongside two potential barriers, one relevant to service providers and users (anxiety) and the other to service users (stigma).

CONCLUSIONS

To maximize the benefits of implementation of HIV POCT, health care providers require appropriate training and supervision to offer and administer POCT.

Prevalence and Correlates of HIV Testing among Sexual Minorities

Objectives: We established baseline prevalence rates of HIV testing among adult, sexual minorities and identified the correlates of never being HIV tested. Methods: We used a 20-state sample of the 2017-2019 Behavioral Risk Factor Surveillance System to identify sexual minorities who responded to the HIV testing question (N=433,042). Using weighted multivariate logistic regression analysis, we identified the characteristics associated with never being HIV tested and the impact of state health departments' HIV testing messages on testing status. Results: Overall, 41.6% of sexual minorities reported never being HIV tested with statistically significant state-level variation. Being younger (18-24 years) or older (65+ years), not black, married, and in good health significantly increased the odds of never being HIV tested as did lacking regular healthcare access and reporting no high-risk HIV behaviors. States' HIV testing messages had no statistically significant effect on HIV testing status. Conclusions: Although sexual minorities were less likely than straight respondents to report never being HIV tested, a sizable population remained untested. Specific characteristics associated with sexual minorities' HIV testing status can be used to tailor public health messages and optimize testing rates.

Acceptability of Nurse-Driven HIV Screening for Key Populations in Emergency Departments: A Mixed-Methods Study

BACKGROUND

Optimizing care continuum entry interventions is key to ending the HIV epidemic. Offering HIV screening to key populations in emergency departments (EDs) is a strategy that has been demonstrated to be effective. Analyzing patient and provider perceptions of such screening can help identify implementation facilitators and barriers.

OBJECTIVES

The aim of this study was to investigate the acceptability of offering nurse-driven HIV screening to key populations based on data collected from patients, nurses, and other service providers.

METHODS

This convergent mixed-methods study was a substudy of a cluster-randomized two-period crossover trial conducted in eight EDs to evaluate the effectiveness of the screening strategy. During the DICI-VIH (Dépistage Infirmier CIblé du VIH) trial, questionnaires were distributed to patients aged 18-64 years. Based on their responses, nurses offered screening to members of key populations.Over 5 days during the intervention period in four EDs, 218 patients were secondarily questioned about the acceptability of screening. Nurses completed 271 questionnaires pre- and posttrial regarding acceptability in all eight EDs. Descriptive analyses were conducted on these quantitative data. Convenience and purposeful sampling was used to recruit 53 providers to be interviewed posttrial. Two coders conducted a directed qualitative content analysis of the interview transcripts independently.

RESULTS

The vast majority of patients (95%) were comfortable with questions asked to determine membership in key populations and agreed (89%) that screening should be offered to key populations in EDs. Nurses mostly agreed that offering screening to key populations was well accepted by patients (62.2% pretrial and 71.4% posttrial), was easy to implement, and fell within the nursing sphere of competence. Pretrial, 73% of the nurses felt that such screening could be implemented in EDs. Posttrial, the proportion was 41%. Three themes emerged from the interviews: preference for targeted screening and a written questionnaire to identify key populations, facilitators of long-term implementation, and implementation barriers. Nurses were favorable to such screening provided specific conditions were met regarding training, support, collective involvement, and flexibility of application to overcome organizational and individual barriers.

DISCUSSION

Screening for key populations was perceived as acceptable and beneficial by patients and providers. Addressing the identified facilitators and barriers would help increase screening implementation in EDs.

Internalized Sexual Minority Stigma is Associated With HIV Testing Behavior Among Chinese Men Who Have Sex With Men: A Cross-Sectional Study

ABSTRACT

Although studies have examined the relationship between HIV-related stigma and HIV testing among men who have sex with men (MSM) in China, there is still a lack of knowledge regarding whether sexual minority stigma and HIV testing are associated. The purpose of this study was to identify the association between sexual minority- and HIV-related stigmas with HIV-testing behavior. A cross-sectional study was conducted in the Hunan Province of China. After controlling for covariates, the multivariate analyses showed that high internalized sexual minority stigma was negatively associated with HIV testing behavior in the previous year. However, anticipated sexual minority- and HIV-related stigmas were not associated with HIV-testing behavior. Findings suggest that internalized sexual minority stigma should be addressed in health care settings to encourage MSM to seek HIV testing services, especially considering the continuing HIV epidemic among MSM in China.

Clinician Barriers and Facilitators to Routine HIV Testing: A Systematic Review of the Literature

Background:

Routine HIV screening rates are suboptimal.

Objectives:

This systematic review identified barriers to/facilitators of routine HIV testing, categorized them using the socioecological model (SEM), and provided recommendations for interventions to increase screening.

Data Sources:

Included articles were indexed in PubMed, EBSCO CINAHL, Scopus, Web of Science, and the Cochrane Library between 2006 and October 2018.

Eligibility Criteria:

Included studies were published in English or Spanish and directly assessed providers’ barriers/facilitators to routine screening.

Data Extraction:

We used a standardized Excel template to extract barriers/facilitators and identify levels in the SEM.

Data Synthesis:

Intrapersonal factors predominated as barriers, while facilitators were directed at the institutional level.

Limitations:

Policy barriers are not universal across countries. Meta-analysis was not possible. We could not quantify frequency of any given barrier/facilitator.

Conclusions:

Increasing reimbursement and adding screening as a quality measure may incentivize HIV testing; however, many interventions would require little resource investment.

Understanding barriers and facilitators to HIV testing in Canada from 2009-2019: A systematic mixed studies review

BACKGROUND

HIV testing is a core pillar of Canada's approach to sexually transmitted and blood-borne infection (STBBI) prevention and treatment and is critical to achieving the first Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target. Despite progress toward this goal, many Canadians remain unaware of their status and testing varies across populations and jurisdictions. An understanding of drivers of HIV testing is essential to improve access to HIV testing and reach the undiagnosed.

OBJECTIVE

To examine current barriers and facilitators of HIV testing across key populations and jurisdictions in Canada.

METHODS

A systematic mixed studies review of peer-reviewed and grey literature was conducted identifying quantitative and qualitative studies of barriers and facilitators to HIV testing in Canada published from 2009 to 2019. Studies were screened for inclusion and identified barriers and facilitators were extracted. The quality of included studies was assessed and results were summarized.

RESULTS

Forty-three relevant studies were identified. Common barriers emerge across key populations and jurisdictions, including difficulties accessing testing services, fear and stigma surrounding HIV, low risk perception, insufficient patient confidentiality and lack of resources for testing. Innovative practices that could facilitate HIV testing were identified, such as new testing settings (dental care, pharmacies, mobile units, emergency departments), new modalities (oral testing, peer counselling) and personalized sex/gender and age-based interventions and approaches. Key populations also face unique sociocultural, structural and legislative barriers to HIV testing. Many studies identified the need to offer a broad range of testing options and integrate testing within routine healthcare practices.

CONCLUSION

Efforts to improve access to HIV testing should consider barriers and facilitators at the level of the individual, healthcare provider and policy and should focus on the accessibility, inclusivity, convenience and confidentiality of testing services. In addition, testing services must be adapted to the unique needs and contexts of key populations.

HIV stigma by association among Australian gay and bisexual men

OBJECTIVE

The negative effects of HIV stigma may extend beyond those who are HIV-positive, to people who are perceived to be at risk of HIV. This article examines HIV stigma by association among Australian gay and bisexual men (GBM).

DESIGN

Cross-sectional, online survey of 1280 Australian gay and bisexual men. This article focuses on HIV stigma from within a larger study that investigated stigma related to sexual identity.

METHODS

Bivariate and multivariable comparisons were made between men who experienced HIV stigma by association and those who did not. A serial mediation model was tested to investigate relationships between GBM community attachment, sexual identity stigma, HIV testing frequency, HIV stigma by association, psychological distress, and rejection of sex partners.

RESULTS

Results found that 5% of participants were HIV-positive, yet over 70% reported that they had been stigmatized by others for their perceived risk of acquiring HIV. Multivariable analysis indicated that HIV stigma by association was associated with more frequent HIV testing, greater GBM community attachment, experiencing stigma related to sexual identity and psychological distress. Our results suggest flow-on effects of HIV stigma by association, such as being more likely to reject other GBM on the basis of their HIV status or not testing for HIV.

CONCLUSION

Our results underscore the notion that HIV stigma can have broader, negative effects on HIV-affected populations. There is a need to address HIV stigma within GBM communities and society more broadly in order to encourage HIV testing and prevention among GBM.

Using Digital Communication Technology to Increase HIV Testing Among Men Who Have Sex With Men and Transgender Women: Systematic Review and Meta-Analysis

BACKGROUND

HIV continues to disproportionately affect men who have sex with men (MSM) and transgender women (TW). Undiagnosed HIV is a major driver of HIV transmission rates, and increasing the uptake of regular HIV testing and facilitating timely initiation of HIV treatment is a global HIV prevention priority. However, MSM and TW experience a range of barriers that limit their access to testing and other prevention services. Given their growing ubiquity, digital communication technologies are increasingly being used to support HIV prevention efforts, and a growing number of studies have trialed the use of digital technology to promote HIV testing among MSM and TW.

OBJECTIVE

We undertook a systematic review and meta-analysis to assess the impact of digital communication technology on HIV testing uptake among MSM and TW. Subanalyses aimed to identify the features and characteristics of digital interventions associated with greater impact.

METHODS

A systematic literature review was undertaken using select databases and conference repositories. Studies describing the use of a digital technology-internet-enabled devices, including phones, tablets, and computers-to increase HIV testing uptake among MSM or TW using either randomized or observational cohort design with measurement of HIV testing rates measured pre- and postintervention, and published in English between 2010 and 2018 were included. Pooled effect estimates were calculated using a random effects meta-analysis. Subanalyses calculated effect estimates grouped by selected features of digital interventions.

RESULTS

A total of 13 randomized or observational studies were included in the final review. Digital interventions most commonly used mainstream, existing social media platforms (n=7) or promotion through online peer educators (n=5). Most interventions (n=8) were categorized as interactive and allowed user engagement and most directly facilitated testing (n=7) either by providing self-testing kits or referral to testing services. A total of 1930 participants were included across the 13 studies. HIV testing uptake among MSM and TW exposed to digital interventions was 1.5 times higher than that of unexposed MSM and TW (risk ratio [RR] 1.5; 95% CI 1.3-1.7). Subanalyses suggested an increased impact on HIV testing uptake among interventions that were delivered through mainstream social media-based platforms (RR 1.7; 95% CI 1.3-2.1), included direct facilitation of HIV testing (RR 1.6; 95% CI 1.4-1.9), were interactive (RR 1.6; 95% CI 1.4-1.8), and involved end users in the design process (RR 1.6; 95% CI 1.3-2.0).

CONCLUSIONS

These findings provide broad support for the integration of technology with existing approaches to promote and facilitate HIV testing among MSM and TW. Our findings identified key features that may be associated with greater impact on HIV testing uptake and can be used to inform future development efforts given the growing interest and application of digital technologies in HIV prevention.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42017070055; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017070055.

An Intersectional Approach to HIV Vulnerabilities and Testing Among Heterosexual African Caribbean and Black Men in London, Ontario: Results From the weSpeak Study

Heterosexual African, Caribbean and Black (ACB) men are a vulnerable group to HIV infection in Canada, but little is known about their uptake of HIV testing services. Studies on ACB men HIV vulnerabilities have largely focused on behavioural factors. While these studies have contributed to the current HIV prevention success in Canada, little attention has been paid to structural factors that intersect with prevailing behaviours to reinforce vulnerabilities. Drawing insights from intersectionality theory, we examined healthcare access and HIV testing among heterosexual ACB men in London, Ontario. We fitted the negative log-log link function to 155 individuals' survey. Results show that participants, who had difficulty accessing healthcare, experienced discrimination, and were young, were all less likely to test for HIV. Even though the probability of testing for HIV increased after accounting for the effect of structural factors, the marginal impact was higher for those without any difficulty accessing healthcare than those with difficulty. Findings are discussed within the broader theory of intersectionality and recommendations made for public health policy.

Factores psicosociales asociados a la realización de la prueba diagnóstica del VIH en estudiantes universitarios colombianos

Los objetivos de esta investigación fueron: (a) relacionar el riesgo sexual, los conocimientos y las actitudes hacia la prueba del VIH con su realización en estudiantes universitarios colombianos; y (b) describir las barreras percibidas en aquellos que no sela habían realizado, identificando las diferencias según el sexo. Se llevó a cabo un estudio transversal en el que particip- aron 1057 estudiantes colombianos, y en el que se utilizó el Cuestionario Confidencial sobre Vida Sexual Activa (CCVSA), el test Barreras Hacia la Prueba del VIH, la Escala de Actitudes hacia el VIH-Sida y un cuestionario ad hoc de conocimien- tos sobre la prueba. Los estudiantes que se realizaron la prueba (n = 214) reportaron una edad inferior de iniciación sexual (p < .01), un número superior de parejas sexuales (p = .01) y un menor uso de condón en la primera (p = .02) y la última (p = .04) relación sexual, así como mayores conocimientos sobre la prueba del VIH (p < .001). Las principales barreras estuvieron relacionadas con la baja percepción del riesgo de la enfermedad (29.8 %), la confianza en las parejas sexuales (29.2 %) y la falta de ofrecimiento de la prueba (25.2 %). En conclusión, la realización de la prueba está relacionada con la exposición a conductas sexuales de riesgo y con los conocimientos, mas no con las actitudes hacia la prueba. La identi- ficación de los factores psicosociales vinculados podría contribuir al diseño de intervenciones orientadas a la prevención y al tratamiento oportuno de la enfermedad.

Trends in HIV testing in the UK primary care setting: a 15-year retrospective cohort study from 2000 to 2015

OBJECTIVES

To estimate trends in HIV testing, positivity and prevalence in UK primary care for 2000-2015 as part of a wider investigation into reasons for late diagnosis of HIV.

DESIGN

Retrospective cohort study using the Clinical Practice Research Datalink (CPRD) which is derived from computerised clinical records produced during consultations in primary care.

SETTING

404 general practices in England.

PARTICIPANTS

5 979 598 adults aged ≥16 years registered between 2000 and 2015 with 45 093 761 person years of observation.

OUTCOMES

Annual HIV testing rates, proportion of positive tests and prevalence of HIV-infected people recorded in primary care 2000-2015.

RESULTS

HIV testing in primary care increased from 2000 to 2010, but then declined. Testing was higher in females than in males and in those aged 16-44 years compared with older adults. Rates per 100 000 in women aged 16-44 years were 177 (95% CI 167 to 188); 1309 (95% CI 1282 to 1336); 1789 (95% CI 1757 to 1821) and 839 (95% CI 817 to 862) in 2000, 2005, 2010 and 2015, respectively, and for non-pregnant women: 22.5 (95% CI 19 to 26); 134 (95% CI 125 to 143); 262 (95% CI 250 to 275); 190 (95% CI 179 to 201). For men aged 16-44 years rates were: 26 (95% CI 22 to 29); 107 (95% CI 100 to 115); 196 (95% CI 185 to 206); 137 (95% CI 127 to 146). Over the study period, there were approximately two positive results per 1000 HIV tests. Men were eightfold more likely to test positive than women. The percentage of HIV diagnoses among adults recorded in CPRD may be as low as 55% in London and 67% in the rest of the UK.

CONCLUSIONS

HIV testing rates in primary care peaked in 2010 and subsequently declined. Access to testing was higher for women despite the prevalence of HIV being higher in men.

IMPLICATIONS AND FURTHER RESEARCH NEEDED

Opportunities remain in primary care for increasing HIV testing to prevent costly late diagnoses and decrease HIV transmission. Interventions to improve targeting of tests and increase adherence to HIV testing guidelines are needed in primary care.

Timeliness of diagnosis of HIV in Newfoundland and Labrador, Canada: A mixed-methods study

BACKGROUND

Late diagnosis of HIV is associated with poor outcomes and increased cost. Novel HIV testing promotion strategies may reduce late diagnosis. The purpose of this study was to determine the timeliness of HIV testing in Newfoundland and Labrador (NL), missed opportunities for testing, and barriers to HIV testing.

METHODS

Demographic and clinical information from individuals diagnosed with HIV in NL from 2006-2016 was retrospectively reviewed. Patients were also invited to participate in semi-structured interviews regarding knowledge about HIV transmission, risk associated with their behaviour, testing decision making, and testing opportunities.

RESULTS

Fifty-eight new HIV diagnoses occurred during the study period: 53/58 (91.4%) were male and 33/58 (56.9%) were men who have sex with men. The mean age at diagnosis was 40.6 (SD 11.05) years. CD4 count at diagnosis ranged from 2 to 1,408 cells/mm³, with a mean of 387 cells/mm³. For 39/58 (67.2%) of individuals, the first-ever HIV test was positive. Of the 58 patients, 55 (94.8%) had had health care contact within the 5 years prior to diagnosis (mean 13.7 contacts). Heterosexual men were more likely to present with a late diagnosis (p = 0.049). Ten (17.2%) individuals agreed to an interview. Thematic analysis revealed that barriers to testing were stigma, negative health care interactions, denial, and fear of the diagnosis.

CONCLUSIONS

HIV diagnosis is made later in NL than in other Canadian provinces. Late diagnosis may be prevented if HIV testing became a routine testing procedure.

Psychological threat avoidance as a barrier to HIV testing in gay/bisexual men

The present study examined how three psychosocial barriers-anticipated HIV stigma, HIV infectiousness-reduction beliefs, and optimism about available HIV treatments-related to HIV testing history and acceptance of an at-home HIV test among men who have sex with men. We also examined the mediating role of a variable that affects medical screening for other health conditions but has not yet been investigated in HIV contexts: the tendency to avoid psychologically threatening information. Volunteers completed a paper and pencil survey and were offered a free at-home HIV test during the 2015 Atlanta Pride Festival in Atlanta, GA. Anticipated HIV stigma, infectiousness beliefs, and treatment optimism were inconsistently related to HIV testing history and acceptance of an at-home HIV test, but all had direct effects on the desire to avoid HIV information. In a mediation model, each of these psychosocial barriers had indirect effects on both HIV testing outcomes via information avoidance. These findings suggest that information avoidance is an important proximal HIV testing barrier, thus providing a novel target for interventions and information campaigns.

Towards achieving the fast-track targets and ending the epidemic of HIV/AIDS in Ethiopia: Successes and challenges

BACKGROUND

Ethiopia has adopted the global plan to end the epidemic of HIV/AIDS. The aim of this study was to assess the progress made towards achieving this plan.

METHODS

A review and analysis of national population-based surveys, surveillance, and routine programme data was executed. The data analysis was conducted using Excel 2016 and Stata 14 (StataCorp LP, College Station, TX, USA).

RESULTS

Between 2011 and 2016, the number of HIV-related deaths dropped by 58%, while that of new HIV infections dropped by only 6%. Discriminatory attitudes declined significantly from 77.9% (95% confidence interval (CI) 77.3-78.4%) in 2011 to 41.5% (95% CI 40.6-42.4%) in 2016. Around 79% of adult people living with HIV (PLHIV) were aware of their HIV status; 90% of PLHIV who were aware of their HIV status were taking antiretroviral treatment (ART) and 88% of adult PLHIV on ART had viral suppression in 2016. The proportion of people aged 15-49 years who had ever been tested for HIV and had received results increased from 39.8% (95% CI 39.2-40.4%) in 2011 to 44.8% (95% CI 44.2-45.4%) in 2016. This proportion was very low among children below age 15 years at only 6.2% (95% CI 5.9-6.5%). Among regions, HIV testing coverage varied from 13% to 72%. Female sex workers had lower coverage for HIV testing (31%) and ART (70%) than the national average in the adult population. International funding for HIV dropped from more than US$ 1.3 billion in 2010-2012 to less than US$ 800 million in 2016-2018.

CONCLUSIONS

Ethiopia is on track to achieve the targets for HIV testing, ART, viral suppression, and AIDS-related deaths, but not for reductions in new HIV infections, discriminatory attitudes, and equity. Ending the epidemic of HIV/AIDS requires a combined response, including prevention and treatment, tailored to key populations and locations, as well as increased funding.

HIV Testing in Men who have Sex with Men: A Follow-up Review of the Qualitative Literature since 2010

The landscape of HIV testing has changed significantly in recent years following the rise in importance of the 'treatment as prevention' strategy and advancements in new HIV testing and prevention technologies. This review provides a synthesis of qualitative research findings published since 2010 on preferences and practices of men who have sex with men (MSM) surrounding HIV testing in high-income settings. MSM are one of the hardest groups to reach with standard or conventional HIV testing approaches. To develop innovative testing strategies for this particular group, a good understanding of their concerns, barriers and facilitators of accessing HIV testing is needed. This updated review provides valuable information for improving existing programs and designing new testing services for MSM.

"I did not see a need to get tested before, everything was going well with my health": a qualitative study of HIV-testing decision-making in KwaZulu-Natal, South Africa

Few studies have examined HIV-testing decision-making since the South African national HIV counseling and testing campaign in 2010-2011 and subsequent expansion in antiretroviral therapy (ART) eligibility in 2012. We describe HIV-testing decision-making and pathways to testing among participants in Pathways to Care, a cohort study of newly-diagnosed HIV-positive adults in KwaZulu-Natal. Our analysis is embedded within a theoretical framework informed by Arthur Kleinman's work on pluralistic healthcare systems, and the concept of diagnostic itineraries (i.e., the route taken to HIV testing). We conducted 26 semi-structured interviews in 2012, within one month of participants' diagnosis. Most (n = 22) deferred testing until they had developed symptoms, and then often sought recourse in non-biomedical settings. Of the eleven symptomatic participants who accessed professional medical services prior to testing, only three reported that a healthcare professional had offered or recommended an HIV test. Although ART emerged as an important motivator, offering hope of health and normalcy, fear of death and HIV-related stigma remained key barriers. Despite national policy changes in testing and treatment, health system and individual factors contributed to ongoing high levels of late diagnosis of HIV in this study population. Encouraging local health systems to direct clients toward HIV testing, and continuing to raise awareness of the benefits of routine testing remain important strategies to reduce delayed diagnoses.

Vending machines in commercial sex venues to increase HIV self-testing among men who have sex with men

BACKGROUND

Commercial sex venues (CSV), bathhouses and sex clubs, have a long history of serving a high-risk population. In those facilities, patrons engage in multiple sexual encounters and often in high-risk sexual behaviors. Designing prevention interventions specifically for CSVs could be an effective way to increase testing and control HIV transmission.

METHODS

In collaboration with the AIDS Healthcare Foundation (AHF), our team distributed free HIV self-test kits using vending machines located at two CSVs in Los Angeles, California. Test kit dispensing rate was monitored remotely. Patrons receiving a test kit were surveyed regarding their testing experience, test result and follow up. Linkage to care was offered to participants.

RESULTS

During 18 months, 1,398 kits were dispensed. The survey was completed by 110 patrons (response rate =7.9%). Among those who reported that they used the test kit (n=96), 17 (17.7%) participants reported a first-time reactive HIV result. At the time of the survey, six participants with reactive results reported seeking confirmatory testing and linkage to care and four had initiated treatment. Two participants requested linkage-to-care assistance. Participants reported valuing the privacy and convenience of the vending machine but were skeptical on the accuracy of their result. The startup cost, including the purchase of two vending machines, was $10,000 and the recurring cost (monitoring, test kits, personnel) was $33.81 per kit vended.

CONCLUSIONS

While survey response was low, our results demonstrate that an intervention using vending machines and HIV self-test kits in CSVs was acceptable, feasible, used by the CSV patrons and can help identify new HIV cases.

Sociodemographic correlates of HIV drug resistance and access to drug resistance testing in British Columbia, Canada

Sociodemographic correlates of engagement in human immunodeficiency virus (HIV) care are well studied, however the association with accessing drug resistance testing (DRT) and the development of drug resistance have not been characterized. Between 1996-2014, 11 801 HIV patients accessing therapy in British Columbia were observed longitudinally. A subset of 9456 patients had testable viral load; of these 8398 were linked to census data. Sociodemographic (census tract-level) and clinical (individual-level) correlates of DRT were assessed using multivariable General Estimating Equation logistic regression adjusted odds ratios (aOR). The mean number of tests per patient was 2.1 (Q1-Q3; 0-3). Separately, any drug resistance was determined using IAS-USA (2013) list for 5703 initially treatment naïve patients without baseline resistance; 5175 were census-linked (mean of 1.5 protease-reverse transcriptase sequences/patient, Q1-Q3; 0-2). Correlates of detecting drug resistance in this subset were analyzed using Cox PH regression adjusted hazard ratios (aHR). Our results indicate baseline CD4 <200 cells/μL (aOR: 1.5, 1.3-1.6), nRTI-only baseline regimens (aOR: 1.4, 1.3-1.6), and unknown (therapy initiation before routine pVL in BC) baseline pVL (aOR: 1.8, 1.5-2.1) were among individual-level clinical covariates strongly associated with having accessed DRT; while imperfect adherence (aHR: 2.2, 1.9-2.5), low baseline CD4 count (aHR: 1.9, 1.6-2.3), and high baseline pVL (aHR: 2.0, 1.6-2.6) were associated with a higher likelihood of developing drug resistance. A higher median income (aOR: 0.83, 0.77-0.89) and higher percentage of those with aboriginal ancestry (aOR: 0.85, 0.76-0.95) were census tract-level sociodemographic covariates associated with decreased access to DRT. Similarly, aboriginal ancestry (aHR: 1.2, 1.1-1.5) was associated with development of drug resistance. In conclusion, clinical covariates continue to be the strongest correlates of development of drug resistance and access to DRT for individuals. Regions of high median income and high aboriginal ancestry were weak census-level sociodemographic indicators of reduced DRT uptake, however high aboriginal ancestry was the only sociodemographic indicator for development of drug resistance.

Patterns of HIV testing practices among young gay and bisexual men living in Scotland: a qualitative study

Background

Increasing overall rates, and frequency, of HIV testing in populations at risk is a key public health objective and a critical dimension of HIV prevention efforts. In the UK, men who have sex with men (MSM) remain one of the communities most at risk of HIV and, within this, young gay men are a key risk group. Understanding HIV testing practices is important in the development of interventions to promote testing among young gay and bisexual men.

Methods

Qualitative interviews were conducted with thirty young gay and bisexual men (aged 18–29) in Scotland. Thematic analysis of men’s accounts of their approach to HIV testing identified three overarching patterns of testing: ‘habitual’, ‘reactive’ and ‘ad hoc’.

Results

This qualitative study, the first to explore patterns of HIV testing practices among young gay and bisexual men in the UK, contributes novel findings around the role of social support and ‘community’ in shaping young men’s approaches to HIV testing. The findings suggest that social support can play an important role in encouraging and facilitating HIV testing among young gay men, however, social norms of non-testing also have the potential to act as a barrier to development of a regular routine. Men with habitual testing practices framed HIV testing as both a personal and ‘community’ responsibility, and more effective than testing in response to risk events or emergent symptoms. Men who reported reactive testing practices described testing for HIV primarily in response to perceived exposure to sexual risk, along with ‘transitional moments’ such as starting, ending or changes to a relationship. Among young men who reported testing on an ad hoc basis, inconvenience and disruptions to HIV testing practices, particularly where men lacked social support, acted as a barrier to developing a routine of regular testing.

Conclusions

Our findings suggest that interventions which seek to increase rates of HIV testing and testing frequency among young gay and bisexual men should include a specific focus on promoting and supporting positive testing practices within young men’s friendship groups and wider gay communities.

Is there a relationship between geographic distance and uptake of HIV testing services? A representative population-based study of Chinese adults in Guangzhou, China

Achieving high coverage of HIV testing services is critical in many health systems, especially where HIV testing services remain centralized and inconvenient for many. As a result, planning the optimal spatial distribution of HIV testing sites is increasingly important. We aimed to assess the relationship between geographic distance and uptake of HIV testing services among the general population in Guangzhou, China. Utilizing spatial epidemiological methods and stratified household random sampling, we studied 666 adults aged 18-59. Computer-assisted interviews assessed self-reported HIV testing history. Spatial scan statistic assessed the clustering of participants who have ever been tested for HIV, and two-level logistic regression models assessed the association between uptake of HIV testing and the mean driving distance from the participant's residence to all HIV testing sites in the research sites. The percentage of participants who have ever been tested for HIV was 25.2% (168/666, 95%CI: 21.9%, 28.5%), and the majority (82.7%) of participants tested for HIV in Centres for Disease Control and Prevention, public hospitals or STIs clinics. None reported using self-testing. Spatial clustering analyses found a hotspot included 48 participants who have ever been tested for HIV and 25.8 expected cases (Rate Ratio = 1.86, P = 0.002). Adjusted two-level logistic regression found an inverse relationship between geographic distance (kilometers) and ever being tested for HIV (aOR = 0.90, 95%CI: 0.84, 0.96). Married or cohabiting participants (aOR = 2.14, 95%CI: 1.09, 4.20) and those with greater social support (aOR = 1.04, 95%CI: 1.01, 1.07) were more likely to be tested for HIV. Our findings underscore the importance of considering the geographical distribution of HIV testing sites to increase testing. In addition, expanding HIV testing coverage by introducing non-facility based HIV testing services and self-testing might be useful to achieve the goal that 90% of people living with HIV knowing their HIV status by the year 2020.

Increasing HIV testing among hard-to-reach groups: examination of RAPID, a community-based testing service in Queensland, Australia

Background

The success of ‘treatment as prevention’ (TasP) to control HIV relies on the uptake of testing across priority population groups. Innovative strategies including; rapid HIV testing (RHT) in community and outreach settings, engaging peer service providers, and not requiring disclosure of sexual history have been designed to increase access. This paper reports on the implementation of ‘RAPID’, a community-based testing program in Queensland, Australia that employs these strategies to increase access to testing.

Methods

Service data, including client registration forms and a satisfaction survey from all clients attending RAPID between August 2014 and July 2015 were analysed.

Results

In 2014/2015 1,199 people attended RAPID to receive a free HIV test. The majority were urban-based gay men. 17.1% were first-time testers and 20.1% of participants were not eligible to access Medicare, Australia’s universal health care scheme.

Conclusions

RAPID’s evidence-based strategies appear to facilitate access to HIV testing, particularly among those who have never tested before; however the implications for the ongoing treatment and care of people ineligible for Medicare, who test positive to HIV warrants careful consideration.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2249-5) contains supplementary material, which is available to authorized users.

Criminalization of HIV Exposure: A Review of Empirical Studies in the United States

This review of literature identifies and describes US empirical studies on the criminalization of HIV exposure, examines findings on key questions about these laws, highlights knowledge gaps, and sets a course for future research. Studies published between 1990 and 2014 were identified through key word searches of relevant electronic databases and discussions with experts. Twenty-five empirical studies were identified. Sixteen of these studies used quantitative methods with more than half of these being cross-sectional survey studies. Study samples included male and female HIV-positive persons, HIV-positive and -negative men who have sex with men, public health personnel, and medical providers. Research questions addressed awareness of and attitudes toward HIV exposure laws, potential influences of these laws on seropositive status disclosure for persons living with HIV, HIV testing for HIV-negative persons, safer sex practices for both groups, and associations between HIV exposure laws and HIV-related stigma. Surveys of the laws and studies of enforcement practices were also conducted. Attention should be shifted from examining attitudes about these laws to exploring their potential influence on public health practices and behaviors related to the HIV continuum of care. Studies examining enforcement and prosecution practices are also needed. Adapting a theoretical framework in future research may be useful in better understanding the influence of HIV exposure laws on HIV risk behaviors.

Can the UNAIDS 90-90-90 target be achieved? A systematic analysis of national HIV treatment cascades

Background

In 2014, the Joint United Nations Programme on HIV and AIDS (UNAIDS) and partners set the ‘90-90-90 targets’; aiming to diagnose 90% of all HIV positive people, provide antiretroviral therapy (ART) for 90% of those diagnosed and achieve viral suppression for 90% of those treated, by 2020. This results in 81% of all HIV positive people on treatment and 73% of all HIV positive people achieving viral suppression. We aimed to analyse how effective national HIV treatment programmes are at meeting these targets, using HIV care continuums or cascades.

Methods

We searched for HIV treatment cascades for 196 countries in published papers, conference presentations, UNAIDS databases and national reports. Cascades were constructed using reliable, generalisable, recent data from national, cross-sectional and longitudinal study cohorts. Data were collected for four stages; total HIV positive people, diagnosed, on treatment and virally suppressed. The cascades were categorised as complete (four stages) or partial (3 stages), and analysed for ‘break points’ defined as a drop >10% in coverage between consecutive 90-90-90 targets.

Results

69 country cascades were analysed (32 complete, 37 partial). Diagnosis (target one—90%) ranged from 87% (the Netherlands) to 11% (Yemen). Treatment coverage (target two—81% on ART) ranged from 71% (Switzerland) to 3% (Afghanistan). Viral suppression (target three—73% virally suppressed) was between 68% (Switzerland) and 7% (China).

Conclusions

No country analysed met the 90-90-90 targets. Diagnosis was the greatest break point globally, but the most frequent key break point for individual countries was providing ART to those diagnosed. Large disparities were identified between countries. Without commitment to standardised reporting methodologies, international comparisons are complex.

Which Psychological Factors are Related to HIV Testing? A Quantitative Systematic Review of Global Studies

Deciding to test for HIV is necessary for receiving HIV treatment and care among those who are HIV-positive. This article presents a systematic review of quantitative studies on relationships between psychological (cognitive and affective) variables and HIV testing. Sixty two studies were included (fifty six cross sectional). Most measured lifetime testing. HIV knowledge, risk perception and stigma were the most commonly measured psychological variables. Meta-analysis was carried out on the relationships between HIV knowledge and testing, and HIV risk perception and testing. Both relationships were positive and significant, representing small effects (HIV knowledge, d = 0.22, 95 % CI 0.14-0.31, p < 0.001; HIV risk perception, OR 1.47, 95 % CI 1.26-1.67, p < 0.001). Other variables with a majority of studies showing a relationship with HIV testing included: perceived testing benefits, testing fear, perceived behavioural control/self-efficacy, knowledge of testing sites, prejudiced attitudes towards people living with HIV, and knowing someone with HIV. Research and practice implications are outlined.

Low HIV testing rate and its correlates among men who inject drugs in Iran

BACKGROUND

Iran has a concentrated HIV epidemic among people who inject drugs (PWID). Low HIV testing uptake could contribute to the significant number HIV-infected PWID, who go undiagnosed. This study aims to assess HIV testing uptake and its correlates among PWID in Iran.

METHODS

Data were collected through a national cross-sectional bio-behavioral study in 2010. Adult male HIV-negative PWID were included in the current analysis. All estimates were adjusted for the clustering effect of the sampling sites. Multivariable logistic regression was used to examine the correlates of recent HIV testing and adjusted odds ratios (AOR) were reported.

RESULTS

Out of the 2146 eligible PWID for this study, 49.8% reported having ever tested for HIV. However, only 24.9% had tested in the previous year and received their test results. Around 65.2% of PWID knew an HIV testing site. In the multivariable analysis, knowing an HIV testing site (AOR=13.9; P-value<0.001), ≥24 years of age (AOR=3.30; P-value=0.027), and multiple incarcerations (AOR=1.71; P-value<0.001) were positively, and a monthly income of ≥65 US dollar (AOR=0.23; P-value=0.009) was negatively associated with having been tested and received the results.

CONCLUSION

Despite the availability of free HIV counselling and testing for PWID in Iran, only one-fourth of adult male PWID had been tested for HIV and received their results. Implementing policies and strategies to normalize routine HIV testing among PWID are crucial steps to help curb the epidemic among Iranian PWID.

Explaining the Presence of "Heterosexual" Female Clients of a Rapid HIV Testing Site Located in the Gay Village of Montreal, Quebec

BACKGROUND

Increasing access and uptake of HIV testing among at-risk women is needed. Examining women's motives for visiting a community-based rapid HIV testing site (Actuel sur Rue-AsR) oriented to men who have sex with men (MSM) could offer suggestions.

OBJECTIVE

To compare the "heterosexual" female and male clients of AsR, located in Montreal's (Canada) gay village, to better understand the women's particular HIV prevention and sexual health service needs.

METHODS

This cross-sectional pilot study analyzed questionnaire data provided by AsR clients and staff (nurse and community agent teams) between July 2012 and November 2013. Women and men reporting only opposite-sex partners were compared with chi-square, Fisher's exact, and Kruskal-Wallis tests, as appropriate, on sociodemographics, HIV-related behaviors, motives for visiting AsR, and health service provision.

RESULTS

AsR received 1901 clients. Among these, 55 women and 147 men reported only opposite-sex partners. Women were significantly younger. Significantly greater proportions of women visited AsR because no appointment was necessary (67% vs. 48%), sought testing for condom failure (18% vs. 5%), and had no regular doctor (44% vs. 27%). Both groups mainly chose AsR for the rapid test results (80% and 77%), visited it to receive the rapid HIV test (71% and 76%), and sought testing due to unprotected vaginal sex (44% and 43%). Similar proportions saw the nurse (91% and 89%), received the rapid HIV test (44% and 35%), and were linked to a medical clinic (49% and 52%), especially, to receive complete sexually transmitted infection testing (50% and 44%).

CONCLUSIONS

The results of this innovative study highlight the draw of rapid HIV testing for "heterosexual" users of a site mainly targeting MSM. They also suggest that further research is warranted into the importance for this group of women clients of drop-in and linkage services, particularly given their possible lesser access to regular care.

Factors associated with antiretroviral treatment uptake and adherence: a review. Perspectives from Australia, Canada, and the United Kingdom

International focus on reducing onward HIV transmission emphasizes the need for routine HIV testing and early uptake of antiretroviral treatment (ART). Strategic targets have been set for 2020 to achieve the goal of 90% of people infected with HIV diagnosed, 90% of identified cases on treatment, and 90% of persons on treatment virally suppressed (90-90-90). It is vital to understand the complexity of factors influencing a person's treatment decisions over time and the context which may enable better adherence. In this paper we present findings from the review of published and gray literature (2003-2013) on the documented factors associated with treatment initiation and adherence in the general adult population of Australia, Canada, and the UK. A framework developed by Begley, McLaws, Ross, and Gold [2008. Cognitive and behavioural correlates of non-adherence to HIV anti-retroviral therapy: Theoretical and practical insight for clinical psychology and health psychology. Clinical Psychologist, 12(1), 9-17] in Australia was adapted to summarize the findings. A systematic database search using keywords and a set of inclusion criteria yielded 17 studies (Australia = 6; Canada = 8; UK = 3). In addition 11 reports were included in the review. We found that a person's abilities and motivations (intrapersonal factors, reported in 7 studies) to start and continue ART are influenced by a host of interconnected factors spanning relationship (interpersonal, 3 studies) and broader structural (extrapersonal, 15 studies) factors that are situated within social determinants of health. People therefore evaluate various costs and benefits of starting and staying on treatment, in which biomedical concerns play an important yet often subsidiary role. In this review the economic barriers to care were found to be significant and under-reported, highlighting the persistent health inequities in terms of access to services. Our understanding of the context around people's use of ART remains poor. Qualitative social research within HIV-positive communities is urgently needed to capture people's lived experiences and may address some of this deficit in understanding.

Barriers to HIV testing and characteristics associated with never testing among gay and bisexual men attending sexual health clinics in Sydney

INTRODUCTION

HIV diagnoses among gay and bisexual men have increased over the past decade in Australia. HIV point-of-care testing (POCT) was introduced in Australia in 2011 as a strategy to increase HIV testing by making the testing process more convenient. We surveyed gay and bisexual men undergoing POCT to assess barriers to HIV testing and characteristics associated with not having previously tested for HIV (never testing).

METHODS

During 2011 and 2012, gay and bisexual men who were undergoing POCT at four Sydney sexual health clinics self-completed questionnaires assessing testing history and psychological and structural barriers to HIV testing. Bivariate and multivariate logistic regression was used to assess associations between patient characteristics and never testing.

RESULTS

Of 1093 participants, 981 (89.9%) reported ever testing for HIV and 110 (10.1%) never testing. At least one barrier to testing was reported by 1046 men (95.7%), with only 47 men (4.3%) not reporting any barrier to testing. The most commonly reported barriers to testing were annoyance at having to return for results (30.2%), not having done anything risky (29.6%), stress in waiting for results (28.4%), being afraid of testing positive (27.5%) and having tested recently (23.2%). Never testing was independently associated with being non-gay-identified (adjusted odds ratio [AOR]: 1.9; 95% confidence interval [CI]: 1.1-3.2), being aged less than 25 years (AOR: 2.4; 95% CI: 1.6-3.8), living in a suburb with few gay couples (AOR: 1.9; 95% CI: 1.2-3.0), being afraid of testing HIV-positive (AOR: 1.6; 95% CI: 1.0-2.4), not knowing where to test (AOR: 3.8; 95% CI: 1.3-11.2) and reporting one or no sexual partners in the last six months (AOR: 2.7; 95% CI: 1.2-6.2).

CONCLUSIONS

Barriers to HIV testing were commonly reported among the clinic-based gay and bisexual men in this study. Our findings suggest further health promotion and prevention strategies are needed to address the knowledge, attitudes and behavioural factors associated with never testing.