Willingness to Take a Free Home HIV Test and Associated Factors among Internet-Using Men Who Have Sex with Men

The effects of HIV self-testing on HIV incidence and awareness of status among men who have sex with men in the United States: Insights from a novel compartmental model

BACKGROUND

The OraQuick In-Home HIV self-test represents a fast, inexpensive, and convenient method for users to assess their HIV status. If integrated thoughtfully into existing testing practices, accompanied by efficient pathways to formal diagnosis, self-testing could enhance both HIV awareness and reduce HIV incidence. However, currently available self-tests are less sensitive, particularly for recent infection, when compared to gold-standard laboratory tests. It is important to understand the impact if some portion of standard testing is replaced by self-tests. We used a compartmental model to evaluate the effects of self-testing in diverse scenarios among gay, bisexual and other men who have sex with men (MSM) in the United States for the period 2020-2030, and to understand which scenarios maximize the advantages of self-testing.

METHODS

We introduced a novel 4-compartment model for HIV self-testing. We employed the model under different screening rates, self-test proportions, and delays to diagnosis for those identified through self-tests to determine the potential effects of self-testing on HIV incidence and awareness of status when applied to the US MSM population. We studied scenarios in which self-tests supplement laboratory-based tests, with no replacement, and scenarios in which some replacement occurs. We also examined how future improvements in self-test sensitivity may affect our results.

RESULTS

When HIV self-tests are supplemental rather than substitutes for laboratory-based testing, self-testing can decrease HIV incidence among MSM in the US by up to 10 % and increase awareness of status among MSM from 85 % to 91 % over a 10-year period, provided linkage to care and formal diagnosis occur promptly following a positive self-test (90 days or less). As self-tests replace a higher percentage laboratory-based testing algorithms, increases in overall testing rates were necessary to ensure reductions in HIV incidence. However, such needed increases were relatively small (under 10 % for prompt engagement in care and moderate levels of replacement). Improvements in self-test sensitivity and/or decreases in the detection period may further reduce any necessary increases in overall testing by up to 40 %.

CONCLUSIONS

If properly utilized, self-testing can provide significant long-term reductions to HIV incidence and improve awareness of HIV status. Ensuring that self-testing increases overall testing and that formal diagnosis and engagement in care occur promptly following a positive self-test are necessary to maximize the benefits of self-testing. Future improvements in self-test sensitivity and reductions in the detection period would further reduce HIV incidence and the potential risks associated with replacing laboratory tests with self-tests.

HIV Testing Strategies, Types of Tests, and Uptake by Men Who have Sex with Men and Transgender Women: A Systematic Review and Meta-analysis

This systematic review and meta-analysis investigated the effectiveness of strategies and types of tests on HIV testing uptake by men who have sex with men (MSM) and transgender women (TGW), and in reaching PLWH. Articles published up to July 2020 were identified from major electronic databases and grey literature. Data were extracted and assessed for risk of bias. Estimates were pooled using random-effect meta-analysis while heterogeneity was evaluated by Cochran's Q test and I². This study is registered with PROSPERO (CRD42020192740). Of 6820 titles, 263 studies (n = 67,288 participants) were included. The testing strategies reported in most studies were community- (71.2%) and facility-based (28.8%). Highest uptake, with facility-based testing, occurred and reached more PLWH while with standard laboratory tests, it occurred with the highest HIV prevalence among MSM. However, urine test showed a highest rate of new HIV infection. Multiple test combinations had the highest uptake and reached more PLWH among TGW. Various testing strategies, considering barriers and regional differences, and different test types, need be considered, to increase uptake among MSM and TGW.

Combating Stigma Through HIV Self-Testing: New York State's HIV Home Test Giveaway Program for Sexual Minorities

CONTEXT

Gay, bisexual, and men who have sex with men (MSM) are disproportionately affected by the HIV/AIDS epidemic more than any other group. In New York State (NYS) outside of New York City (NYC), MSM accounted for 57% of new HIV/AIDS diagnoses in 2017. HIV/AIDS home testing initiatives have been effective at getting priority populations tested for HIV.

OBJECTIVES

The NYS Department of Health (NYSDOH) administered the HIV Home Test Giveaway (HHTG) program through social media and mobile applications popular among the priority populations to (1) promote HIV screening among gay and bisexual men, MSM, transgender (TG), and gender queer/gender nonconforming (GNC) individuals who have sex with men, and (2) identify individuals with undiagnosed HIV infection.

DESIGN/SETTING

The NYSDOH recruited participants from NYS (excluding NYC) through social media campaigns between November 2016 and January 2018. Interested individuals were directed to an online eligibility survey. Eligible participants received a coupon via e-mail for a free HIV self-test (HIVST) kit through the manufacturer's Web site. Eligible participants received a $20 to $25 Amazon online gift card if they completed a voluntary online follow-up survey regarding their test results, experiences with the HHTG, and HIV/AIDS risk behaviors. Participants were also able to request assistance from the NYSDOH with further testing and various prevention and supportive services.

PARTICIPANTS

In total, 6190 individuals participated and 3197 (52%) were eligible and received a coupon. Of the eligible, 2022 (63%) redeemed coupons for HIVST.

RESULTS

Among eligible participants, 976 (31%) reported having never been tested for HIV. On the follow-up survey, 922 (29%) participants reported having used the HIVST kit for themselves; 203 (22%) were first-time testers; and 7 (0.8%) tested HIV reactive. Of the follow-up survey participants, 761 (59%) requested assistance with various services.

CONCLUSIONS

Media campaigns were effective in promoting HIV testing among priority populations and reaching individuals who have never been tested for HIV.

Willingness to Participate in At-Home HIV Testing Among Young Adults Who Use Opioids in Rural Appalachia

New HIV infections associated with injection drug use are of major concern in rural US communities. This study explores acceptability of, consent for, and uptake of free at-home HIV testing among people who use drugs (PWUD) in one of the nation’s epicenters for drug-related harms and HIV vulnerability: Rural Central Appalachia. Eligible participants were 18–35 years old, lived in Appalachian Kentucky, and reported using opioids to get high in the previous 30 days. A majority reported being likely (63.6%, 96/151) to take a free at-home HIV tests and 66.9% (101/151) consented to receive one. Among those who were randomly selected to receive a Home Access HIV-1 test kit (n = 37), 37.8% mailed in blood spots and 21.6% called to receive results. This study provides evidence that PWUD may be willing to take an at-home test, but other barriers may inhibit actual completion.

Willingness to Use HIV Self-Testing With Online Supervision Among App-Using Young Men Who Have Sex With Men in Bangkok

ABSTRACT

An online assessment among social media-using young men who have sex with men found that 87% were willing to use HIV self-testing with online supervision. Correlates included never tested, having higher numbers of sexual partners, and seeking partners online. HIV self-testing with online supervision may be appropriate for young men who have sex with men who have high risks and may not access venue-based settings.

Awareness and Acceptability of Undetectable = Untransmittable Among a U.S. National Sample of HIV-Negative Sexual and Gender Minorities

While the "Undetectable = Untransmittable" (U=U) message is widely endorsed, little is known about its breadth and reach. Our study describes socio-demographic characteristics and sexual behaviors associated with having heard of and trusting in U =U in a U.S. national sample of HIV-negative participants. Data were derived from the Together 5,000 cohort study, an internet-based U.S. national cohort of cis men, trans men and trans women who have sex with men. Approximately 6 months after enrollment, participants completed an optional survey included in the present cross-sectional analysis (n = 3286). Measures included socio-demographic and healthcare-related characteristics; questions pertaining to knowledge of and trust in U=U (dependable variable). We used descriptive statistics and multivariable logistic models to identify characteristics associated with these variables and explored patterns in willingness to engage in condomless anal sex (CAS) with regard to trust in U=U. In total, 85.5% of participants reported having heard of U=U. Among those aware of U=U, 42.3% indicated they trusted it, 19.8% did not, and 38.0% were unsure about it. Latinx, Asian, lower income, and Southern participants were less likely to have heard of U=U. Having had a recent clinical discussion about PrEP or being a former-PrEP user were associated with trust in U=U. Willingness to engage in CAS was positively associated with trust in U=U, and varied based on the partner's serostatus, PrEP use and viral load. Although we found high rates of awareness and low levels of distrust, our study indicated that key communities remain unaware and/or skeptical of U=U.

Eliciting Preferences for HIV Prevention Technologies: A Systematic Review

Background

Many human immunodeficiency virus (HIV) prevention technologies (pre-exposure prophylaxis, microbicides, vaccines) are available or in development. Preference elicitation methods provide insight into client preferences that may be used to optimize products and services. Given increased utilization of such methods in HIV prevention, this article identifies and reviews these methods and synthesizes their application to HIV prevention technologies.

Methods

In May 2020, we systematically searched peer-reviewed literature in PubMed, CINAHL, and Web of Science for studies employing quantitative preference elicitation methods to measure preferences for HIV prevention technologies among populations of any age, sex, or location. Quality assessment used an existing checklist (PREFS) and a novel adaptation of the Newcastle–Ottawa Scale (PROSPERO #CRD42018087027).

Results

We screened 5022 titles and abstracts, reviewed 318 full texts, and included 84 studies. Common methods employed were discrete-choice experiment (33%), conjoint analysis (25%), and willingness-to-participate/try/accept (21%). Studies were conducted in 25 countries and had a mean of 768 participants (range = 26–7176), two-thirds of them male. Common HIV prevention technologies included pre-exposure prophylaxis (23%), voluntary testing and counseling (19%), HIV self-testing (17%), vaccines (15%), and topical microbicides (9%). Most attributes focused on product design (side effects, frequency), service design (provider type, location), acceptability or willingness to accept/pay; results are summarized in these categories, by prevention type. Mean quality-adapted Newcastle–Ottawa Scale score was 4.5/8 (standard deviation = 2.1) and mean PREFS scores was 3.47/5 (standard deviation = 0.81).

Conclusions

This review synthesizes extant literature on quantitative measurement of preferences for HIV prevention technologies. This can enable practitioners to improve prevention products and interventions, and ultimately reduce HIV incidence.

Maximizing Response Rates to Ads for Free At-Home HIV Testing on a Men-for-Men Geosocial Sexual Networking App: Lessons Learned and Implications for Researchers and Providers

Internet-based recruitment can be effective in reaching large numbers of geographically diverse individuals. Geosocial sexual networking apps on smartphones have emerged as the modal way in which men who have sex with men (MSM) meet sex partners, and as venues for sexual health research. We report on the performance of three types of ads-text-only, text with male figure (no face), and text with male figure (with face)-used on a geosocial sexual networking app to advertise free at-home HIV testing and to enroll in an online study. We ran five 2-week-long ads on a popular MSM geosocial app between fall 2017 and spring 2018 (~2.19 million impressions). Ads were evaluated in terms of the click-through rate (CTR = advertisement clicks/advertisement impressions), conversion rates (CR = number of enrolled participants/ad-generated clicks), cost per enrolled participant, and demographic composition of survey respondents. We enrolled n = 4,023 individuals, n = 2,430 of whom completed HIV testing-$6.21 spent on advertising per participant enrolled and $10.29 spent for everyone who completed HIV testing. Cost per enrolled participant was associated with the content of the ad used-ads featuring male figures (with or without a face shown) were more cost efficient than ads featuring text alone. These ads also outperformed text-only ads across a range of metrics, including responsiveness among younger MSM as well as MSM of color. Advertising materials that combine text with images may have greater appeal among priority populations.

Effect of Internet-Distributed HIV Self-tests on HIV Diagnosis and Behavioral Outcomes in Men Who Have Sex With Men: A Randomized Clinical Trial

IMPORTANCE

Undiagnosed HIV infection results in delayed access to treatment and increased transmission. Self-tests for HIV may increase awareness of infection among men who have sex with men (MSM).

OBJECTIVE

To evaluate the effect of providing HIV self-tests on frequency of testing, diagnoses of HIV infection, and sexual risk behaviors.

DESIGN, SETTING, AND PARTICIPANTS

This 12-month longitudinal, 2-group randomized clinical trial recruited MSM through online banner advertisements from March through August 2015. Those recruited were at least 18 years of age, reported engaging in anal sex with men in the past year, never tested positive for HIV, and were US residents with mailing addresses. Participants completed quarterly online surveys. Telephone call notes and laboratory test results were included in the analysis, which was completed from August 2017 through December 2018.

INTERVENTIONS

All participants had access to online web-based HIV testing resources and telephone counseling on request. Participants were randomized in a 1:1 ratio to the control group or a self-testing (ST) group, which received 4 HIV self-tests after completing the baseline survey with the option to replenish self-tests after completing quarterly surveys. At study completion, all participants were offered 2 self-tests and 1 dried blood spot collection kit.

MAIN OUTCOMES AND MEASURES

Primary outcomes were HIV testing frequency (tested ≥3 times during the trial) and number of newly identified HIV infections among participants in both groups and social network members who used the study HIV self-tests. Secondary outcomes included sex behaviors (eg, anal sex, serosorting).

RESULTS

Of 2665 participants, the mean (SD) age was 30 (9.6) years, 1540 (57.8%) were white, and 443 (16.6%) had never tested for HIV before enrollment. Retention rates at each time point were more than 54%, and 1991 (74.7%) participants initiated 1 or more follow-up surveys. More ST participants reported testing 3 or more times during the trial than control participants (777 of 1014 [76.6%] vs 215 of 977 [22.0%]; P < .01). The cumulative number of newly identified infections during the trial was twice as high in the ST participants as the control participants (25 of 1325 [1.9%] vs 11 of 1340 [0.8%]; P = .02), with the largest difference in HIV infections identified in the first 3 months (12 of 1325 [0.9%] vs 2 of 1340 [0.1%]; P < .01). The ST participants reported 34 newly identified infections among social network members who used the self-tests.

CONCLUSIONS AND RELEVANCE

Distribution of HIV self-tests provides a worthwhile mechanism to increase awareness of HIV infection and prevent transmission among MSM.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02067039.

Stimulant Use and Study Protocol Completion: Assessing the Ability of Men Who Have Sex with Men to Collect Dried Blood Spots for Laboratory Measurement of HIV Viral Load

Stimulant use is associated with higher HIV viral load (VL) and sexual HIV transmission risk among men who have sex with men (MSM) living with HIV. There is little research on willingness of drug users living with HIV to fully participate in studies, especially those involving self-collection of biomarker data. This study presents findings from an at-home dried blood spot collection study measuring laboratory-quantified VL among U.S. HIV-positive MSM who reported high-risk sexual behavior and/or suboptimal antiretroviral therapy (ART) adherence to assess the association between drug-use behavior and (1) ability to complete a study protocol and (2) VL outcomes. Among recruited participants (n = 766), 35% reported stimulant drug use (amphetamines, cocaine, crack, crystal meth, ecstasy, or a combination of stimulant drugs), 39% reported using other drugs (heroin, marijuana, prescription opioids, and others), and 27% reported no drug use in the past 3 months. In all, 61% of enrolled participants completed the study protocol. Stimulant drug users were less likely (ARR 0.84; 95% CI 0.72-0.98) to complete the protocol than other drug users. Furthermore, other drug users were significantly less likely than non-drug users (ARR 0.52; 95% CI 0.28-0.97) to have an HIV VL result ≥ 1500 copies/mL. This study provides important estimates regarding the likelihood of participation in biomedical research activities among HIV-positive MSM with varying drug-use behaviors, showing that it is feasible to conduct such biomedical studies with drug-using MSM who report high-risk sexual behavior and struggle with their ART adherence.

HIV Self-Testing Increases HIV Testing Frequency in High-Risk Men Who Have Sex With Men: A Randomized Controlled Trial

BACKGROUND

Self-testing may increase HIV testing and decrease the time people with HIV are unaware of their status, but there is concern that absence of counseling may result in increased HIV risk.

SETTING

Seattle, Washington.

METHODS

We randomly assigned 230 high-risk HIV-negative men who have sex with men to have access to oral fluid HIV self-tests at no cost versus testing as usual for 15 months. The primary outcome was self-reported number of HIV tests during follow-up. To evaluate self-testing's impact on sexual behavior, we compared the following between arms: non-HIV-concordant condomless anal intercourse and number of male condomless anal intercourse partners in the last 3 months (measured at 9 and 15 months) and diagnosis with a bacterial sexually transmitted infection (STI: early syphilis, gonorrhea, and chlamydial infection) at the final study visit (15 months). A post hoc analysis compared the number of STI tests reported during follow-up.

RESULTS

Men randomized to self-testing reported significantly more HIV tests during follow-up (mean = 5.3, 95% confidence interval = 4.7 to 6.0) than those randomized to testing as usual (3.6, 3.2 to 4.0; P < 0.0001), representing an average increase of 1.7 tests per participant over 15 months. Men randomized to self-testing reported using an average of 3.9 self-tests. Self-testing was noninferior with respect to all markers of HIV risk. Men in the self-testing arm reported significantly fewer STI tests during follow-up (mean = 2.3, 95% confidence interval = 1.9 to 2.7) than men in the control arm (3.2, 2.8 to 3.6; P = 0.0038).

CONCLUSIONS

Access to free HIV self-testing increased testing frequency among high-risk men who have sex with men and did not impact sexual behavior or STI acquisition.

HIV testing self-efficacy is associated with higher HIV testing frequency and perceived likelihood to self-test among gay and bisexual men

Background Regular testing of individuals at higher-risk of HIV is central to current prevention strategies. The aim of the present study was to examine the extent to which confidence in one's perceived ability to undertake various aspects of HIV testing and self-testing (self-efficacy) affected HIV testing outcomes. We assessed factors, including self-efficacy, associated with HIV testing frequency and the likelihood to self-test among gay and bisexual men (GBM).

METHODS

Participants were HIV-negative GBM at an increased risk of HIV (more than five partners or condomless anal intercourse in the previous 3 months) enrolled in a randomised controlled trial of HIV self-testing. The baseline questionnaire captured data regarding sociodemographic characteristics, HIV and/or sexually transmissible infection testing history, sexual behaviour, beliefs and attitudes towards HIV and eight items capturing confidence in HIV testing ability that were combined as a single broad measure of HIV testing self-efficacy (α=0.81). Factors associated with three or more HIV tests in the past year and the likelihood of self-testing in the future were determined using logistic regression.

RESULTS

Of 354 GBM, 34% reported three or more HIV tests in the past year, and 64% reported being 'very likely' to self-test. Factors independently associated with three or more HIV tests in the past year were: higher self-efficacy (adjusted odds ratio (aOR) 1.08 per unit increase; 95% confidence interval (CI) 1.02-1.14; P=0.004); >10 male partners in the past 6 months (aOR 1.79; 95% CI 1.05-3.04; P=0.031) and higher optimism regarding the effects of HIV treatments on HIV transmission (aOR 1.14; 95% CI 1.00-1.29; P=0.044). Only higher self-efficacy was independently associated with reporting a greater likelihood to self-test in the future (aOR 1.10; 95% CI 1.05-1.15; P < 0.001).

CONCLUSIONS

Improving self-efficacy by enhancing GBM's knowledge and experience may lead to higher testing frequency. The self-efficacy measure used in the present study could be useful in identifying GBM likely to face difficulties with HIV testing and self-testing.

Recruiting vulnerable populations to participate in HIV prevention research: findings from the Together 5000 cohort study

PURPOSE

The aim of the article was to examine factors associated with completing enrollment milestones in the Together 5000 cohort of at-risk men (n = 8661), transmen (n = 53), and transwomen (n = 63) who have sex with men.

METHODS

Between 2017 and 2018, participants completed an online enrollment survey and were offered opportunities to complete an incentivized secondary online survey as well as self-administered at-home HIV testing (OraSure). We explored factors associated with completing each study component.

RESULTS

In total, 8777 individuals completed our enrollment survey, 6166 (70.3%) completed the secondary survey, and 5010 returned the at-home HIV test kit that was mailed to them (81.3% of those mailed a kit). In our multivariable models, those who were White, with more years of education, were more likely to complete study components, although the magnitude of these associations was small. For example, 50.9% of those enrolled, 47.9% of those completing the secondary survey, and 46.8% of those completing HIV testing were persons of color-a statistically significant, but meaningfully insignificant decline.

CONCLUSIONS

These findings highlight the need for researchers to identify barriers that may prevent persons of color and younger individuals from participating in research studies.

Acceptability and Feasibility of Self-Collecting Biological Specimens for HIV, Sexually Transmitted Infection, and Adherence Testing Among High-Risk Populations (Project Caboodle!): Protocol for an Exploratory Mixed-Methods Study

BACKGROUND

Men who have sex with men (MSM) in the United States experience a disproportionate burden of HIV and bacterial sexually transmitted infections (STIs), such as gonorrhea and chlamydia. Screening levels among MSM remain inadequate owing to barriers to testing such as stigma, privacy and confidentiality concerns, transportation issues, insufficient clinic time, and limited access to health care. Self-collection of specimens at home and their return by mail for HIV and bacterial STI testing, as well as pre-exposure prophylaxis (PrEP) adherence monitoring, could be a resource-efficient option that might mitigate some of these barriers.

OBJECTIVE

Project Caboodle! is a mixed-methods study that explores the acceptability and feasibility of self-collecting and returning a bundle of 5 different specimens for HIV and bacterial STI testing, as well as PrEP adherence monitoring, among sexually active HIV-negative or unknown status MSM in the United States aged 18 to 34 years.

METHODS

Participants will be recruited using age, race, and ethnicity varied advertising on social networking websites and mobile gay dating apps. In Phase 1, we will send 100 participants a box containing materials for self-collecting and potentially returning a finger-stick blood sample (for HIV testing), pharyngeal swab, rectal swab, and urine specimen (for gonorrhea and chlamydia testing), and hair sample (to assess adequacy for potential PrEP adherence monitoring). Specimen return will not be incentivized, and participants can choose to mail back all, some, or none of the specimens. Test results will be delivered back to participants by trained counselors over the phone. In Phase 2, we will conduct individual in-depth interviews using a video-based teleconferencing software (VSee) with 32 participants from Phase 1 (half who returned all specimens and half who returned some or no specimens) to examine attitudes toward and barriers to completing various study activities.

RESULTS

Project Caboodle! was funded in May 2018, and participant recruitment began in March 2019. The processes of designing a study logo, creating advertisements, programming Web-based surveys, and finalizing step-by-step written instructions accompanied by color images for specimen self-collection have been completed. The boxes containing 5 self-collection kits affixed with unique identification stickers are being assembled, and shipping procedures (for mailing out boxes to participants and for specimen return by participants using prepaid shipping envelopes) and payment procedures for completing the surveys and in-depth interviews are being finalized.

CONCLUSIONS

Self-collection of biological specimens at home and their return by mail for HIV and bacterial STI testing, as well as PrEP adherence monitoring, might offer a practical and convenient solution to improve comprehensive prevention efforts for high-risk MSM. The potentially reduced time, expense, and travel associated with this approach could facilitate a wider implementation of screening algorithms and remote monitoring strategies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/13647.

Self-sampling kits to increase HIV testing among black Africans in the UK: the HAUS mixed-methods study

BACKGROUND

Timely diagnosis of human immunodeficiency virus (HIV) enables access to antiretroviral treatment, which reduces mortality, morbidity and further transmission in people living with HIV. In the UK, late diagnosis among black African people persists. Novel methods to enhance HIV testing in this population are needed.

OBJECTIVES

To develop a self-sampling kit (SSK) intervention to increase HIV testing among black Africans, using existing community and health-care settings (stage 1) and to assess the feasibility for a Phase III evaluation (stage 2).

DESIGN

A two-stage, mixed-methods design. Stage 1 involved a systematic literature review, focus groups and interviews with key stakeholders and black Africans. Data obtained provided the theoretical base for intervention development and operationalisation. Stage 2 was a prospective, non-randomised study of a provider-initiated, HIV SSK distribution intervention targeted at black Africans. The intervention was assessed for cost-effectiveness. A process evaluation explored feasibility, acceptability and fidelity.

SETTING

Twelve general practices and three community settings in London.

MAIN OUTCOME MEASURE

HIV SSK return rate.

RESULTS

Stage 1 - the systematic review revealed support for HIV SSKs, but with scant evidence on their use and clinical effectiveness among black Africans. Although the qualitative findings supported SSK distribution in settings already used by black Africans, concerns were raised about the complexity of the SSK and the acceptability of targeting. These findings were used to develop a theoretically informed intervention. Stage 2 - of the 349 eligible people approached, 125 (35.8%) agreed to participate. Data from 119 were included in the analysis; 54.5% (65/119) of those who took a kit returned a sample; 83.1% of tests returned were HIV negative; and 16.9% were not processed, because of insufficient samples. Process evaluation showed the time pressures of the research process to be a significant barrier to feasibility. Other major barriers were difficulties with the SSK itself and ethnic targeting in general practice settings. The convenience and privacy associated with the SSK were described as beneficial aspects, and those who used the kit mostly found the intervention to be acceptable. Research governance delays prevented implementation in Glasgow.

LIMITATIONS

Owing to the study failing to recruit adequate numbers (the intended sample was 1200 participants), we were unable to evaluate the clinical effectiveness of SSKs in increasing HIV testing in black African people. No samples were reactive, so we were unable to assess pathways to confirmatory testing and linkage to care.

CONCLUSIONS

Our findings indicate that, although aspects of the intervention were acceptable, ethnic targeting and the SSK itself were problematic, and scale-up of the intervention to a Phase III trial was not feasible. The preliminary economic model suggests that, for the acceptance rate and test return seen in the trial, the SSK is potentially a cost-effective way to identify new infections of HIV.

FUTURE WORK

Sexual and public health services are increasingly utilising self-sampling technologies. However, alternative, user-friendly SSKs that meet user and provider preferences and UK regulatory requirements are needed, and additional research is required to understand clinical effectiveness and cost-effectiveness for black African communities.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014010698 and Integrated Research Application System project identification 184223.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and the BHA for Equality in Health and Social Care.

Quantification of HIV-1 RNA Among Men Who Have Sex With Men Using an At-Home Self-Collected Dried Blood Spot Specimen: Feasibility Study

BACKGROUND

Suboptimal antiretroviral therapy (ART) adherence and disengagement in care present significant public health challenges because of the increased probability of HIV transmission. In the United States, men who have sex with men (MSM) continue to be disproportionately affected by HIV, highlighting a critical need to engage high-risk MSM living with HIV who are not engaged or retained in care.

OBJECTIVE

The aim of the study was to assess the feasibility of at-home blood self-collection and laboratory quantification of HIV-1 RNA viral load (VL) to report laboratory-based VL outcomes and compare self-reported and laboratory-reported VL.

METHODS

Between 2016 and 2017, 766 US HIV-positive MSM enrolled in a Web-based behavioral intervention were invited to participate in an at-home dried blood spot (DBS) collection study using HemaSpot-HF kits (Spot On Sciences, Inc, Austin, TX) for laboratory-quantified VL.

RESULTS

Of those invited to participate, 72.3% (554/766) enrolled in the DBS study. Most (79.2%, 439/554) men enrolled reported attempting to collect their blood, 75.5% (418/554) of participants mailed a DBS specimen to the research laboratory, and 60.8% (337/554) had an adequate blood sample for VL testing. Of the 337 specimens tested for VL by the laboratory, 52.5% (177/337) had detectable VL (median: 3508 copies/mL; range: 851-1,202,265 copies/mL). Most men (83.9%, 135/161) who returned a DBS specimen with laboratory-quantified detectable VL self-reported an undetectable VL during their last clinical visit.

CONCLUSIONS

Home collection of DBS samples from HIV-positive MSM is feasible and has the potential to support clinical VL monitoring. Discrepant laboratory HIV-1 RNA values and self-reported VL indicate a need to address perceived VL status, especially in the era of treatment as prevention. Most participants were willing to use an at-home DBS kit in the future, signaling an opportunity to engage high-risk MSM in long-term HIV care activities.

Facilitating HIV/AIDS and HIV testing literacy for emergency department patients: a randomized, controlled, trial

Background

Although this has not been fully studied, videos and pictorial brochures might be equivalent methods of delivering HIV/AIDS and HIV testing information to emergency departments (ED) patients. It also is not known how well or for how long such knowledge is retained, if this information should be tailored according to patient health literacy, and if retention of this knowledge impacts future HIV testing behavior.

Methods

We will conduct a multi-site, randomized, controlled, longitudinal trial among 600 English- and 600 Spanish-speaking 18–64-year-old ED patients to investigate these questions. We will stratify our sample within language (English vs. Spanish) by health literacy level (lower vs. higher) and randomly assign patients to receive HIV/AIDS and HIV testing information by video or pictorial brochure. All patients will be tested for HIV in the ED. At 12-months post-enrollment, we will invite participants to be tested again for HIV. As primary aims, we will compare the efficacy of pictorial brochures and videos in improving short-term (in ED) HIV/AIDS and HIV testing knowledge and retaining this knowledge over 12 months. We will determine if and how short-term improvement and longer-term retention of knowledge interacts with information delivery mode (pictorial brochure or video), patient health literacy level (lower or higher), and language (English or Spanish). As secondary aims, using the Information-Motivation-Behavioral Skills (IMB) model as a heuristic framework, we will measure constructs from the IMB model relevant to our study, and assess their impact on HIV re-testing behavior; we will also examine the moderating influences of information delivery mode, language, and health literacy level. In addition, we will explore simplified screening strategies to identify ED patients with lower health literacy as ways to implement a tailored approach to HIV/AIDS and HIV testing information delivery in EDs.

Discussion

Study findings will guide ED-based delivery of HIV/AIDS and HIV testing information; that is, whether delivery modes (video or pictorial brochure) should be selected for patients by language and/or health literacy level. The results also will inform EDs when, how, and for whom information needs to be provided for those undergoing testing again for HIV within a one-year period.

Trial registration

ClinicalTrials.gov Identifier: NCT02284451. Posted November 6, 2014.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0172-7) contains supplementary material, which is available to authorized users.

Acceptability of HIV self-sampling kits (TINY vial) among people of black African ethnicity in the UK: a qualitative study

Background

Increasing routine HIV testing among key populations is a public health imperative, so improving access to acceptable testing options for those in need is a priority. Despite increasing targeted distribution and uptake of HIV self-sampling kits (SSKs) among men who have sex with men in the UK, little is known about why targeted SSK interventions for black African users are not as wide-spread or well-used. This paper addresses this key gap, offering insight into why some groups may be less likely than others to adopt certain types of SSK interventions in particular contexts. These data were collected during the development phase of a larger study to explore the feasibility and acceptability of targeted distribution of SSKs to black African people.

Methods

We undertook 6 focus groups with members of the public who self-identified as black African (n = 48), 6 groups with specialists providing HIV and social services to black African people (n = 53), and interviews with HIV specialist consultants and policy-makers (n = 9). Framework analysis was undertaken, using inductive and deductive analysis to develop and check themes.

Results

We found three valuable components of targeted SSK interventions for this population: the use of settings and technologies that increase choice and autonomy; targeted offers of HIV testing that preserve privacy and do not exacerbate HIV stigma; and ensuring that the specific kit being used (in this case, the TINY vial) is perceived as simple and reliable.

Conclusions

This unique and rigorous research offers insights into participants’ views on SSK interventions, offering key considerations when targeting this population.. Given the plethora of HIV testing options, our work demonstrates that those commissioning and delivering SSK interventions will need to clarify (for users and providers) how each kit type and intervention design adds value. Most significantly, these findings demonstrate that without a strong locus of control over their own circumstances and personal information, black African people are less likely to feel that they can pursue an HIV test that is safe and secure. Thus, where profound social inequalities persist, so will inequalities in HIV testing uptake – by any means.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5256-5) contains supplementary material, which is available to authorized users.

Individual-level characteristics associated with oral HIV test acceptability among Peruvian men who have sex with men and transgender women: a cross-sectional study

OBJECTIVES

Peruvian men who have sex with men (MSM) and transgender women (TGW) are highly vulnerable to HIV infection (HIV), but stigma, access issues and fear of venipuncture hamper testing. The oral HIV test-which uses oral fluids and provides results in 20 minutes-could reduce these barriers. The objective of this study was to determine the acceptability of the oral HIV test and the individual-level factors associated with its acceptability among MSM and TGW.

METHODS

We conducted a cross-sectional secondary analysis among Peruvian MSM and TGW attending a community-based health centre between February 2012 and February 2013 to determine the individual-level factors associated with oral HIV test acceptability.

RESULTS

Of 334 participants, 88% were MSM and 12% TGW. Overall, 85% of participants indicated their acceptability of the oral HIV test. Acceptability was higher in MSM than TGW (85.7% vs 80.0%) but this difference was not significant. Factors associated with acceptability in MSM were: tertiary or higher education (prevalence ratio (PR)=1.18, 95% CI 1.06 to 1.32 and PR=1.16, 95% CI 1.03 to 1.30, respectively); sex with drug use (PR=1.19, 95% CI 1.05 to 1.36); believing that HIV is transmitted by saliva (PR=1.20, 95% CI 1.08 to 1.33); and potential use of the oral test at home (PR=1.56, 95% CI 1.32 to 1.85). The only factor associated with lower acceptability was having had first anal intercourse between 14 and 19 years of age (PR=0.89, 95% CI 0.80 to 0.98).

CONCLUSIONS

We identified the individual factors associated with oral HIV test acceptability among Peruvian MSM and TGW. Expanded use of the oral HIV test to increase testing rates among Peruvian MSM and TGW is recommended.

TRIAL REGISTRATION NUMBER

NCT01387412, post-results.

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

This guideline is intended for use in UK Genitourinary medicine clinics and sexual health services but is likely to be of relevance in all sexual health settings, including general practice and Contraception and Sexual Health (CASH) services, where men who have sex with men (MSM) seek sexual health care or where addressing the sexual health needs of MSM may have public health benefits. For the purposes of this document, MSM includes all gay, bisexual and all other males who have sex with other males and both cis and trans men. This document does not provide guidance on the treatment of particular conditions where this is covered in other British Association for Sexual Health and HIV (BASHH) Guidelines but outlines best practice in multiple aspects of the sexual health care of MSM. Where prevention of sexually transmitted infections including HIV can be addressed as an integral part of clinical care, this is consistent with the concept of combination prevention and is included. The document is designed primarily to provide guidance on the direct clinical care of MSM but also makes reference to the design and delivery of services with the aim of supporting clinicians and commissioners in providing effective services. Methodology This document was produced in accordance with the guidance set out in the BASHH CEG's document 'Framework for guideline development and assessment' published in 2010 at http://www.bashh.org/guidelines and with reference to the Agree II instrument. Following the production of the updated framework in April 2015, the GRADE system for assessing evidence was adopted and the draft recommendations were regraded. Search strategy (see also Appendix 1) Ovid Medline 1946 to December 2014, Medline daily update, Embase 1974 to December 2014, Pubmed NeLH Guidelines Database, Cochrane library from 2000 to December 2014. Search language English only. The search for Section 3 was conducted on PubMed to December 2014. Priority was given to peer-reviewed papers published in scientific journals, although for many issues evidence includes conference abstracts listed on the Embase database. In addition, for 'Identification of problematic recreational drug and alcohol use' section and 'Sexual problems and dysfunctions in MSM' section, searches included PsycINFO. Methods Article titles and abstracts were reviewed and if relevant the full text article was obtained. Priority was given to randomised controlled trial and systematic review evidence, and recommendations made and graded on the basis of best available evidence. Piloting and feedback The first draft of the guideline was circulated to the writing group and to a small group of relevant experts, third sector partners and patient representatives who were invited to comment on the whole document and specifically on particular sections. The revised draft was reviewed by the CEG and then reviewed by the BASHH patient/public panel and posted on the BASHH website for public consultation. The final draft was piloted before publication. Guideline update The guidelines will be reviewed and revised in five years' time, 2022.

Observational study of factors associated with return of home sampling kits for sexually transmitted infections requested online in the UK

OBJECTIVES

To investigate factors associated with the return of home sampling kits for sexually transmitted infections (STIs).

SETTING

Online STI testing service offered to the residents of Birmingham and Solihull.

PARTICIPANTS

All patients requesting STI home sampling kits via the Umbrella sexual health service website between 15 July 2016 and 14 December 2016.

INTERVENTIONS

Associations between data collected at online registration and the rate of return of STI home sampling kits within 30 days of request was assessed.

RESULTS

A total of 5310 kits were requested, of which 3099 (58.4%) were returned to the medical microbiology laboratory. On multivariable analysis, women and men who have sex with men were similarly likely to return their sampling kits (adjusted OR (OR_adj) 1.06, 95% CI 0.86 to 1.30), while heterosexual men were significantly less likely to return their sampling kits (OR_adj 0.63, 95% CI 0.55 to 0.72, p<0.001 vs women). Patients reporting symptoms were also less likely to return kits (OR_adj 0.77, 95% CI 0.67 to 0.89, p=0.001 vs asymptomatic patients). Kits that were delivered to the patient's home, rather than to a clinic or pharmacy (p<0.001), and those requested from less economically deprived neighbourhoods (p=0.029) were significantly more likely to be returned.

CONCLUSION

STI self-sampling testing kits delivered to patients' homes are most likely to be returned. Heterosexual men and those from more economically deprived areas are the less likely groups to return the kits. Further research on the barriers to return self-sampling STI testing kits of these subgroups of patients is warranted.

TRIAL REGISTRATION NUMBER

Registered with R&D department at University Hospitals Birmingham; CARMS-13551.

Technologies for HIV prevention and care: challenges for health services

This article aims to consider some relevant challenges to the provision of "new prevention technologies" in health services in a scenario where the "advances" in the global response to AIDS control are visible. We take as material for analysis the information currently available on the HIV post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), treatment as prevention (TASP) and over the counter. The methodology consisted of the survey and analysis of the Biblioteca Virtual em Saúde (BVS: MEDLINE, LILACS, WHOLIS, PAHO, SciELO) articles that addressed the issue of HIV prevention and care in the context of so-called new prevention technologies. The results of the studies show that there is assistance on the ground of clinics for the treatment of disease responses, but there are several challenges related to the sphere of prevention. The articles list some challenges regarding to management, organization of services and the attention given by health professionals to users. The current context shows evidence of the effectiveness of antiretroviral therapy in reducing the risk of HIV transmission, but the challenges for the provision of preventive technologies in health services permeate health professionals and users in their individual dimensions and health services in organizational and structural dimension. Interventions should be made available in a context of community mobilization; there should be no pressure on people to make HIV testing, antiretroviral treatment or for prevention. In the management is responsible for the training of health professionals to inform, clarify and make available to users, partners and family information about the new antiretroviral use strategies.

Preferences for oral fluid rapid HIV self-testing among social media-using young black, Hispanic, and white men-who-have-sex-with-men (YMSM): implications for future interventions

OBJECTIVES

We assessed preferences of social media-using young black, Hispanic and white men-who-have-sex-with-men (YMSM) for oral fluid rapid HIV self-testing, as compared to other currently available HIV testing options. We also identified aspects of the oral fluid rapid HIV self-test that might influence preferences for using this test instead of other HIV testing options and determined if consideration of HIV testing costs and the potential future availability of fingerstick rapid HIV self-testing change HIV testing preferences.

STUDY DESIGN

Anonymous online survey.

METHODS

HIV-uninfected YMSM across the United States recruited from multiple social media platforms completed an online survey about willingness to use, opinions about and their preferences for using oral fluid rapid HIV self-testing and five other currently available HIV testing options. In a pre/post questionnaire format design, participants first indicated their preferences for using the six HIV testing options (pre) before answering questions that asked their experience with and opinions about HIV testing. Although not revealed to participants and not apparent in the phrasing of the questions or responses, the opinion questions concerned aspects of oral fluid rapid HIV self-testing (e.g. its possible advantages/disadvantages, merits/demerits, and barriers/facilitators). Afterward, participants were queried again about their HIV testing preferences (post). After completing these questions, participants were asked to re-indicate their HIV testing preferences when considering they had to pay for HIV testing and if fingerstick blood sample rapid HIV self-testing were an additional testing option. Aspects about the oral fluid rapid HIV self-test associated with increased preference for using the test (post-assessment vs pre-assessment of opinion topics) were identified through multivariable regression models that adjusted for participant characteristics.

RESULTS

Of the 1975 YMSM participants, the median age was 22 years (IQR 20-23); 19% were black, 36% Hispanic, and 45% white; and 18% previously used an oral fluid rapid HIV self-test. Although views about oral fluid rapid HIV self-testing test were favorable, few intended to use the test. Aspects about the oral fluid rapid HIV self-test associated with an increased preference for using the test were its privacy features, that it motivated getting tested more often or as soon as possible, and that it conferred feelings of more control over one's sexual health. Preferences for the oral fluid rapid HIV self-test were lower when costs were considered, yet these YMSM were much more interested in fingerstick blood sampling than oral fluid sampling rapid HIV self-testing.

CONCLUSIONS

Despite the perceived advantages of the oral fluid rapid HIV self-test and favorable views about it by this population, prior use as well as future intention in using the test were low. Aspects about oral fluid rapid HIV self-testing identified as influential in this study might assist in interventions aimed to increase its use among this high HIV risk population as a means of encouraging regular HIV testing, identifying HIV-infected persons, and linking them to care. Although not yet commercially available in the United States, fingerstick rapid HIV self-testing might help motivate YMSM to be tested more than oral fluid rapid HIV self-testing.

Factors Associated with Returning At-Home Specimen Collection Kits for HIV Testing among Internet-Using Men Who Have Sex with Men

BACKGROUND

In the United States, men who have sex with men (MSM) are known to disproportionately have HIV. The authors sought to describe the acceptability of providing at-home dried blood spot specimen collection kits for HIV testing among MSM.

METHODS

Between August 2010 and December 2010, the authors recruited Internet-using, HIV-negative or -unknown MSM to participate in a 12-month study of behavioral risks. Eligible participants were mailed an at-home HIV test.

RESULTS

Of the 896 men who were sent a test kit, 735 (82%) returned the kit. Returning a test kit was significantly associated with race (P = .002), highest level of education (P = .012), and annual income (P = .026). The adjusted odds of black, non-Hispanic men returning a test kit were about half of the odds of white, non-Hispanic men returning a test kit (adjusted odds ratios: 0.49; 95% confidence intervals: 0.31-0.78).

CONCLUSIONS

Men who have sex with men are willing to provide biological specimens as part of an Internet-based HIV prevention study.

How Different are Men Who Do Not Know Their HIV Status from Those Who Do? Results from an U.S. Online Study of Gay and Bisexual Men

We compared self-described HIV-positive (31.6 %, n = 445), HIV-negative (56.8 %, n = 801), and HIV-unknown (11.6 %, n = 164) gay and bisexual men on sociodemographic and behavioral characteristics. Participants from across the U.S. were enrolled via a popular sexual networking website to complete an online survey. In total, 44.8 % of HIV-negative and HIV-unknown men said they had not been tested for HIV in the CDC-recommended last 6 months. HIV-unknown men significantly differed from HIV-negative and HIV-positive men in sexual behavior and HIV status disclosure patterns. HIV-unknown men were more willing than HIV-negative men to take PrEP; however, HIV-unknown men were significantly less likely than others to have health insurance or a primary care provider. Given the observed differences, researchers should consider analyzing men who are HIV-unknown distinctly from HIV-negative and HIV-positive men.

Acceptability and Feasibility of HIV Self-Testing Among Transgender Women in San Francisco: A Mixed Methods Pilot Study

An estimated one in four transgender women (trans women) in the U.S. are infected with HIV. Rates of HIV testing are not commensurate with their risk, necessitating alternative strategies for early detection and care. We explored the feasibility and acceptability of HIV self-testing (HIVST) with 50 HIV-negative adult trans women in San Francisco. Participants received three self-test kits to perform once a month. Acceptability and behavioral surveys were collected as were 11 in-depth interviews (IDIs). Among 50 participants, 44 reported utilizing HIVST at least once; 94 % reported the test easy to use; 93 % said results were easy to read; and 91 % would recommend it to others. Most participants (68 %) preferred HIVST to clinic-based testing, although price was a key barrier to uptake. IDIs revealed a tension between desires for privacy versus support found at testing sites. HIVST for trans women was acceptable and feasible and requires careful consideration of linkage to support services.

Correlates of recent HIV testing among substance-using men who have sex with men

Men who have sex with men are disproportionately impacted by HIV and substance use is a key driver of HIV risk and transmission among this population. We conducted a cross-sectional survey of 3242 HIV-negative substance-using men who have sex with men aged 18 + in the San Francisco Bay Area from March 2009 to May 2012. Demographic characteristics and sexual risk and substance use behaviors in the last six months were collected using structured telephone questionnaires. We used multivariable logistic regression to identify independent demographic and behavioral predictors of recent HIV testing. In all, 65% reported having an HIV test in the last six months. In multivariable analysis, increasing age (aOR = 0.87, 95% CI = 0.84-0.90) and drinking alcohol (<1 drink/day: 0.65, 0.46-0.92; 2-3 drinks/day: 0.64, 0.45-0.91; 4 + drinks/day: 0.52, 0.35-0.78) were negatively associated with recent HIV testing. Having two or more condomless anal intercourse partners (2.17, 1.69-2.79) was positively associated with having a recent HIV test, whereas condomless anal intercourse with serodiscordant partners was not significantly associated with testing. Older men who have sex with men and those who drink alcohol may benefit from specific targeting in efforts to expand HIV testing. Inherently riskier discordant serostatus of partners is not as significant a motivator of HIV testing as condomless anal intercourse in general.

Recruiting a U.S. national sample of HIV-negative gay and bisexual men to complete at-home self-administered HIV/STI testing and surveys: Challenges and Opportunities

We describe enrollment for the One Thousand Strong panel, present characteristics of the panel relative to other large U.S. national studies of gay and bisexual men (GBM), and examine demographic and behavioral characteristics that were associated with passing enrollment milestones. A U.S. national sample of HIV-negative men were enrolled via an established online panel of over 22,000 GBM. Participants (n = 1071) passed three milestones to join our panel. Milestone 1 was screening eligible and providing informed consent. Milestone 2 involved completing an hour-long at-home computer-assisted self-interview (CASI) survey. Milestone 3 involved completing at-home self-administered rapid HIV testing and collecting/returning urine and rectal samples for gonorrhea and chlamydia testing. Compared to those who completed milestones: those not passing milestone 1 were more likely to be non-White and older; those not passing milestone 2 were less likely to have insurance or a primary care physician; and those not passing milestone 3 were less educated, more likely to be bisexual as opposed to gay, more likely to live in the Midwest, had fewer male partners in the past year, and less likely to have tested for HIV in the past year. Effect sizes for significant findings were small. We successfully enrolled a national sample of HIV-negative GBM who completed at-home CASI assessments and at-home self-administered HIV and urine and rectal STI testing. This indicates high feasibility and acceptability of incorporating self-administered biological assays into otherwise fully online studies. Differences in completion of study milestones indicate a need for further investigation into the reasons for lower engagement by certain groups.

Rationale and design of FORTH: a randomised controlled trial assessing the effectiveness of HIV self-testing in increasing HIV testing frequency among gay and bisexual men

BACKGROUND

Gay and bisexual men (GBM) are a major risk group for HIV acquisition, yet the majority of higher-risk GBM test for HIV less often than recommended (3-6 monthly). HIV self-testing has the potential to increase testing frequency and improve awareness of personal HIV status. HIV self-tests have been approved in some countries, however there are concerns whether self-testing would increase HIV testing frequency enough to compensate for the reduced sensitivity of self-tests in early infection. We describe here a randomised controlled trial to assess the effectiveness of self-testing in increasing HIV testing frequency among higher-risk GBM, and its acceptability.

METHODS/DESIGN

Participants are higher-risk HIV negative GBM (>5 partners or condomless anal intercourse in previous 3 months; n = 350), including 50 GBM who tested for HIV over two years ago or never tested before ('infrequent-testers'). Participants are recruited from sexual health clinics and community-based organisations, and randomised 1:1 to either self-testing or standard-care (routine clinic-based testing) arms. The trial employs a wait-list control design: participants in the standard-care arm switch to self-testing arm in the second year, and gain access to self-test kits. Participants in the self-testing arm receive four oral-fluid self-test kits at enrolment, with additional kits provided on request. Demographics, sexual behaviour and HIV testing preferences are collected at baseline, and the frequency and pattern of HIV and sexually transmissible infection (STI) testing is collected via online 3-monthly questionnaires. The acceptability of self-testing is assessed at 12 months via an online questionnaire and in-depth interviews. A 24-h telephone support is provided, with expedited follow-up of those with reactive self-test results. The primary outcome is HIV testing frequency (mean number of HIV tests per person) over 12 months, and the secondary outcomes are: mean number of STI tests (chlamydia, gonorrhoea, syphilis) per person; reasons for HIV testing; and acceptability of HIV self-testing.

DISCUSSION

This is the first trial to evaluate the use of self-testing among GBM in Australia, and the first internationally among infrequent testers. The study will provide evidence on whether self-testing increases HIV testing frequency, and its acceptability among GBM. The findings will improve our understanding of self-testing patterns, and whether GBM supplement or replace their existing testing routine.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registration number: ACTRN12613001236785 , registered on November 12, 2013.

"Just Because It's Out There, People Aren't Going to Use It." HIV Self-Testing Among Young, Black MSM, and Transgender Women

HIV disproportionately affects young black MSM and transgender women in the US. Increasing HIV testing rates among these populations is a critical public health goal. Although HIV self-tests are commercially available, there is a need to better understand access to and uptake of HIV self-testing among this population. Here, we report results of a qualitative study of 30 young black MSM and transgender women residing in the New York City area to understand facilitators of and barriers to a range of HIV testing approaches, including self-testing. Mean age was 23.7 years (SD = 3.4). Over half (54%) had some college or an associate's degree, yet 37% had an annual personal income of less than $10,000 per year. Most (64%) participants had tested in the past 6 months; venues included community health/free clinics, medical offices, mobile testing units, hospitals, emergency departments, and research sites. Just one participant reported ever using a commercially available HIV self-test. Facilitators of self-testing included convenience, control, and privacy, particularly as compared to venue-based testing. Barriers to self-testing included the cost of the test, anxiety regarding accessing the test, concerns around correct test operation, and lack of support if a test result is positive. Participants indicated that instruction in correct test operation and social support in the event of a positive test result may increase the likelihood that they would use the self-test. Alongside developing new approaches to HIV prevention, developing ways to increase HIV self-testing is a public health priority for young, black MSM, and transgender women.

Anticipated and actual reactions to receiving HIV positive results through self-testing among gay and bisexual men

We explored anticipated and actual reactions to receiving HIV positive results through self-testing with a diverse group of 84 gay and bisexual men in New York City. Grounded Theory was used to investigate these reactions in a two-phase study, one hypothetical, followed by a practical phase in which self-tests were distributed and used. Three major themes emerged when participants were asked about their anticipated reactions to an HIV positive self-test result: managing emotional distress, obtaining HIV medical care, and postponing sexual activity. When participants were asked about their anticipated reactions to a partner's HIV positive self-test result, five themes emerged: provide emotional support; refrain from engaging in sex with casual partner; avoid high-risk sexual activity with both main and casual partners; seek medical services; and obtain a confirmatory test result. Although none of the participants tested positive, seven of their partners did. Participants provided emotional support and linked their partners to support services. The availability of HIV self-testing kits offers potential opportunities to tackle HIV infection among individuals with high-risk practices.

A review of Human Immunodeficiency Virus (HIV) rapid testing

BACKGROUND

In Canada, it is estimated that 71,300 persons were living with HIV at the end of 2011. Approximately 25% (14,500 to 21,500) of prevalent cases were unaware of their HIV infection. Expanded use of HIV rapid tests may increase the detection of undiagnosed infections, enable earlier treatment and support services and prevent the onward transmission of HIV.

OBJECTIVE

To examine patient acceptability, impact (defined as receipt of test results and linkage to care) and cost-effectiveness of HIV rapid tests.

METHODS

A search was conducted for systematic reviews on HIV rapid testing, with studies from both developed and developing countries, published in English and between 2000 and 2013. The Assessment of Multiple Systematic Review (AMSTAR) tool was used to assess the included systematic reviews for methodological quality. Results were summarized narratively for each of the outcomes.

RESULTS

Eight systematic reviews were included. Acceptability of HIV rapid tests was generally high in medical settings (69% to 98%) especially among pregnant women and youth attending emergency rooms but was lower in non-medical settings (14% to 46%). The percentage of people who obtained their test results was variable. It was high (83% to 93%) in emergency rooms but was low in a rapid care setting with regular business hours (27%). Impact on linkage to care was limited. Only one systematic review examined cost-effectiveness of rapid testing and concluded that HIV rapid tests were cost-effective in comparison to traditional methods; however, results were all based on static models.

CONCLUSION

Overall, HIV rapid tests demonstrated generally high acceptability, variability in receiving test results and limited impact on linkage to care. While these findings suggest that HIV rapid tests may be useful, further research is needed to confirm in whom, when and where they are best used and how to ensure better linkage to care.

Acceptability of self-conducted home-based HIV testing among men who have sex with men in Brazil: data from an on-line survey

The Brazilian HIV/AIDS epidemic is concentrated among men who have sex with men (MSM), however HIV testing rates among MSM are not commensurate with their risk. Strategies to expand early diagnosis may include use of self-conducted home-based testing kits, which are now available for purchase in the US. In April 2011 we conducted a survey with Brazilian MSM using Facebook to assess HIV testing preferences and acceptability of home-based testing. Among 356 previously tested, HIV-negative MSM, 47% reported a preference for home-based testing, 27% preferred clinic-based testing, and 26% had no preference. Less frequent testers and those who had considered testing but failed to test were more likely to prefer home-based testing. Close to 90% reported that they would use self-test kits; 62% and 54% said they would use home-based testing to make choices about unprotected sex with regular and new partners, respectively. Concerns included difficulty to understand the tests (32%) and receiving results alone (23%). Overall, home-based testing may appeal to MSM and result in increased testing frequency. Research on feasibility and utilization of self-tests in practice is needed.

Acceptability and intended usage preferences for six HIV testing options among internet-using men who have sex with men

Background

Men who have sex with men (MSM) continue to be disproportionately impacted by the Human Immunodeficiency Virus (HIV) epidemic in the United States (US). Testing for HIV is the cornerstone of comprehensive prevention efforts and the gateway to early engagement of infected individuals in medical care. We sought to determine attitudes towards six different HIV testing modalities presented collectively to internet-using MSM and identify which options rank higher than others in terms of intended usage preference.

Methods

Between October and November 2012, we surveyed 973 HIV-negative or -unknown status MSM and assessed their acceptability of each of the following services hypothetically offered free of charge: Testing at a physician’s office; Individual voluntary counseling and testing (VCT); Couples’ HIV counseling and testing (CHCT); Expedited/express testing; Rapid home self-testing using an oral fluid test; Home dried blood spot (DBS) specimen self-collection for laboratory testing. Kruskal-Wallis tests were used to determine whether the stated likelihood of using each of these modalities differed by selected respondent characteristics. Men were also asked to rank these options in order of intended usage preference, and consensual rankings were determined using the modified Borda count (MBC) method.

Results

Most participants reported being extremely likely or somewhat likely to use all HIV testing modalities except DBS self-collection for laboratory testing. Younger MSM indicated greater acceptability for expedited/express testing (P < 0.001), and MSM with lower educational levels reported being more likely to use CHCT (P < 0.001). Non-Hispanic black MSM indicated lower acceptability for VCT (P < 0.001). Rapid home self-testing using an oral fluid test and testing at a physician’s office were the two most preferred options across all demographic and behavioral strata.

Conclusions

Novel approaches to increase the frequency of HIV testing among US MSM are urgently needed. Combination testing packages could enable high risk MSM in putting together annual testing strategies personalized to their circumstances, and warrant due consideration as an element of combination HIV prevention packages.

Gay and bisexual men's use of the Internet: research from the 1990s through 2013

We document the historical and cultural shifts in how gay and bisexual men have used the Internet for sexuality between the 1990s and 2013-including shifting technology as well as research methods to study gay and bisexual men online. Gay and bisexual men have rapidly taken to using the Internet for sexual purposes: for health information seeking, finding sex partners, dating, cybersex, and pornography. Men have adapted to the ever-evolving technological advances that have been made in connecting users to the Internet-from logging on via dial-up modem on a desktop computer to geo-social-sexual networking via handheld devices. In kind, researchers have adapted to the Internet to study gay and bisexual men. Studies have carefully considered the ethics, feasibility, and acceptability of using the Internet to conduct research and interventions. Much of this work has been grounded in models of disease prevention, largely as a result of the ongoing HIV/AIDS epidemic. The need to reduce HIV in this population has been a driving force to develop innovative research and Internet-based intervention methodologies. The Internet, and specifically mobile technology, is an environment gay and bisexual men are using for sexual purposes. These innovative technologies represent powerful resources for researchers to study and provide outreach.

Factors associated with intention to use internet-based testing for sexually transmitted infections among men who have sex with men

BACKGROUND

Internet-based testing programs are being increasingly used to reduce testing barriers for individuals at higher risk of infection, yet the population impact and potential for exacerbation of existing health inequities of these programs are not well understood.

OBJECTIVE

We used a large online sample of men who have sex with men (MSM) in Canada to measure acceptability of Internet-based testing and perceived advantages and disadvantages of this testing approach.

METHODS

We asked participants of the 2011/2012 Sex Now Survey (a serial online survey of gay and bisexual men in Canada) whether they intended to use Internet-based testing and their perceived benefits and disadvantages of use. We examined whether intention to use was associated with explanatory variables spanning (A) sociodemographics, (B) Internet and technology usage, (C) sexually transmitted infections (STI)/ human immunodeficiency virus (HIV) and risk, and (D) health care access and testing, using multivariable logistic regression (variable selection using Bayesian information criterion).

RESULTS

Overall, intention to use was high (5678/7938, 71.53%) among participants with little variation by participant characteristics. In our final model, we retained the variables related to (B) Internet and technology usage: use of Internet to cruise for sex partners (adjusted odds ratio [AOR] 1.46, 95% CI 1.25-1.70), use of Internet to search for sexual health information (AOR 1.36, 95% CI 1.23-1.51), and mobile phone usage (AOR 1.19, 95% 1.13-1.24). We also retained the variables for (D) health care access and testing: not "out" to primary care provider (AOR 1.24, 95% CI 1.10-1.41), delayed/avoided testing due to privacy concerns (AOR 1.77, 95% CI 1.49-2.11), and delayed/avoided testing due to access issues (AOR 1.65, 95% CI 1.40-1.95). Finally, we retained the variable being HIV positive (AOR 0.56, 95% CI 0.46-0.68) or HIV status unknown (AOR 0.89, 95% CI 0.77-1.01), age <30 years (AOR 1.41, 95% CI 1.22-1.62), and identifying as bisexual (AOR 1.18, 95% CI 1.04-1.34) or straight/other (AOR 0.67, 95% CI 0.50-0.90). The greatest perceived benefits of Internet-based testing were privacy (2249/8388, 26.81%), general convenience (1701/8388, 20.28%), and being able to test at any time (1048/8388, 12.49%). The greatest perceived drawbacks were the inability to see a doctor or nurse (1507/8388, 17.97%), wanting to talk to someone about results (1430/8388, 17.97%), not wanting online results (1084/8388, 12.92%), and low trust (973/8388, 11.60%).

CONCLUSIONS

The high and wide-ranging intention to use that we observed suggests Internet-based testing has the potential to reach into all subgroups of MSM and may be particularly appealing to those facing current barriers to accessing STI/HIV testing and who are more comfortable with technology. These findings will be used to inform the promotion and further evaluation of an Internet-based testing program currently under development in British Columbia, Canada.

HIV testing patterns among black men who have sex with men: a qualitative typology

BACKGROUND

Black men who have sex with men (MSM) in the Southeastern United States are disproportionately affected by HIV. Black MSM are more likely to have unrecognized HIV infection, suggesting that testing may occur later and/or infrequently relative to current recommendations. The objective of this qualitative study was to explore the HIV testing behaviors of Black MSM in Atlanta, Georgia, who were participants in the HIV Prevention Trials Network Brothers Study (HPTN 061).

METHODS AND FINDINGS

We conducted 29 in-depth interviews and four focus groups with a community-recruited sample. Modified grounded theory methodologies were used to guide our inductive analysis, which yielded a typology comprised of four distinct HIV testing patterns. Participants could be categorized as: (1) Maintenance Testers, who tested regularly as part of routine self-care; (2) Risk-Based Testers, whose testing depended on relationship status or sexual behavior; (3) Convenience Testers, who tested irregularly depending on what testing opportunities arose; or (4) Test Avoiders, who tested infrequently and/or failed to follow up on results. We further characterized these groups with respect to age, socioeconomic factors, identity, stigma and healthcare access.

CONCLUSIONS

Our findings highlight the heterogeneity of HIV testing patterns among Black MSM, and offer a framework for conceptualizing HIV testing in this group. Public health messaging must account for the diversity of Black MSM's experiences, and multiple testing approaches should be developed and utilized to maximize outreach to different types of testers.

Rapid HIV self-testing: long in coming but opportunities beckon

The recent approval by the United States Food and Drug Administration of a rapid HIV self-test marks a significant milestone in the evolution of HIV testing approaches. With nearly one in five people living with HIV in the United States still undiagnosed and an even higher proportion unaware of their infection globally, this decision reflects a new willingness to offer diverse options to get tested for HIV. Rapid self-testing offers several distinct opportunities to improve testing among those with undiagnosed HIV: to encourage testing among those who might not otherwise be tested, to increase the frequency of testing among persons at highest risk for new infection, and to facilitate mutual HIV testing with sex partners. To date, the path to regulatory approval has been long but instructive. The studies and clinical trials required for regulatory approval in the United States provide insight into the performance and potential implications of HIV self-tests as they become available for sale directly to consumers. Although some persistent reservations about self-testing for HIV remain, including the 'window period' of the current test kit, its cost, and its effectiveness for facilitating entry to medical care, others have been dispelled. Self-testing in resource-constrained settings is also promising, including self-testing of health professionals. At present, although the impact has yet to be determined, availability of this new option might offer potential opportunities to improve HIV diagnosis and facilitate both treatment and prevention.

Willingness to use the oral fluid HIV rapid test among men who have sex with men in Beijing, China

Background

Early detection of HIV infection enables timely care and treatment. However, many men who have sex with men (MSM) remain unaware of their HIV status because they do not or are unable to access HIV testing services. Oral fluid HIV rapid tests have the potential to increase HIV testing. This study is the first to evaluate willingness to use the oral fluid test among MSM in China.

Methods

A cross-sectional study was conducted in Beijing from July to October, 2012. Data were collected by self-administered questionnaires.

Results

Of 262 who participated in the survey, 223(85.1%) reported that they were willing to use the oral fluid HIV rapid test. Willingness to use the oral fluid test was associated with higher education (adjusted odds ratio (AOR): 2.40, 95% confidence interval (CI): 1.13–5.10), lack of unprotected anal intercourse (UAI) with male partners in the past one month (AOR: 2.38; 95% 95%CI: 1.15–4.95), having taken more than 4 HIV tests (AOR: 3.54; 95%CI:1.52–8.28), and having ever heard of the oral fluid HIV rapid test from gay friends or gay organizations (AOR: 3.24, 95%CI: 1.40–7.51). Among those who expressed willingness to use the oral fluid HIV rapid test, the median amount of money they were willing to pay was 8 dollars. Among the 39 participants who were unwilling to use the oral fluid test, 79.5% (31/39) expressed concerns about the accuracy of the oral fluid HIV rapid test results and 17.9%(7/39) reported that they were not familiar with the oral fluid test and did not know how to use such a test.

Conclusions

A high proportion of MSM in Beijing appear to be willing to use the oral fluid HIV rapid test. Appropriate cost and education measures could help improve acceptance of the oral fluid test.

Assessing willingness to test for HIV among men who have sex with men using conjoint analysis, evidence for uptake of the FDA-approved at-home HIV test

Men who have sex with men (MSM) in the USA, represent a vulnerable population with lower rates of HIV testing. There are various specific attributes of HIV testing that may impact willingness to test (WTT) for HIV. Identifying specific attributes influencing patients' decisions around WTT for HIV is critical to ensure improved HIV testing uptake. This study examined WTT for HIV by using conjoint analysis, an innovative method for systematically estimating consumer preferences across discrete attributes. WTT for HIV was assessed across eight hypothetical HIV testing scenarios varying across seven dichotomous attributes: location (home vs. clinic), price (free vs. $50), sample collection (finger prick vs. blood), timeliness of results (immediate vs. 1-2 weeks), privacy (anonymous vs. confidential), results given (by phone vs. in-person), and type of counseling (brochure vs. in-person). Seventy-five MSM were recruited from a community-based organization providing HIV testing services in Los Angeles to participate in conjoint analysis. WTT for HIV score was based on a 100-point scale. Scores ranged from 32.2 to 80.3 for eight hypothetical HIV testing scenarios. Price of HIV testing (free vs. $50) had the highest impact on WTT (impact score = 31.4, SD = 29.2, p<0.0001), followed by timeliness of results (immediate vs. 1-2 weeks) (impact score = 13.9, SD = 19.9, p≤0.0001) and testing location (home vs. clinic) (impact score = 10.3, SD = 22.8, p=0.0002). Impacts of other HIV testing attributes were not significant. Conjoint analysis method enabled direct assessment of HIV testing preferences and identified specific attributes that significantly impact WTT for HIV among MSM. This method provided empirical evidence to support the potential uptake of the newly FDA-approved over-the-counter HIV home test kit with immediate results, with cautionary note on the cost of the kit.

Integrating routine HIV screening into a primary care setting in rural North Carolina

Blacks living in the southern United States are disproportionately affected by HIV infection. Identifying and treating those who are infected is an important strategy for reducing HIV transmission. A model for integrating rapid HIV screening into community health centers was modified and used to guide implementation of a testing program in a primary care setting in a small North Carolina town serving a rural Black population. Anonymous surveys were completed by 138 adults who were offered an HIV test; of these, 61% were female and 89.9% were Black. One hundred patients (72%) accepted the test. Among those Black survey respondents who accepted an offer of testing, 58% were women. The most common reason for declining an HIV test was lack of perceived risk; younger patients were more likely to get tested. Implementation of the testing model posed challenges with time, data collection, and patient flow.

A review of self-testing for HIV: research and policy priorities in a new era of HIV prevention

Global progress toward universal human immunodeficiency virus (HIV) testing remains slow. Interest in HIV self-testing is high and may increase knowledge of HIV status; however, empirical research on selftesting is limited, resulting in lack of evidence on which to base policy recommendations.

Inadequate uptake of testing for human immunodeficiency virus (HIV) remains a primary bottleneck toward universal access to treatment and care, and is an obstacle to realizing the potential of new interventions for preventing HIV infection, including treatment for prevention and preexposure prophylaxis. HIV self-testing offers an approach to scaling up testing that could be high impact, low cost, confidential, and empowering for users. Although HIV self-testing was first considered >20 years ago, it has not been widely implemented. We conducted a review of policy and research on HIV self-testing, which indicates that policy is shifting toward a more flexible approach with less emphasis on pretest counseling and that HIV self-testing has been adopted in a number of settings. Empirical research on self-testing is limited, resulting in a lack of an evidence base upon which to base policy recommendations. Relevant research and investment in programs are urgently needed to enable consideration of developing formalized self-testing programs.