Sexual Risk and HIV Testing Disconnect in Men who Have Sex With Men (MSM) Recruited to an Online HIV Self-Testing Trial

AJ Rodger; D Dunn; L McCabe; P Weatherburn; FC Lampe; TC Witzel; F Burns; D Ward; R Pebody; R Trevelion; M Brady; PD Kirwan; J Khawam; VC Delpech; M Gabriel; Y Collaco-Moraes; AN Phillips; S McCormack

Disclosures

HIV Medicine. 2020;21(9):588-598. 

In This Article

Abstract and Introduction

Abstract

Objectives: We report the frequency of previous HIV testing at baseline in men who have sex with men (MSM) who enrolled in an HIV self-testing (HIVST) randomized controlled trial [an HIV self-testing public health intervention (SELPHI)].

Methods: Criteria for enrolment were age ≥ 16 years, being a man (including trans men) who ever had anal intercourse (AI) with a man, not being known to be HIV positive and having consented to national HIV database linkage. Using online survey baseline data (2017–2018), we assessed associations with never having tested for HIV and not testing in the previous 6 months, among men who reported at least two recent condomless AI (CAI) partners.

Results: A total of 10 111 men were randomized; the median age was 33 years [interquartile range (IQR) 26–44 years], 89% were white, 20% were born outside the UK, 0.8% were trans men, 47% were degree educated, and 8% and 4% had ever used and were currently using pre-exposure prophylaxis (PrEP), respectively. In the previous 3 months, 89% reported AI and 72% reported CAI with at least one male partner. Overall, 17%, 33%, 54%, and 72% had tested for HIV in the last 3 months, 6 months, 12 months and 2 years, respectively; 13% had tested more than 2 years ago and 15% had never tested. Among 3972 men reporting at least two recent CAI partners, only 22% had tested in the previous 3 months. Region of residence and education level were independently associated with recent HIV testing. Among current PrEP users, 15% had not tested in the previous 6 months.

Conclusions: Most men in SELPHI, particularly those reporting at least two CAI partners and current PrEP users, were not testing in line with current UK recommendations. The results of the trial will inform whether online promotion of HIVST addresses ongoing testing barriers.

Introduction

There is clear value for people living with undiagnosed HIV infection in ascertaining their HIV status so that antiretroviral therapy (ART) can be initiated as early as possible, which has benefits both for the health of the individual[1,2] and for the wider population as a consequence of reduced transmission risk.[3,4] However, low diagnosis rates remain the largest gap in terms of achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 goals, i.e. 90% of people with HIV know their HIV status, 90% of people who know their HIV-positive status access treatment, and 90% of people on treatment have a suppressed viral load.[5] It is estimated that 25% of the global population with HIV infection remain undiagnosed,[6] which contributes disproportionally to new transmissions.

In the UK, men who have sex with men (MSM) remain the group at highest risk of HIV infection. In recent years, however, there has been a reduction in HIV incidence in MSM, largely as a consequence of increased frequent HIV testing, rapid ART initiation following HIV diagnosis, and expanded use of pre-exposure prophylaxis (PrEP) among HIV-negative people.[7–9] The number of HIV diagnoses in MSM fell from 3165 in 2014 to 1908 in 2018 (a 40% reduction) in the UK overall, and from 1523 to 736 in London (a 52% reduction).[8,9] In 2018, each component of the 90–90–90 target was exceeded, reaching levels of 92–98–98 nationally.[8]

Both international and national UK guidelines recommend that MSM test annually for HIV and more frequently if at higher risk, and it is recognized that increasing levels of HIV testing in MSM remains key to reducing incidence.[10,11] However, levels of ever and repeat HIV testing in UK MSM do not meet these testing recommendations, with studies reporting that 28% of MSM had never tested and only 55% tested annually.[12,13] There are particular issues around meeting the 3-monthly testing recommendation for MSM at higher risk of HIV infection – those who have had recent condomless anal intercourse (CAI) with partners of unknown or serodifferent HIV status, and/or use drugs during sex (chemsex). A 2016 study reported that only 27% of men considered at "higher risk" of HIV infection tested even 6-monthly.[12] In addition, it was estimated that 8.6% of MSM with HIV infection in the UK remained undiagnosed in 2017.[8]

There has been increasing interest in the potential of HIV self-testing (HIVST) to improve rates of ever and repeat testing.[14] HIVST enables the person not only to take the sample but also to process it themselves, so that, at the time of testing, only they are aware of the result. The potential advantage of HIVST is that it may address structural and psycho-social barriers to testing,[15–18] including stigma and concerns around privacy and confidentiality, and that it offers time saving and autonomy. HIVST may enable MSM who test suboptimally to meet norms around testing expectations which they might not otherwise be able to meet.[19] HIVST is also a viable means to support PrEP provision, where guidelines recommend 3-monthly HIV testing.[20]

We report on the frequency of previous HIV testing and associated factors at baseline in MSM (including trans men) who opted to enrol in a large online HIV self-testing randomized controlled trial (RCT) [an HIV self-testing public health intervention (SELPHI)].

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