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


HIV Medicine. 2020;21(9):588-598. 

In This Article


Baseline Characteristics

Overall, 10 111 MSM were recruited to the trial, including 81 (0.8%) trans men (Table 1). The median age of participants was 33 years [interquartile range (IQR) 26–44 years]. Most men were of white British ethnicity (75.5%), followed by white other (14.0%), with 19.7% reporting that they had been born outside the UK. Most men identified as gay/homosexual (68.6%) followed by bisexual (8.6%); a large proportion (22.2%) either did not complete this question or selected the option "I don't usually use a term." Only 1.6% of participants were of black ethnicity and 4.3% of Asian ethnicity, despite recruitment strategies aimed at increasing participation from these ethnic groups. The majority of men recruited to the trial were highly educated, 47.1% having a university education and a further 11.2% reporting education beyond the age of 18 years. Overall, 83.7% of men lived within 10 km of a GUM clinic, with 72.3% having a travel time of ≤ 20 min and 91.1% a travel time of ≤ 30 min.

In the previous 3 months, 89.5% of men reported that they had had AI with at least one male partner and 27.9% reported AI with five or more partners in the previous 3 months. In terms of CAI partners, 70.0% of men reported at least one male partner in the past 3 months and 39.1% two or more partners. HIV or ART status of the partners was not available.

Overall, 12.1% of men had ever used PEP and 3.8% currently used PrEP. As expected, current PrEP use was mainly observed among men with at least two CAI partners in the previous 3 months (7.6% used PrEP), compared to those who did not report at least two CAI partners (1.4%). PrEP was only available in England and Wales during SELPHI enrolment through the Impact trial (England), through implementation pilots (Wales) and from online pharmacies. Of the 389 current users, 295 (75.8%) sourced PrEP via the internet, 60 (15.4%) through participation in a trial, 12 (3.1%) by a private prescription, nine (2.3%) from a friend, and 13 (3.3%) via other or unspecified means.

Sociodemographic characteristics were similar in men who had at least two CAI partners in the previous 3 months compared to the overall sample, with the exception of sexual risk behaviours (by definition) and the use of PEP or PrEP.

HIV Testing Behaviours

Overall, 16.9% of men had tested for HIV in the 3 months prior to trial entry, 33.2% in the previous 6 months, 54.1% in the previous 12 months and 71.7% in the previous 2 years. It was reported that 13.0% of men had last tested for HIV > 2 years prior to trial entry and 15.3% had never tested for HIV (Table 2). Figure 2 shows the distribution of time since last HIV test by geographical region.

Figure 2.

Time since last HIV test by geographical region.

Among men with at least two CAI partners in the previous 3 months, only 22.6% had tested for HIV in the 3 months prior to entry to the trial; 58.8% had not tested in the previous 6 months and 11.5% had never tested (Table 2). Overall, 61.2% of men reported that their last HIV test was in a sexual health clinic, compared with 16.6% who had last tested via self-sampling and 6.7% via a self-test. Men with at least two CAI partners in the previous 3 months were slightly more likely to have had their last HIV test in a sexual health clinic, but there were no marked differences between the two groups for other venues. Of the 389 current PrEP users, 382 completed the question on time since last HIV test, of whom 56 (14.7%) had not tested in the previous 6 months.

Associations With Never Having Been Tested for HIV

Never having tested was least common in London (8.3%) and most common in Wales (27.0%), with proportions ranging between 14.6% and 18.7% across the English regions (Table 3). Never having tested was markedly higher among men aged 16–19 years [45.7%; adjusted odds ratio (OR) 3.54 compared with age 20–29 years]. Men aged 30–39 years were least likely to have never tested (9.4%). Sexual identity was a powerful predictor of never having tested, with an adjusted OR of 2.72 for bisexual men (31.2%) and 9.50 for heterosexual men (54.9%), compared with gay men, although the number in the latter category was small (n = 31). The comparatively large group who declined to state their sexual identity were slightly more likely never to have tested compared with gay men (adjusted OR 1.23). There was a gradient across level of education, with men whose highest level of education was to the age of 16 years only having an adjusted OR of 1.52 compared with men who attended university. There was no independent association between never having tested for HIV and ethnicity or distance or journey time (not shown) to nearest sexual health clinic. Neither previous PEP nor PrEP use was included in these models, as ever HIV testing was nearly ubiquitous in these groups (98.8% and 99.3%, respectively); this finding was as expected, as HIV testing comprises part of the clinical management package of these interventions.

Associations With not Having Recently Tested Among Men With at Least Two CAI Partners in the Previous 6 Months

Similar, although not identical, associations were observed in a multivariable logistic regression analysis of not having had a recent (previous 6 months) test among men with at least two CAI partners in the previous 3 months (Table 4). Geographical region remained a strong predictor, although southeast England more closely resembled London in having a higher rate of recent testing, and northeast England joined Wales as the lowest ranking areas. A U-shaped relationship was again observed for the effect of age, although it was somewhat less pronounced, and the same strong gradient was evident for educational level. There was a difference in testing rates according to ethnicity, driven by higher rates of recent testing among the white other group, who were mainly white Europeans born outside of the UK (adjusted OR 0.77 compared to white British). A weak association was observed with distance to nearest GUM clinic, with a 17% lower odds of not having recently tested among men living within 2 km compared with those living between 2 and 5 km away. A noticeable finding was the lack of an association between recent testing and sexual identity in this group, in contrast to the analysis of never having tested.