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


Among people enrolling in the SELPHI trial, the most striking finding was the relatively low rate of HIV testing among men with at least two CAI partners in the previous 3 months, who should, according to current UK recommendations on HIV testing frequency in MSM, be testing at least quarterly.[11] This recommendation is more frequent than current European guidance, which recommends testing at least annually.[23] Almost 60% of this high-risk group had not tested in the previous 6 months and 23% had not tested in the last 3 months. Even higher levels of infrequent testing were observed in certain regions (Wales and northeast England) and among less well-educated men. Among the men who were taking PrEP at the point of enrolment, approximately 15% had not tested in the previous 6 months, most of whom had sourced PrEP themselves [as a consequence of the current National Health Service England (NHSE) policy of not making it freely available through the NHS]. This is concerning, as regular testing is important in this group to quickly identify breakthrough infections and initiate full ART, and self-testing could fill an important gap in this regard. It also indicates the importance of providing PrEP through the NHS as part of a structured programme of care with regular HIV and testing prior to prescription of further supplies of PrEP.

In the UK, an estimated 3600 MSM were living with undiagnosed HIV infection in 2018.[8] Starting ART at HIV diagnosis is now recommended for individual and public health benefit,[24] and attaining a durably suppressed HIV viral load eliminates onward transmission of the virus.[3,4,25,26] Therefore, reducing the time from HIV infection to diagnosis in MSM remains a key objective for micro-elimination strategies, as up to 80% of all HIV transmissions are estimated to derive from those who are undiagnosed.[7]

It is recognized that levels of ever or repeat HIV testing in UK MSM, although increasing, remain lower than recommended in guidelines, particularly in MSM at increased risk of HIV infection through CAI with multiple partners.[9,26] Frequent HIV testing (3-monthly) is an essential component for management of men taking PrEP. We found that 33 men currently taking PrEP who had at least two CAI partners in the previous 3 months had not tested for HIV in the 6 months prior to entering the study. A recent study used a discrete choice experiment (DCE) design to determine whether MSM preferred a remote HIV test option (self-sampling or self-testing) or to test through a health care professional. In this study, a small group of participants preferred HIV self-sampling (HIVSS) or HIVST and they were more likely to have never previously tested, to be of non-white ethnicity and also to be current PrEP users than those who preferred facility-based testing.[27] Men were also reluctant to pay for HIVST and preferred testing options that were free at the point of delivery.

The motivations underlying testing behaviours in MSM, in particular in men who are not testing in line with the recommended frequency or who have never tested, are complex. Lack of testing may be attributable to structural barriers to obtaining an HIV test (e.g. clinics being difficult to access because of time constraints or capacity issues or distance); lack of knowledge about how to obtain a test; low perceived risk of HIV infection and individual psycho-social issues, including potential fear of the result, fear of needles or medical procedures, and issues around disclosure of homosexual activity and perceived stigma.[15,17,27,28] Individuals enrolled in this cohort in the knowledge that they would participate in an RCT of HIVST. This suggests that HIVST is acceptable to this cohort and may overcome some of these structural and psychological barriers.

Associations with lower levels of ever and repeat testing in our study suggest that targeting promotion and expanding testing opportunities in younger men and in those with lower levels of education may improve access to and uptake of HIV testing. Our results also suggest that HIVST may provide a route for HIV testing for men who are not gay identified, as these men were more likely to have never tested for HIV prior to entering the trial. This association of frequency of HIV testing and sexual identity has been noted in other studies in MSM which found that non-gay-identified MSM were least likely to have tested previously for HIV.[26] There is also a suggestion in our data that there are particular barriers to HIV testing for those who live outside London, most especially in Wales where provision of sexual health services varies hugely between regions.[28] HIVST may play a role in meeting unmet HIV testing needs in these areas.

There are several important considerations in interpreting the results of our study. First, the trial participants were, by definition, interested in HIV self-testing or may have been interested in testing in any case and should not be regarded as representative of the general MSM population. However, our analysis is important in understanding the profile of individuals to whom self-testing may have appeal. For example, when we designed the trial we were uncertain if the online advertising would mainly attract men who had never tested before (possibly through unwillingness to engage with the health care system) or who had tested before but saw self-testing as a more convenient testing modality. The fact that 85% of participants had previously tested points to the latter explanation being more dominant. However, this percentage varied markedly according to certain characteristics. A particularly strong effect was observed for age, with almost one half of men aged 16–19 years not having tested previously. Self-testing may be especially useful in motivating younger men to initiate regular HIV testing.

Secondly, only limited and brief questions were asked about previous HIV testing (time of previous test, number of tests in the previous 12 months and venue of the previous test) and sexual history (number of AI and number of CAI partners in the previous 3 months). Therefore, an individual who last tested 3 years ago, say, may not have been noncompliant with testing guidelines if he only recently started having sex again after a long period of celibacy or may have enrolled in SELPHI in order to obtain an HIV test following recent risk behaviour. Similarly, a partial explanation for the high rate of never testing among young men is that their sexual debut may have been a recent event. While it would have been desirable to ask more detailed questions, ideally linking historical testing behaviour to historical sexual behaviour, the priority was to keep the enrolment process short to maximize recruitment to the trial. Thirdly, we recruited low numbers of black minority ethnic and trans men, who are key groups at risk of HIV infection, which may make the results less generalizable.[29,30]

In summary, we found that men with at least two CAI partners had been testing at lower than recommended levels at entry to an online HIVST trial. The current UK HIV testing policy in MSM focusses on increasing the rate of annual testing among all MSM, including those at lower risk of HIV infection [i.e. younger men, much older men (≥ 65 years old) and non-gay-identified MSM].[8] Instead, the results of our study suggest that promotion of more frequent testing among the groups most at risk of infection should be prioritized in order to reduce the time between infection and diagnosis. Our study suggests that free provision of HIVST could play a role in overcoming barriers to frequent HIV testing, and that online ordering for postal delivery is a feasible and acceptable means of delivery for MSM.