Home sampling for HIV testing

Terrence Higgins Trust’s pilot home sampling project has shown that it reaches significant numbers of individuals who haven’t tested for HIV before and individuals who are HIV positive.

Individuals can order a sampling kit online, take their own sample and mail it back for laboratory analysis. Negative results are communicated by text message and reactive results by a phone call from a trained member of staff, who helps with linkage to care.

This is therefore home sampling, rather than home testing. (The sale of home testing kits was legalised this month, although no licensed kits are available yet.)

Over eleven months, just under 10,000 individuals requested a kit, with two thirds returning a sample. The service was mostly used by men who have sex with men – fewer than 5% of samples were returned by African people. Uptake of testing was very closely linked with marketing activities, such as advertising and use of social media.

Around 1 in 60 of the returned samples (1.7%) were HIV positive, with especially high rates amongst those African people who did use the service (3.6%). There was good evidence of linkage to care for three-quarters of those who tested positive.

Participants didn’t seem to have problems providing a fingerprick blood sample and surveys showed that users were very satisfied with the service. The project seems to attract people who don’t like using sexual health clinics – one third had never tested before.

Two other home sampling projects have also reported similar results.

Taken together, they show that home sampling is feasible and acceptable in the UK, especially to gay men – it is not clear whether the limited engagement of African people is due to there being fewer African-specific media channels to promote the service in, or whether the offer is less appealing for other reasons.

And it remains to be seen whether home sampling is simply part of the preparation for true home testing, or whether it is an option that will be retained.

Chemsex

Gay men involved in ‘chemsex’ (taking recreational drugs such as mephedrone, GHB/GBL and crystal methamphetamine during sex) have a range of experiences, with no single narrative able to sum up the impact of drug use on sexual behaviour and possible HIV transmission, according to a study from south London.

One group of HIV-positive men had made conscious decisions to have unprotected sex with other HIV-positive men. Drug use allowed them to have more sex but was not the main driver of their lack of condom use.

A second group frequently engaged in chemsex but felt in control of their actions, enjoyed their sex lives, and were able to maintain consistent condom use.

A third group described numerous instances of unintended and regretted risk behaviour while under the influence of drugs. Some described being so focused on sexual gratification that they could not consider the longer-term consequences, while others said they were not sure what they had done while incapacitated. These men often had pre-existing problems negotiating safer sex, which were exacerbated by drug use.

The final group of men – much smaller in number than the other three – acknowledged that their relationship with drugs and sexual risk-taking behaviour was more complex. They sought out risky sex and the drugs seemed to facilitate this.

Some men were seeking greater control over their drug use and some had sought professional help. When it was available, men valued clear, honest and non-judgmental information about how to use drugs and have chemsex safely – the researchers recommend better provision of harm reduction information.

Many men said they trusted sexual health services (seen to understand gay lifestyles), so one possibility could be commissioning of integrated drugs and sexual health services.

Who’s taking PrEP in the UK?

The pilot phase of the UK's study of HIV pre-exposure prophylaxis (PrEP) for gay men, known as PROUD, is now fully enrolled, with over 500 participants. At present, participation in the study is the only way to access PrEP in the UK.

Some data on the demographics and risk behaviour of the participants have been released. All are men who have sex with men, most are well educated, their average age is 35, and 80% are white.

The study has succeeded in recruiting individuals at elevated risk of infection – large numbers had recently had sexually transmitted infections and 40% had used post-exposure prophylaxis (PEP) in the past year.

They reported an average of ten anal sex partners in the last three months, using condoms with around half the partners. When asked why condoms weren’t always used, the most common response was that sex is more enjoyable without a condom.

Three-quarters had used recreational drugs (including poppers and Viagra) in the past year.

The researchers have applied for funding to expand PROUD into a full-scale efficacy trial with 2300 participants. A final decision on this is expected in November, meaning that any further recruitment of participants could not happen until spring 2015.

Acute infection and expanded testing

A study from Canada shows that people living with undiagnosed HIV have considerably more medical appointments than HIV-negative people. In the years before their diagnosis, people in their twenties who had undiagnosed HIV were almost as likely to see a GP as people in their fifties who were HIV negative. They were also more likely to be admitted to hospital.

This suggests missed opportunities for HIV testing. Individuals may have been attending with symptoms of HIV seroconversion or with an ‘indicator condition’ that is associated with HIV infection.

And a pilot programme of expanded HIV testing in hospitals in the same Canadian province has had some interesting results. Although only 44% of patients newly admitted to hospital were offered a test and 36% took a test, the programme led to a doubling of the number of HIV tests and a doubling of new diagnoses in this setting.

As is commonly found in hospital settings, a large proportion of those diagnosed were quite ill and were diagnosed very late – 35% had a CD4 cell count below 200 cells/mm3, compared to 12% of those diagnosed in other settings.

Unexpectedly, the hospital programme also detected people who had acute (recent) infection – 25% of those diagnosed, compared with 15% in other settings. This again suggests that people with symptoms of HIV seroconversion frequently seek medical help.

In the UK, a significant improvement in the diagnosis of acute infection has been achieved in Brighton & Hove through numerous initiatives to expand HIV testing, including training general practitioners to recognise seroconversion symptoms.

Case study: community testing

LASS (Leicestershire AIDS Support Services) offers rapid HIV testing both at its premises and at external events, for example during meetings of community groups from different African countries, at the city’s Caribbean Carnival or with faith groups. The organisation devotes time to building strong relationships with community groups and, in doing so, recruits volunteers who are trained to provide rapid HIV tests themselves. Celia Fisher of LASS explains that the volunteers and key individuals in partner organisations act as champions, encouraging members of their communities to test for HIV.

Celia says that they have tried to learn from the response of each person who tests with them, and have evolved the way they offer HIV testing as a result. They have sometimes been inspired by examples from other countries, such as a Kenyan project which found that involving the person testing in reading their own test result was very powerful. Before the point-of-care test is used, the individual is told how a negative or a reactive result will appear. He or she announces the test result before the member of staff or volunteer confirms it – this seems to help acceptance and understanding of the result.

LASS also offers couples the possibility of testing and learning their results together, a strategy that is increasingly used in other countries. The test counsellor creates a safe environment for the couple to learn each other’s status and talk through the implications. In Leicester, it is an option that is popular with younger African couples, especially those making decisions about condom use. The number of people diagnosed with HIV is relatively high.

Following the lead of numerous African projects, they have also organised their own football tournament between local African teams and taken their HIV testing van to sporting events. In many other settings, women are the first to come forward, but sport has proven an effective way of engaging men, with many men either testing on the day or in the following weeks at LASS’ premises.

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