Regular HIV testing becoming the norm among gay men in Scotland

The number of gay men testing for HIV in Scotland increased significantly between 2000 and 2010, a study published in HIV Medicine shows.

The percentage of men reporting a test in the previous year increased from 27 to 57%. There was also an increase in the proportion of men who perceived testing as beneficial and as a community norm.

However, significant barriers to testing still remained. These included: fear of a positive result; reservations about opening times and waiting periods at testing clinics; and a concern that testing HIV positive would lead to rejection by potential sexual partners who believed themselves to be HIV negative.

Nevertheless, the investigators believe their results point towards the “normalization of HIV testing”.

Testing is a cornerstone of efforts to control the HIV epidemic.

Prompt diagnosis of the infection has considerable individual health benefits, enabling people to access treatment and care. Late diagnosis of HIV is an important factor underlying much of the remaining HIV-related mortality seen in the UK.

Early detection of HIV also has public health benefits. There are compelling epidemiological data showing that the majority of onward transmissions in the United Kingdom originate in undiagnosed individuals.

Gay men are one of the groups most affected by HIV in the UK. Guidelines recommend an annual HIV test for sexually active gay men and more frequent testing is advocated for those at highest risk of the infection. In an effort to increase the uptake of testing, screening for HIV at genitourinary clinics is now offered on an opt-out basis.

There have been major improvements in HIV treatment and care over the past decade. Antiretroviral therapy is generally safe, tolerable and taken once daily. A number of studies have shown that, with the right treatment and care, the life expectancy of many HIV-positive people is now near normal. In addition, there is now a consensus that people taking HIV therapy that suppresses their viral load to undetectable levels are highly unlikely to transmit the virus to their sexual partners.

Investigators in Scotland wanted to see if efforts to promote testing, together with these major improvements in HIV treatment, had had an impact on testing rates and attitudes towards testing among gay men.

They therefore compared the results of cross-sectional research enquiring about these issues; the studies were conducted in 2000 and again in 2010.

Participants were recruited at commercial gay venues across Scotland. To be eligible for inclusion in the study, participants were required to be resident in Scotland.

The total number of men included in the 2000 sample was 686; the 2010 sample comprised 696 men.

Overall, the men recruited in 2010 were older than those participating in the 2000 survey (p = 0.006) and were more likely to report unprotected anal sex in the previous year (47 vs 38%, p = 0.001).

Rates of HIV testing were significantly higher for the 2010 sample.

In 2000, 27% of men said they had been tested for HIV in the previous twelve months. This had increased to 57% in 2010. The proportion of men who had never been tested for HIV fell from 50% in 2000 to 20% in 2010.

“These changes over time were independent of both demographic factors and sexual behaviour,” note the authors. “This represents a key change in HIV-related health behaviour akin to the profound changes in condom use noted during the 1980s within this population…and are coterminous with the policy change from opt-in to opt-out HIV testing.”

The perceived benefits of testing increased between 2000 and 2010 (p < 0.001), and testing was more likely to be considered a community norm in 2010 (p < 0.001).

However, fear of a positive test result, concern about clinic opening hours and waiting times, and a belief that testing positive would lead to sexual rejection were as significant barriers to testing in 2010 as they had been in 2000.

“Despite the availability of testing through the opt-out policy, the success of antiretroviral therapy, and the reduced risk of transmission associated with undetectable viral load, HIV infection remains to some extent a stigmatized and dreaded condition,” suggest the investigators. “Social marketing campaigns…could highlight the reduced infectivity of HIV-positive men who are on treatment with an undetectable viral loads, and simultaneously highlight the increased potential infectiousness of those who have not tested recently (yet might be highly infectious if they have recently seroconverted).”

Flowers P et al. Has testing been normalized? An analysis of changes in barriers to HIV testing among men who have sex with men between 2000 and 2010 in Scotland, UK. HIV Med, online edition. DOI: 10. 1111/j.1468-1293.2012.01041x, 2012.