Home testing

Results from a mathematical modelling study suggest that if people replace clinic-based HIV testing with less sensitive home tests, the prevalence and incidence of HIV could rise.

As shown by a recent study comparing different HIV tests, the fourth-generation laboratory tests used in clinics detect almost 100% of infections and have short window periods. However, the OraQuick test that has been licensed for home testing in the United States is less accurate when used with a sample of oral fluid – it misses around one-in-ten infections and has a longer window period (up to twelve weeks).

The modelling compared the outcomes if people switched from testing in a clinic to testing at home with OraQuick. The same results would not necessarily apply if a more sensitive home test were available. Nor would they apply if home sampling was used in combination with a more sensitive test – as is the case with the Terrence Higgins Trust postal test scheme, using a test with a window period of four weeks. Another UK home sampling project, Dean Street at Home is offering a fingerprick blood test with a window period of four weeks or an oral fluid test with a window period of 14 weeks.

The modelling study found that OraQuick’s longer window period could mean that people with recent HIV infection remain undiagnosed.

This would be particularly likely to occur if a person who already tests every six months switched from testing in a clinic to using a home test. If this person had HIV, it is highly likely that he or she would have a recent infection – one which the home test might miss.

In contrast, if home testing was mostly used by people who tested less frequently (for example, every few years) or previously did not test at all, it is more likely that they would have had HIV for longer. Self tests are able to detect most of these infections.

Also, if home testing leads to people testing more often or to avoiding unprotected sex with individuals of a different HIV status, it could help lower prevalence.

While home sampling projects are already provided in the UK, home testing will become legal in April. This study highlights the importance of the technical specifications of the tests used and also of the frequency with which people test. At the moment we cannot know who will use home tests and whether their use will supplement or replace other HIV and STI screening practices.

While it can be hoped that home testing will help reduce the number of people with undiagnosed HIV and lead to fewer infections, this model shows that in certain circumstances it could have a negative effect.

Sexual health: LGV and shigella

New information was released this month about two bacterial infections that can be spread during sexual contact – lymphogranuloma venereum (LGV) and Shigella dysentery. Both have been linked to drug use and sex parties among gay men, particularly men living with HIV. While they currently affect fewer people than some other sexually transmitted infections, their symptoms can be extremely unpleasant. Nonetheless, antibiotic treatments are effective for both.

Cases of LGV were first reported a decade ago and it affects around 400 gay men a year. It is a bacterial STI caused by strains of Chlamydia.

A study has now shown that the main risk factor for infection with LGV is unprotected receptive anal sex. Infection is also associated with anonymous sex, use of the drugs GHB/GBL and fisting – the researchers believe that in a group sex situation, the infection can be passed from one rectum to another on the hand or penis of a man who does not necessarily have LGV himself.

But the main prevention message drawn from the study is that condoms do protect against LGV.

Cases of shigella linked to sex between men have been reported since 2010, with over 200 cases in 2013. It is a form of dysentery caused by the Shigella bacterium, a gut infection that causes severe diarrhoea and stomach cramps. It is spread through oral contact with faeces – sex that may lead to contact with tiny amounts of faeces is a risk, for example anal sex, fingering or rimming. Gay men are encouraged to wash their hands thoroughly and shower after sex.

There’s a need to raise awareness of both infections among gay men, especially among men living with HIV. Information on shigella should focus on recognising its symptoms. For LGV, sexual health clinics are asked to identify men at risk, encourage frequent STI screening and offer behavioural support.

Gay men’s mental health

Qualitative research in Amsterdam has explored the issues lying behind poor mental health in gay men – several studies have found that gay men have higher rates of mood disorders, anxiety disorders and suicidal thoughts than heterosexual men.

The researchers found that, while most men had grown up in an environment that was accepting of legal and social equality for gay people, they were keenly aware that homosexuality was not ‘normal’ (or gewoon in the Dutch language). As adolescents they did not fear outright rejection, but were anxious about being different and not living up to their families’ expectations.

Some of the respondents had found it difficult to form and maintain long-term sexual relationships. Some attributed this to not having gained experience of dating when they were younger, while the researchers also point to the way in which men interact with each other. They describe respondents ‘shopping’ for the ideal man and losing interest when it became clear that a partner was less than perfect. Some men’s experiences on the gay scene eroded their self-esteem.

“The behaviours and stories of many respondents testified to potent practices of self-regulation as they endeavoured to reach and uphold ideals associated with gewoon and heteronormative masculinity,” the researchers say.

The study highlights the persistence of poor mental health in gay men, even in a society where legal and social equality is far advanced. There are likely to be connections between mental health issues and difficulties negotiating safer sex, compulsive sexual behaviour and drug use.

Men who don’t test

A Scottish study has looked at the characteristics of gay and bisexual men who have not recently taken an HIV test. In this 2010 survey, 57% of men in Glasgow bars and clubs had tested for HIV in the previous year, 22% had tested more than a year ago and 20% had never tested.

Relatively few men over the age of 45 had recently tested, while men under the age of 25 were likely to have either tested within the previous year or not at all. Men who had unprotected anal sex were more likely than others to have tested, but men with particularly risky sexual behaviour (e.g. unprotected sex with multiple partners of unknown HIV status) were not especially likely to have tested recently.

A number of beliefs and attitudes did not appear to influence testing behaviour. For example, men who had never tested were just as aware of the benefits of taking a test as men who had tested recently.

But men who had a greater fear of receiving a positive result were somewhat less likely to have tested than other men, as were men who did not think that most of their gay friends had been tested.

The researchers suggest that interventions on HIV testing should promote a positive norm for testing and challenge men’s fear of a positive test result. Interventions should focus on men under 25 and above 45, especially those whose sexual behaviour puts them at particular risk.

Individual responsibility

Canadian researchers who invited HIV-negative and HIV-positive gay men to discuss anti-HIV stigma and sexual risk-taking have concluded that ideas of “individual responsibility” and “looking after one’s health” are flawed as models of how to deal with the risk of HIV in the gay community.

The researchers argue that the idea that “everyone is responsible for their own health” often creates a situation in which responsibility is passed to the other person in a sexual encounter. While some respondents used the metaphor of “it takes two to tango” they did not describe sexual partners discussing or sharing decisions – the metaphor seemed more to suggest that both partners should take individual responsibility as isolated, self-determined persons.

Moreover, the idea of individual responsibility seemed linked to a rigid exclusion of certain people, such as men with diagnosed HIV. The researchers argue that these strategies may keep individuals physically free from HIV and STIs but can also paradoxically increase risk and entrench stigma within the gay community.

They urge the revival of a more community-centred, mutual and dialogue-based approach to HIV risk that does not leave men to deal, or fail to deal, with HIV alone and which involves honest and respectful dialogue about sexual risk and HIV, both between couples and within the community.

Case study: chemsex

In recent months, staff at Yorkshire MESMAC have noticed an increasing number of their service users talking about drug and alcohol use. Individuals using the rapid HIV testing service are asked about the circumstances in which they took their last sexual risk, and substance use has figured in a number of the accounts of men who have sex with men in Leeds. Most commonly alcohol is mentioned, with other men mentioning mephedrone, cocaine and MDMA. Although most men take mephedrone through the nose, a few report injecting (‘slamming’) the drug, a phenomena that has also been noticed by clinicians at the local HIV clinic.

For the moment, this appears to be a relatively small-scale problem, certainly in comparison with the way the media describe ‘chemsex’ in London. Only a few men have mentioned using crystal meth. However, a few men have taken extra sexual risks, acquired hepatitis C co-infection or had difficulties controlling their drug use.

In order to respond to this emerging issue, Yorkshire MESMAC is teaming up with two local providers of drug and alcohol services, St Anne’s Community Services and BARCA-Leeds. At present, gay men rarely attend these services.

Beginning in March, a joint drop-in will be offered. To prepare for the new service, each organisation will train the other on their area of expertise – the drug and alcohol services will train Yorkshire MESMAC staff on harm reduction, who will in turn provide training on sexuality and sexual health. Following this, the organisations will offer a teaching session to GUM clinic staff to share best practice.

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