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 in the UK, 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.

Comment: Self-testing (often called home testing) is being legalised in the UK and France this year. 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. 

Risk factors for LGV identified

A case-control study released this month shed light on the risk factors for lymphogranuloma venereum (LGV), a bacterial sexually transmitted infection that is caused by strains of Chlamydia. Its symptoms can be extremely unpleasant but antibiotic treatments are effective.

Outbreaks of LGV have been reported over the past decade in the Netherlands, the United Kingdom, Spain, France, Germany and other countries. Many of those acquiring LGV are HIV-positive gay men.

The current study compared gay men who had LGV (cases) with gay men attending sexual health clinics who did not have LGV (controls). The study found 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.

Comment: In many settings, very little information about LGV and its symptoms is provided to gay men. A key prevention message is that condoms protect against LGV; in addition, care is needed in group sex situations. Sexual health clinics should identify men at risk, encourage frequent screening, provide treatment and contact tracing, 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 gewoon (a Dutch term for normal, usual or customary). 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.

Comment: 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.

Attrition in the treatment cascade

Data over a 15-year period shows that patients are being lost at each stage of the HIV care ‘cascade’ in British Columbia, Canada. While the findings show that the situation has improved steadily since 1996, there remains significant attrition – in 2011, only 35% of HIV-positive people had an undetectable viral load.

Efforts to reduce the rate of undiagnosed infections and improve engagement with care are central to strategies to maximise individual and public health benefits of HIV treatment.

Over the 15 years of the study, the proportion of people living with HIV who had been diagnosed increased from 51 to 71%. But not everyone was linked to care and around 20% of people linked to care subsequently stopped attending. Some people taking HIV treatment did not or could not adhere to it. The greatest improvements observed during the study related to viral suppression, which increased from 5% of those on treatment in 1996 to 78% in 2011.

Comment: British Columbia is frequently held up as showing the potential of a ‘seek, test and treat’ approach. Unlike other Canadian provinces, HIV treatment and care are free, so there are relatively few financial barriers to accessing treatment. But while these data show that undiagnosed HIV can be successfully reduced over time, they also indicate how challenging it is to link people to care and retain them in the healthcare system over time. A better understanding of barriers to retention in care, the characteristics of individuals who drop out of care and of interventions to improve retention is required.

The limits of 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.

The researchers 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.

Online press conference: HIV treatment as prevention community consensus statement

On Thursday 27 February 2014, NAM and EATG, Europe's community group for people with HIV, are launching a consensus statement, for endorsement by the HIV community, on using HIV treatment to prevent the transmission of HIV.

The consensus statement was developed via an open online consultation, a community meeting in September 2013, and further consultation with key opinion leaders in the HIV community. 

You are invited to an online press conference about the statement, on Thursday 27 February, from 2-2.30pm GMT (3-3.30pm CET; 8-8.30am CST). 

You can register for the press conference online or find out more in the NAM blog.

Reminders will be sent the day before the press conference, with instructions of how to log in from your computer. The briefing will combine online slides with a live audio presentation and opportunities to ask questions in real time. The briefing will be in English.

Other recent news headlines

Black people have low levels of engagement and retention in HIV care in the US

Intensified efforts are needed to improve engagement by black people in the HIV care continuum in the United States, according to data published in the 7 February edition of Morbidity and Mortality Weekly Report.

HIV testing interventions should challenge fears of a positive result

Among gay and bisexual men in Glasgow, not having recently taken an HIV test is associated with being under the age of 25, over the age of 45, a fear of receiving an HIV-positive result and not perceiving HIV testing to be typical amongst gay friends. Interventions to promote HIV testing should address these issues, researchers suggest in the March issue of AIDS Care.