Pilot projects, testing innovative ways for individuals to
take their own saliva or blood sample and return it to a laboratory for
analysis, have found that the approach is successful at reaching significant
numbers of individuals who haven’t tested before and individuals who are HIV
Data on three projects were presented to the joint
conference of the British HIV Association (BHIVA) and the British Association for
Sexual Health and HIV (BASHH) in Liverpool yesterday.
The projects that were discussed were all of home sampling, which should be distinguished
from home testing. With home sampling,
the individual takes a saliva or blood sample in their own home and mails it to
a laboratory, which makes the results available online, by text message or by
phone. Home testing involves the individual taking a sample and interpreting
their own results.
Home sampling has always been legal in the UK, but the sale
of licensed home testing kits only became possible this week, following a
change in legislation. Ironically, it is only with the imminent prospect of home
testing that health organisations have investigated the potential of home
The most detailed data were presented by the Terrence
Higgins Trust (a large sexual health charity), which targets its service towards
men who have sex with men (MSM) and black African people. Testing kits can be
requested online and are sent free of charge.
A second service is provided by 56 Dean Street (a central
London sexual health clinic popular with gay men). A third is offered by a
collaboration between GMFA (a gay men’s sexual health charity) and Homerton
Common features of the services include: publicity by
high-profile, community-orientated health organisations; online facilities to
conduct basic risk assessments and order test kits; assays requiring samples of
either saliva or fingerprick blood; provision of negative test results by text
message; provision of reactive results by phone call from a healthcare worker,
who offers a referral for confirmatory testing and follow-up.
Between January and November 2013, 9868 individuals
requested a kit from the Terrence Higgins Trust (THT). Just under two thirds (63.6%)
returned a sample – a similar rate of return was seen in the other pilots.
Most of those taking part were gay and other men who have
sex with men (73%), with fewer than 5% of samples being returned by African
Around 1 in 60 of the returned samples (1.7%, 105 people)
were HIV positive, with especially high rates amongst those African people who
did use the service (3.6%) and men who have sex with men (1.8%).
There was good evidence of linkage to care for
three-quarters of those tested positive. Staff providing reactive results
offered to arrange an appointment with a clinic, although a significant number
of individuals preferred to make their own arrangements.
Eleven of 105 people with reactive results were in fact
already aware that they had HIV. This is not an entirely novel finding – other
community testing projects have attracted individuals wanting to confirm their
HIV status or re-engage with care.
Since November, a further 7761 test kits have been
requested, with slightly better engagement of African people – full results
will be available at a later date.
In the 56 Dean Street project, 4838 kits were requested
over a 22-month period. Of those returned, 2.3% were HIV positive.
The GMFA and Homerton service required those wanting to
receive a test kit to complete a risk assessment. During an eleven-month period, 647 kits were sent
out, with eight (1.9%) being reactive, including four (1.0%) confirmed as newly
diagnosed individuals who were successfully linked to care. (The remaining four
were either already aware of their positive status, had a reactive result that was
not confirmed with subsequent testing, or were lost to follow-up.)
The GMFA and Homerton project asked for saliva samples and its
service users expressed a strong preference for this method. However,
fingerprick blood samples provide more consistently accurate results and the
Terrence Higgins Trust was able to achieve high uptake despite a requirement
for blood samples.
Terrence Higgins Trust noted that uptake of testing was very
closely linked with marketing activities. The organisation already has a very
strong media presence and promoted the testing kits through multiple channels,
including advertising campaigns for HIV Prevention England, publicity for HIV
Testing Week, advertising on gay men’s dating apps, Twitter and Facebook groups. In weeks
without particular activity, around 200 kits were mailed out, but a
co-ordinated marketing push over a single weekend led to a ten-fold increase in
All three services have found very high rates of user
satisfaction. Users would most frequently recommend the service to a friend who
they expected to receive a negative result (over 95% of both THT and 56 Dean
Street users), with fewer recommending it to a friend expected to test HIV
positive (65 and 58% of THT and 56 Dean Street users respectively).
Even among individuals who did not return their sample to THT, 89% said they would use the service
again. Typically, these individuals said they had not completed the testing
process because it didn’t feel important to test immediately, they didn’t like
the testing method, or they were worried about receiving a positive result.
Individuals who did return a sample typically said that they
chose home sampling because they did not want to attend a sexual health
clinic or that clinic opening times were inconvenient. Moreover, one third had
never tested before and a quarter had not tested in the previous year.
GMFA services users said that a home sampling service would
make it more likely that they would test at least once a year, and many would
welcome an annual email to remind them to do so.
However, a much smaller pilot study, run from the sexual
health clinic at St Mary’s Hospital, did not find that home sampling encouraged
young, high-risk gay men to test more frequently. Fifty men were trained
to self-sample and given six kits which they could send back over the next
year. Thirty-five men didn’t use any kits at all, ten men sent in one sample
and five did so more than once. It may be that these men were already happy
with clinic-based services – many of those who didn’t use the home sampling did
return to the clinic for a check-up.
It remains to be seen whether home sampling is simply part
of the preparation for true home testing (two thirds of THT service users said
that they would prefer that), or whether it is an option that will be retained.
One key advantage over home testing is that the provision of reactive results
by phone creates an opportunity to help with linkage to care.
The pilots have certainly shown that home sampling is
feasible and acceptable, especially to gay men, and the process is likely to be
cheaper than clinic-based testing. “Home sampling could potentially be a major
contribution to increasing uptake of HIV testing,” concluded Dr Michael Brady
of Terrence Higgins Trust.