A major household survey of adults in the UK shows that, even among people who perceive themselves to be at risk of HIV infection, only 14% had recently taken an HIV test. While people with riskier sexual behaviour and people who were aware of their vulnerability to HIV were more likely to take a test than other people, a majority in this group had never taken an HIV test.
Very few men who have sex with men (MSM) followed the recommendation that they take an HIV test at least once a year. Testing rates were also low in black African people.
The data come from the National Survey of Sexual Attitudes and Lifestyles (Natsal), conducted between 2010 and 2012. As this study recruited a large, representative sample from households throughout Great Britain, it is more likely than most other studies to give an accurate picture of HIV testing behaviours across the population.
The new analysis is published online ahead of print in AIDS. A report from Natsal showing that testing rates have increased since the 1990s was published in The Lancet in 2013.
The study
Sexual health researchers typically recruit samples of people who are in contact with specialised sexual health services or who attend locations associated with particular sections of the population (e.g. gay bars). The National Survey of Sexual Attitudes and Lifestyles is one of the only studies that has had the financial resources and political backing needed to enrol a representative sample of the wider population. An individual with no identifiable risk factors for HIV is as likely to be recruited as a person with multiple risk factors.
Between 2010 and 2012, interviewers approached people aged 16 to 74 years who were living in households across England, Scotland and Wales. Two-thirds of those who were contacted agreed to take part, with 15,162 individuals completing the survey. The sample was statistically adjusted so that it matched the profile of the population in the country’s census in terms of geographical spread, age and gender (e.g. slightly fewer men than women had been recruited).
Respondents took part in hour-long interviews, with sensitive questions about sexual health being asked on a self-completed computer survey, to ensure confidentiality.
HIV testing and risk perception
Overall, 3.5% of men and 5.4% of women had taken an HIV test in the past year, with 18% and 23% having ever tested. (HIV tests carried out in the context of blood donation were excluded).
Respondents were asked about their perception of being at risk of becoming infected with HIV. While the vast majority of people thought they were not at all at risk (76% and 83% of men and women respectively) or not very much at risk (21% and 14%), small numbers also acknowledged being at “quite a lot of risk” or “greatly at risk”. This was the case for 3.4% of men and 2.5% of women.
Being aware of their risk of HIV was more common in gay and bisexual men, people of non-white ethnicity, younger people and people without academic qualifications. Unsurprisingly it was also more common in those who reported various sexual risk behaviours: greater partner numbers, not using a condom during the first sexual encounter with a partner, having two or more partners without a condom, and overlap between sexual partners.
However, within the group of men who acknowledged their own risk of HIV, only 14% had tested within the last year and only 25% had ever tested.
Within the comparable group of women, 14% had tested in the last year and 36% had ever tested.
Amongst black Africans who were aware of their risk of HIV, only 44% had tested in the last year. Amongst men who have sex with men who were aware of their risk, 41% had done so.
The researchers also found that over 80% of MSM and black Africans who reported not using a condom during their first sexual encounter with a partner didn’t perceive themselves to be at risk of HIV. Similarly, around 80% of both groups had not recently tested for HIV.
Why people test
Respondents were asked why they had tested. Women had typically tested during pregnancy (47%) or as part of a sexual health check-up (33%). Men had done so for a sexual health check-up (41%), general health check-up (27%) or out of concern about risks (11%).
The authors note the very limited numbers who had been advised to test by a doctor – 4.8% of men and 2.6% of women.
Most tests were done in sexual health clinics (53% of men and 37% of women) and antenatal clinics (24% of women). In addition, many more tests were done in GP surgeries than would have been expected a few years ago (22% of men and 26% of women). But few people reported testing in hospital.
A significant proportion of all people testing, especially those testing in GP surgeries and antenatal clinics, reported few sexual risks and did not perceive themselves to be at risk of HIV. The authors note that this may be in line with current testing guidelines which aim to normalise HIV testing in high-prevalence areas.
Comparison with the United States
The UK study was published on the same day as an analysis of testing in the United States, based on several million people enrolled in Medicaid or commercial insurance programmes. The proportion who had taken an HIV test in the past year is comparable to that in the UK – 5.7% of men enrolled in Medicaid, 3.0% of men with insurance, and 2.5% of women in either programme.
Almost all were tested for sexually transmitted infections at the same time, suggesting that provision of HIV testing is largely based on sexual risk factors or symptoms. There is little evidence of it being provided in a routine way to larger populations, in line with testing guidelines.
Clifton S et al. HIV testing, risk perception, and behaviour: findings from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). AIDS, published online ahead of print, 2015.
Dietz PM et al. HIV Testing among Outpatients with Medicaid and Commercial Insurance. PLOS One 10(12): e0144965, 2015.