HIV testing in hospital

Experience from Croydon University Hospital in south London shows that HIV screening for new hospital admissions can work. Although this policy is recommended for areas of high HIV prevalence, not all hospitals have implemented it.

The Acute Medical Unit (part of the hospital’s emergency services) started offering opt-out HIV testing to adult patients in 2011. Just over 4000 patients were tested during a 21-month period – representing one third of patients admitted to the unit.

Twenty people were diagnosed with HIV during this time. This amounts to a prevalence of around 0.5% in those tested (similar to the prevalence in the local community). HIV testing is usually thought to be cost-effective if 0.1% or more people test positive.

A third of the diagnoses would have been missed if only people with clinical indicator diseases had been tested.

In high-prevalence areas, more widespread implementation of opt-out testing in acute settings could make an important contribution to reducing the levels of undiagnosed infection and late diagnosis. The Croydon findings show that the testing policy is acceptable, feasible, sustainable and cost-effective.

The researchers attribute the success of the policy to close support during the early stages from members of the hospital’s HIV team, ownership of the policy by Acute Medical Unit staff (despite high staff turnover), and the enthusiasm of nurses, who eventually took the lead in implementing the policy.

Male sex workers

Male sex workers are significantly more likely to be diagnosed with sexually transmitted infections than other men who have sex with men, surveillance data show. Researchers looked at the profile of just under 500 male attendees of English sexual health clinics who disclosed selling sex, and compared it with data on other male patients.

After statistical adjustment, male sex workers were over three times more likely to be diagnosed with HIV than other men, and also more likely to have chlamydia or gonorrhoea. Male sex workers attended sexual health clinics more often than other men, and were more likely to have a full sexual health screen.

Whereas it’s often assumed that male sex workers are mostly young men, in fact these men were slightly older than other clinic attendees – 30% were over 35 years old.

Almost two-fifths had moved to the UK from elsewhere, primarily countries in South America and in Europe. In terms of sexual orientation, three-quarters of the migrant men identified as being a man who has sex with men, but only a third of the British-born men did so.

This study points to the need for investment in HIV prevention work with men who sell sex.

Computerised counselling

A randomised controlled trial of a computer programme for people living with HIV has shown that it led to an increase in condom use, as well as improved treatment adherence and reduced viral load. The study took place in Seattle (United States) and most participants were men.

The intervention used tablet computers and involved the user being asked a series of questions about health and lifestyle, given personalised feedback and shown videos in which peers demonstrate healthy behaviours, with the user asked to develop a personalised plan for better adherence or safer sex. A mix of health behaviour theories were used to develop the content.

Topics included treatment adherence, viral load, HIV disclosure, condom use and drug use. The intervention was delivered every three months over a nine-month period, usually during people’s regular clinic visits.

Participants in the control group received standard care.

At the end of the study, fewer people in the intervention group reported instances of unprotected sex, or of problems using condoms – a change that was not seen in the control group.

The intervention also had an impact on participants’ viral load and self-reported adherence, especially in those participants who had a detectable viral load to begin with. Also, most participants completed the programme and said it was as good as face-to-face sessions.

Gay men’s risk careers

A study that looked at the way risk of HIV transmission changed over time in a group of gay men during a six- to eight-year period has found that there was considerable variation in the degree of risk men subjected themselves to and that this often changed over time.

The researchers analysed the sexual risks that men took (measured every six months) and allocated the participants to three groups.

One-in-seven men belonged to a very high risk group, 32% of whom became infected with HIV over the study period. While men who had high-risk behaviours in one six-month period most often continued to do so in the following six months, this was not always the case. Men went in and out of being at risk of HIV as their relationship status changed or as they adopted different sexual practices.

Just under a quarter belonged to a moderate risk group, of whom 10% became HIV positive.

The other two-thirds were at low risk of HIV, except for short periods of time – 3% of them acquired HIV.

The researchers did this analysis because they wanted better information that could help clinicians to provide pre-exposure prophylaxis (PrEP) to men who have ‘seasons of risk’. PrEP is only likely to be cost-effective if it is taken by people with the highest risk of infection. But the study is of broader interest as it is the first to document gay men’s ‘risk careers’ over a long period of time and in such detail.

Opportunities to promote HIV testing through social networks

A study from Malawi found that people newly diagnosed with HIV or a sexually transmitted infection (STI) often have individuals with HIV in their social network. A project offering HIV testing to people in patients’ social networks identified many cases of undiagnosed infection.

People attending a sexual health clinic were asked to recruit up to five individuals in their social network for a health promotion programme. This covered a wide range of health issues, and included HIV testing.

Around half of the ‘index patients’ did recruit at least one person, most often a friend or neighbour. Only one-in-ten contacts were sexual partners.

When index patients had themselves been newly diagnosed with HIV, one third of their contacts tested HIV positive. This partly reflects the very high prevalence of HIV in Malawi, but also the likelihood that individuals with higher-risk behaviours know other people with similar behaviours. A control group of index patients, recruited in the local community, encouraged more people to test, but had fewer contacts with undiagnosed HIV.

In order to identify one new case of HIV, it was necessary to screen eight contacts of the HIV-positive index patients; ten contacts of index patients who had an STI but not HIV; and 18 contacts of the community controls.

This approach offers an alternative or supplement to traditional partner notification. Similar interventions have already been tested in urban areas of the United States – they have been shown to help identify people with undiagnosed HIV who may be otherwise hard to reach.

Case study: online engagement with Africans

It is often thought that web-based interventions about HIV are less likely to reach black African people than other groups, but the success of HIV Prevention England’s online engagement work shows that barriers can be overcome.

Some research suggests that black Africans are actually more likely to have internet access than other UK residents. But a challenge for health promoters is identifying websites which can reach an African audience.

“Africans are using online media but they are scattered,” says Takudzwa Mukiwa of Terrence Higgins Trust. The most popular websites are the same as for other ethnic groups (Daily Mail, You Tube, etc.) but advertisements would be expensive and could not target an African audience. There are African-focused websites but they are often specific to citizens of one country or more likely to be used by people overseas than UK residents.

However, Facebook is extremely popular and facilitates targeted advertising, as well as sharing of content between friends.

For the It Starts With Me campaign, there are two Facebook pages, one primarily for African audiences and the other aimed at gay men. The African page is almost as popular as the gay page – 5681 people have ‘liked’ it. During November (which included National HIV Testing Week) just under 13,000 people engaged with the page in some way – for example, by sharing a link, taking part in an online discussion or completing a quiz about HIV testing.

In order to use advertising in a cost-effective way, advertisements only appear on certain Facebook users’ pages. An English location, an age range and a gender can be specified. These factors are combined with a long list of ‘interests’ which are more likely to be expressed by African people than others – for example, African musicians, politicians, cities and regions.

This has been developed through trial and error, as has identifying the types of content which users engage with. While some HIV awareness themes and discussions about relationships are popular, material discussing safer sex has led some people to ‘unlike’ the page.

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