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 positive.
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 sampling.
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 University Hospital.
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 people.
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 requests.
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.
Brady M et al. Home HIV sampling linked to national HIV testing campaigns: a novel approach to improve HIV diagnosis, abstract O21.
Brady M et al. Acceptability of home HIV sampling and testing: a user survey, abstract P230.
Reeves I et al. “A Great way of doing it from the comfort of my home”: expanding opportunities for HIV testing through home sampling, abstract P241.
Elmahdi R et al. SPIT (Saliva Patient Initiated Testing for HIV) Study: Feasibility and acceptability of repeat home-based HIV saliva testing using self-sampling amongst men who have sex with men, abstract P264.
All presentations from the Third Joint Conference of BHIVA and BASHH, Liverpool, April 2014.