Downloaded from http://sti.bmj.com/ on April 20, 2015 - Published by group.bmj.com
Health services research
SHORT REPORT
The acceptability of different HIV testing approaches: cross-sectional study among GMSM in Australia M Yang,1 G Prestage,1,2 B Maycock,3 G Brown,2,3 J de Wit,4 M McKechnie,1 R Guy,1 P Keen,1 C K Fairley,5,6,7 I B Zablotska1 1
The Kirby Institute, The University of New South Wales Australia, Sydney, New South Wales, Australia 2 The Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Victoria, Australia 3 Curtin University, Perth, Western Australia, Australia 4 Centre for Social Research in Health, The University of NSW Australia, Sydney, New South Wales, Australia 5 Melbourne School of Population Health, University of Melbourne, Victoria, Australia 6 Melbourne Sexual Health Centre, Melbourne, Victoria, Australia 7 Central Clinical School, Monash University, Alfred Hospital, Melbourne, Victoria, Australia Correspondence to Dr Iryna B Zablotska, Senior Lecturer, The Kirby Institute, The University of New South Wales Australia, Sydney, NSW 2052, Australia; [email protected] IBZ and CKF equally contributed as senior authors in this paper. Received 13 January 2014 Revised 22 May 2014 Accepted 14 June 2014 Published Online First 11 July 2014
ABSTRACT Background We explored the attitudes of Australian gay and other men who have sex with men (GMSM) about the current standard-of-care (non-rapid tests at healthcare settings) and alternative approaches (rapid tests and testing in non-healthcare settings) to better understand the acceptability of alternative testing approaches. Methods The Contemporary Norms in Networks and Communities of GMSM study enrolled GMSM in Sydney, Melbourne and Perth in 2011–2012 using peer referrals. We explored the self-reported preferences for testing: rapid versus non-rapid and in non-healthcare settings (community-based or home-based testing) versus in healthcare settings, and examined factors associated with preferences for these approaches. Analyses of associations used standard univariate and age-adjusted logistic regression models. Results Among 827 sexually active non-HIV-positive participants, 89% had been tested for HIV. Most preferred by participants was home rapid testing (46%), followed by standard-of-care (23%) and rapid testing in healthcare (20%) or community settings (7%). About 73% of participants preferred rapid over non-rapid testing, and 56% preferred testing in non-healthcare settings rather than in healthcare settings. Preference for rapid testing was associated with being fully employed (adjusted OR (aOR): 1.81; 95% CI 1.16 to 2.82), managerial/professional occupation (aOR: 2.03; 95% CI 1.19 to 3.46) and engaging in unprotected anal intercourse with casual partners (aOR: 1.89; 95% CI 1.29 to 2.78). The same factors were associated with preference for testing in non-healthcare settings. Conclusions Australian GMSM prefer alternative testing approaches, possibly due to their convenience. The availability of new testing approaches may provide more options for GMSM at risk for HIV infection, improve access to HIV testing and potentially increase HIV testing rates.
INTRODUCTION
To cite: Yang M, Prestage G, Maycock B, et al. Sex Transm Infect 2014;90:592–595. 592
Gay and other men who have sex with men (GMSM) continued to contribute to the majority (∼70%) of new HIV diagnoses in Australia, with a 43% increase over the past decade.1 Australia maintains a high level of HIV testing conducted in healthcare settings using non-rapid test based on individual consent (current standard-of-care).2 However, it is estimated that 20–30% of GMSM living with HIV are still unaware of their status, and up to 31% of new HIV infections could be acquired from such men.3 Among reasons why
some GMSM are not being tested are perception of low risk, fear of testing positive, embarrassment or fear of talking to a doctor and perceived discrimination and rejection.4 The availability of alternative testing approaches could potentially help to overcome these barriers and improve testing rates.4–6 Internationally, various alternative approaches have been made available to improve the rates of testing among GMSM.7 At the time of data collection for this study, alternative tests were not yet licensed for use in Australia. By May 2014 only one test (Alere Determine HIV Combo POCT) had been approved by the Australian Therapeutic Goods Administration and just started being available through the limited number of point-of-care demonstration programmes. Some studies in Australia have suggested that GMSM would prefer new testing approaches for their convenience.5 However, there is still a lack of understanding regarding whether rapid testing and testing in non-healthcare settings is acceptable among GMSM in Australia. This study aims to explore the acceptability among Australian GMSM of the current standard-of-care and alternative approaches (rapid tests and testing in non-healthcare settings) and to identify the associated factors, to inform further development of HIV testing services.
METHODS We used data from the Contemporary Norms in Networks and Communities of GMSM (CONNECT) study funded by The National Health and Medical Research Council for the period of 2010–2013. The methods of the CONNECT study have been described previously.8 This cross-sectional quantitative study used peer referral and recruited sexually active GMSM (ie, those who had sexual partners in the past 12 months), who were at least 18 years old and lived in metropolitan Sydney, Melbourne or Perth. Participants completed an online questionnaire about perceptions and practices related to HIV transmission and prevention. This study has been approved by The Human Research Ethics Committee of The University of New South Wales Australia. Our sample included 827 men who were HIV negative or did not know their status and reported their most preferred HIV testing approach (‘standard testing provided by clinics or general practitioner services’, ‘standard testing provided by community-based organisations’, ‘rapid testing
Yang M, et al. Sex Transm Infect 2014;90:592–595. doi:10.1136/sextrans-2013-051495
Downloaded from http://sti.bmj.com/ on April 20, 2015 - Published by group.bmj.com
Health services research provided by clinics or GP services’, ‘rapid testing provided by community-based organisations’ or ‘home-based rapid testing’). Based on the responses, we constructed two outcome variables: (1) preference for rapid versus non-rapid testing (ie, for testing speed) and (2) preference for testing in non-healthcare settings versus in healthcare settings (ie, for testing location). Independent variables included age, ethnic background, employment, occupation, education, having been tested for HIV in the past and recruitment site. For the type of partner, we constructed a hierarchical variable with three categories (‘having familiar casual and possibly new casual partners’/‘having only new casual partners’ versus ‘having a regular partner independent of having familiar causal or new casual partners’ within the last 6 months). Sexual practice variables included unprotected anal intercourse with regular partners (UAIR) and with any familiar or new casual partners (UAIC), both measured within the last 6 months. Engagement with gay social life was measured by two variables: number of friends who are gay and time spent with gay friends. Associations were evaluated using logistic regression models, with type I error of 5%. Robust variance estimation was used to take outliers into consideration. We presented age-adjusted ORs and 95% CIs. We chose to adjust only for age because most of the independent sociodemographic variables were correlated with each other. All analyses were executed using STATA V.12.0 (StataCorp, College Station, Texas, USA).
RESULTS Respondents were from Sydney (33%), Melbourne (24%) and Perth (43%). Their mean age was 34.9 years (SD=11.44). The majority (60%) were of Anglo-Australian background; 53% had completed university-level education; 73% were employed full time and 10% part time, while 17% were unemployed. Most participants (66%) reported managerial/professional occupation; others reported occupations in trades, sales, clerical, production, labour or other profession. Those who did not report any occupation were either unemployed or students. The majority of men (89%) had previously tested for HIV, with 72% in the previous 12 months. Sixty-eight per cent reported having a regular partner/s with or without other partner/s in the past 6 months; 22% reported having familiar casual partner/s with or without new casual partner/s, and 10% reported having only new casual partner/s in the past 6 months. One-third (39%) of the men reported engaging in UAIR, and 31% had UAIC. Approximately half (49%) of the respondents reported that most or all of their friends were gay, and 46% spent most or all of their time with their gay friends. Seventy-three per cent of all respondents preferred rapid testing (of whom 20% preferred testing in healthcare settings, 7% in community settings and 46% at home) over non-rapid testing (of whom 23% preferred testing in healthcare settings and 3% in community settings). As to the testing location, 56% expressed a preference for non-healthcare settings, community/ home-based (53% rapid and 3% non-rapid testing) and 44% preferred to be tested in healthcare settings (20% rapid and 23% non-rapid testing). Neither preference for testing speed or location was associated with previous history of testing. The likelihood of expressing preference for rapid testing (see table 1) was significantly higher among men who were employed full time (aOR 1.81; 95% CI 1.16 to 2.82) compared with unemployed men; men in managerial/professional occupations compared with the combined category of men with no occupation, unemployed or students (OR 2.03; 95% CI 1.19 to Yang M, et al. Sex Transm Infect 2014;90:592–595. doi:10.1136/sextrans-2013-051495
3.46), and men who reported UAIC compared with men who did not (OR 1.89; 95% CI 1.29 to 2.78). We also investigated testing in non-healthcare settings versus testing in healthcare setting, and the same factors were significantly associated with the outcome: being employed full time (OR 1.85; 95% CI 1.21 to 2.84) or part time (OR 1.94; 95% CI 1.05 to 3.58), having a managerial/professional occupation (OR 2.15; 95% CI 1.31 to 3.54), reporting UAIC (OR 1.75; 95% CI 1.26 to 2.43), as well as living in Perth (OR 1.84; 95% CI 1.30 to 2.60).
DISCUSSION Consistent with previous studies on preferences for alternative testing approaches,9 the main findings of this study suggest that rapid testing and/or testing in non-healthcare settings are highly preferred by GMSM, particularly those who engaged in risky sexual behaviours (UAIC) and/or having a busy lifestyle (employed full time and in professional or managerial occupations, making it difficult to take time off work) and hence a desire for testing convenience and rapidly accessible results. Three quarters of the participants expressed preferences for rapid testing over the current standard-of-care and more than half preferred to be tested in non-healthcare settings. Such preferences were not associated with previous history of testing, but rather seemed to be a product of pragmatic choice of convenience. Indeed, despite the cost of testing being covered by Australian Medicare scheme and availability of gay friendly providers, appointments for testing still need to be made (often during working hours), which makes testing services inconvenient to many GMSM. Internationally, alternative testing has already been successfully used in many settings,10 while the process of introduction of rapid testing in Australia has been slower. Despite high levels of testing in Australia,5 a substantial proportion (31%) of new HIV infections could be the result of transmissions from HIV-positive men who are not tested and unaware of their status.3 This group is important, and one Australian study has predicted that an increase in HIV testing rates could have substantial epidemiological benefits over time.3 However, men who are not engaged with HIV testing might have little understanding of current standard-of-care or alternative approaches or might not want to be tested due to other reasons. Although alternative testing intends to remove any perceived barriers to testing and provide more opportunities for tested, it may not necessarily address all reasons for why some GMSM are not being tested. Another Australian study has shown that the current Australian testing rates have already reached ‘saturation’, and any further increase in HIV testing rates could only be achieved by introducing alternative testing options.11 While preferences may not necessarily translate into the uptake of a service, introducing more convenient testing approaches could provide more choices for clients and may be an effective addition to HIV prevention strategy. We acknowledge limitations of this study. Our sample was recruited by peer referral and findings may not be generalisable to all GMSM. We did not have information to explore in detail the participant’s barriers to testing or costs associated with testing. The levels of preferences for different testing approaches may therefore not be indicative of their uptake if these approaches were currently made available. Participants’ awareness, prior knowledge and experience with alternative tests were also not assessed, which could potentially affect their responses about testing preferences. 593
Downloaded from http://sti.bmj.com/ on April 20, 2015 - Published by group.bmj.com
Health services research Table 1 Factors associated with preference for rapid versus non-rapid testing† and testing in healthcare settings versus testing in non-healthcare settings‡
Variable Age
Health services research
SHORT REPORT
The acceptability of different HIV testing approaches: cross-sectional study among GMSM in Australia M Yang,1 G Prestage,1,2 B Maycock,3 G Brown,2,3 J de Wit,4 M McKechnie,1 R Guy,1 P Keen,1 C K Fairley,5,6,7 I B Zablotska1 1
The Kirby Institute, The University of New South Wales Australia, Sydney, New South Wales, Australia 2 The Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Victoria, Australia 3 Curtin University, Perth, Western Australia, Australia 4 Centre for Social Research in Health, The University of NSW Australia, Sydney, New South Wales, Australia 5 Melbourne School of Population Health, University of Melbourne, Victoria, Australia 6 Melbourne Sexual Health Centre, Melbourne, Victoria, Australia 7 Central Clinical School, Monash University, Alfred Hospital, Melbourne, Victoria, Australia Correspondence to Dr Iryna B Zablotska, Senior Lecturer, The Kirby Institute, The University of New South Wales Australia, Sydney, NSW 2052, Australia; [email protected] IBZ and CKF equally contributed as senior authors in this paper. Received 13 January 2014 Revised 22 May 2014 Accepted 14 June 2014 Published Online First 11 July 2014
ABSTRACT Background We explored the attitudes of Australian gay and other men who have sex with men (GMSM) about the current standard-of-care (non-rapid tests at healthcare settings) and alternative approaches (rapid tests and testing in non-healthcare settings) to better understand the acceptability of alternative testing approaches. Methods The Contemporary Norms in Networks and Communities of GMSM study enrolled GMSM in Sydney, Melbourne and Perth in 2011–2012 using peer referrals. We explored the self-reported preferences for testing: rapid versus non-rapid and in non-healthcare settings (community-based or home-based testing) versus in healthcare settings, and examined factors associated with preferences for these approaches. Analyses of associations used standard univariate and age-adjusted logistic regression models. Results Among 827 sexually active non-HIV-positive participants, 89% had been tested for HIV. Most preferred by participants was home rapid testing (46%), followed by standard-of-care (23%) and rapid testing in healthcare (20%) or community settings (7%). About 73% of participants preferred rapid over non-rapid testing, and 56% preferred testing in non-healthcare settings rather than in healthcare settings. Preference for rapid testing was associated with being fully employed (adjusted OR (aOR): 1.81; 95% CI 1.16 to 2.82), managerial/professional occupation (aOR: 2.03; 95% CI 1.19 to 3.46) and engaging in unprotected anal intercourse with casual partners (aOR: 1.89; 95% CI 1.29 to 2.78). The same factors were associated with preference for testing in non-healthcare settings. Conclusions Australian GMSM prefer alternative testing approaches, possibly due to their convenience. The availability of new testing approaches may provide more options for GMSM at risk for HIV infection, improve access to HIV testing and potentially increase HIV testing rates.
INTRODUCTION
To cite: Yang M, Prestage G, Maycock B, et al. Sex Transm Infect 2014;90:592–595. 592
Gay and other men who have sex with men (GMSM) continued to contribute to the majority (∼70%) of new HIV diagnoses in Australia, with a 43% increase over the past decade.1 Australia maintains a high level of HIV testing conducted in healthcare settings using non-rapid test based on individual consent (current standard-of-care).2 However, it is estimated that 20–30% of GMSM living with HIV are still unaware of their status, and up to 31% of new HIV infections could be acquired from such men.3 Among reasons why
some GMSM are not being tested are perception of low risk, fear of testing positive, embarrassment or fear of talking to a doctor and perceived discrimination and rejection.4 The availability of alternative testing approaches could potentially help to overcome these barriers and improve testing rates.4–6 Internationally, various alternative approaches have been made available to improve the rates of testing among GMSM.7 At the time of data collection for this study, alternative tests were not yet licensed for use in Australia. By May 2014 only one test (Alere Determine HIV Combo POCT) had been approved by the Australian Therapeutic Goods Administration and just started being available through the limited number of point-of-care demonstration programmes. Some studies in Australia have suggested that GMSM would prefer new testing approaches for their convenience.5 However, there is still a lack of understanding regarding whether rapid testing and testing in non-healthcare settings is acceptable among GMSM in Australia. This study aims to explore the acceptability among Australian GMSM of the current standard-of-care and alternative approaches (rapid tests and testing in non-healthcare settings) and to identify the associated factors, to inform further development of HIV testing services.
METHODS We used data from the Contemporary Norms in Networks and Communities of GMSM (CONNECT) study funded by The National Health and Medical Research Council for the period of 2010–2013. The methods of the CONNECT study have been described previously.8 This cross-sectional quantitative study used peer referral and recruited sexually active GMSM (ie, those who had sexual partners in the past 12 months), who were at least 18 years old and lived in metropolitan Sydney, Melbourne or Perth. Participants completed an online questionnaire about perceptions and practices related to HIV transmission and prevention. This study has been approved by The Human Research Ethics Committee of The University of New South Wales Australia. Our sample included 827 men who were HIV negative or did not know their status and reported their most preferred HIV testing approach (‘standard testing provided by clinics or general practitioner services’, ‘standard testing provided by community-based organisations’, ‘rapid testing
Yang M, et al. Sex Transm Infect 2014;90:592–595. doi:10.1136/sextrans-2013-051495
Downloaded from http://sti.bmj.com/ on April 20, 2015 - Published by group.bmj.com
Health services research provided by clinics or GP services’, ‘rapid testing provided by community-based organisations’ or ‘home-based rapid testing’). Based on the responses, we constructed two outcome variables: (1) preference for rapid versus non-rapid testing (ie, for testing speed) and (2) preference for testing in non-healthcare settings versus in healthcare settings (ie, for testing location). Independent variables included age, ethnic background, employment, occupation, education, having been tested for HIV in the past and recruitment site. For the type of partner, we constructed a hierarchical variable with three categories (‘having familiar casual and possibly new casual partners’/‘having only new casual partners’ versus ‘having a regular partner independent of having familiar causal or new casual partners’ within the last 6 months). Sexual practice variables included unprotected anal intercourse with regular partners (UAIR) and with any familiar or new casual partners (UAIC), both measured within the last 6 months. Engagement with gay social life was measured by two variables: number of friends who are gay and time spent with gay friends. Associations were evaluated using logistic regression models, with type I error of 5%. Robust variance estimation was used to take outliers into consideration. We presented age-adjusted ORs and 95% CIs. We chose to adjust only for age because most of the independent sociodemographic variables were correlated with each other. All analyses were executed using STATA V.12.0 (StataCorp, College Station, Texas, USA).
RESULTS Respondents were from Sydney (33%), Melbourne (24%) and Perth (43%). Their mean age was 34.9 years (SD=11.44). The majority (60%) were of Anglo-Australian background; 53% had completed university-level education; 73% were employed full time and 10% part time, while 17% were unemployed. Most participants (66%) reported managerial/professional occupation; others reported occupations in trades, sales, clerical, production, labour or other profession. Those who did not report any occupation were either unemployed or students. The majority of men (89%) had previously tested for HIV, with 72% in the previous 12 months. Sixty-eight per cent reported having a regular partner/s with or without other partner/s in the past 6 months; 22% reported having familiar casual partner/s with or without new casual partner/s, and 10% reported having only new casual partner/s in the past 6 months. One-third (39%) of the men reported engaging in UAIR, and 31% had UAIC. Approximately half (49%) of the respondents reported that most or all of their friends were gay, and 46% spent most or all of their time with their gay friends. Seventy-three per cent of all respondents preferred rapid testing (of whom 20% preferred testing in healthcare settings, 7% in community settings and 46% at home) over non-rapid testing (of whom 23% preferred testing in healthcare settings and 3% in community settings). As to the testing location, 56% expressed a preference for non-healthcare settings, community/ home-based (53% rapid and 3% non-rapid testing) and 44% preferred to be tested in healthcare settings (20% rapid and 23% non-rapid testing). Neither preference for testing speed or location was associated with previous history of testing. The likelihood of expressing preference for rapid testing (see table 1) was significantly higher among men who were employed full time (aOR 1.81; 95% CI 1.16 to 2.82) compared with unemployed men; men in managerial/professional occupations compared with the combined category of men with no occupation, unemployed or students (OR 2.03; 95% CI 1.19 to Yang M, et al. Sex Transm Infect 2014;90:592–595. doi:10.1136/sextrans-2013-051495
3.46), and men who reported UAIC compared with men who did not (OR 1.89; 95% CI 1.29 to 2.78). We also investigated testing in non-healthcare settings versus testing in healthcare setting, and the same factors were significantly associated with the outcome: being employed full time (OR 1.85; 95% CI 1.21 to 2.84) or part time (OR 1.94; 95% CI 1.05 to 3.58), having a managerial/professional occupation (OR 2.15; 95% CI 1.31 to 3.54), reporting UAIC (OR 1.75; 95% CI 1.26 to 2.43), as well as living in Perth (OR 1.84; 95% CI 1.30 to 2.60).
DISCUSSION Consistent with previous studies on preferences for alternative testing approaches,9 the main findings of this study suggest that rapid testing and/or testing in non-healthcare settings are highly preferred by GMSM, particularly those who engaged in risky sexual behaviours (UAIC) and/or having a busy lifestyle (employed full time and in professional or managerial occupations, making it difficult to take time off work) and hence a desire for testing convenience and rapidly accessible results. Three quarters of the participants expressed preferences for rapid testing over the current standard-of-care and more than half preferred to be tested in non-healthcare settings. Such preferences were not associated with previous history of testing, but rather seemed to be a product of pragmatic choice of convenience. Indeed, despite the cost of testing being covered by Australian Medicare scheme and availability of gay friendly providers, appointments for testing still need to be made (often during working hours), which makes testing services inconvenient to many GMSM. Internationally, alternative testing has already been successfully used in many settings,10 while the process of introduction of rapid testing in Australia has been slower. Despite high levels of testing in Australia,5 a substantial proportion (31%) of new HIV infections could be the result of transmissions from HIV-positive men who are not tested and unaware of their status.3 This group is important, and one Australian study has predicted that an increase in HIV testing rates could have substantial epidemiological benefits over time.3 However, men who are not engaged with HIV testing might have little understanding of current standard-of-care or alternative approaches or might not want to be tested due to other reasons. Although alternative testing intends to remove any perceived barriers to testing and provide more opportunities for tested, it may not necessarily address all reasons for why some GMSM are not being tested. Another Australian study has shown that the current Australian testing rates have already reached ‘saturation’, and any further increase in HIV testing rates could only be achieved by introducing alternative testing options.11 While preferences may not necessarily translate into the uptake of a service, introducing more convenient testing approaches could provide more choices for clients and may be an effective addition to HIV prevention strategy. We acknowledge limitations of this study. Our sample was recruited by peer referral and findings may not be generalisable to all GMSM. We did not have information to explore in detail the participant’s barriers to testing or costs associated with testing. The levels of preferences for different testing approaches may therefore not be indicative of their uptake if these approaches were currently made available. Participants’ awareness, prior knowledge and experience with alternative tests were also not assessed, which could potentially affect their responses about testing preferences. 593
Downloaded from http://sti.bmj.com/ on April 20, 2015 - Published by group.bmj.com
Health services research Table 1 Factors associated with preference for rapid versus non-rapid testing† and testing in healthcare settings versus testing in non-healthcare settings‡
Variable Age
