UK sexual health clinics may be missing recent HIV infections in gay men

Sexual health clinics in the UK can do more to reduce the number of gay men with undiagnosed primary HIV infection, a study published in the online edition of Sexually Transmitted Infections suggests.

Although the study found that 86% of gay men attending sexual health services were being offered an HIV test, and that 82% of these men accepted a test, there were a range of reasons why clinics were not offering tests. One of these was the presence of risky sex within the “window period” for the development of HIV antibodies. This period can last up to three months. But the investigators note that this practice could mean that patients with recent HIV infection and high infectivity are being missed, particularly as newer HIV testing technology is now able to detect very recent HIV infections.

Surprisingly the investigators also found that clinics were more likely to offer tests to individuals attending for routine sexual health screens than to patients who were seeking care because they had symptoms of a sexually transmitted infection, even though the presence of such symptoms can be a good indicator of recent HIV risk activity.

Gay men remain the group most at risk of HIV infection in the UK. But it is thought that as many as a third of all HIV cases amongst gay men are undiagnosed, and there is good evidence that significant numbers of men with undiagnosed HIV are leaving sexual health clinics without such infection being diagnosed.

Late diagnosis of HIV is a concern at both a public health and individual level: patients with undiagnosed HIV are thought to be more infectious, and late HIV diagnosis is the underlying cause of much of the HIV-related illness and death seen in the UK. Reducing the number of late HIV diagnoses in the UK has been identified as a priority by the UK government and clinicians and as part of this strategy gay men attending sexual health clinics should now be offered annual, opt-out HIV tests.

Several studies have looked at the factors associated with the offer and acceptance of an HIV test to and by gay men. These studies suggest that clinic testing policy, waiting time for results, perceptions of risk and behaviour, age and ethnicity are all important.

To gain a better understanding of these issues investigators designed a cross-sectional or snap shot study. The aim was to determine the proportion of men being offered and accepting a test, and to describe the factors associated with the offer and acceptance of an HIV screen.

There are 238 sexual health clinics in the UK and questionnaires were sent to each requesting details of sexual health consultations with the first ten - 30 gay male patients seen in the week beginning February 7^th 2005.

A total of 189 clinics participated in the study and provided details for 2,162 patients. Half of these individuals were new patients, 38% were re-attending and 12% were attending for follow-up appointments. Median age was 32 years and 82% of patients were white.

All the clinics reported offering an HIV test to gay men attending for their first sexual health appointment. However, only 61% said that they routinely offered tests to gay men who were re-attending.

Overall, 86% of gay men were offered an HIV test, this included 97% of new patients, 86% of patients who were re-attending, and 39% of those attending for follow-up appointments.

Reasons for not offering an HIV tests included: negative HIV test in the last three months (39%); patient declining the previous offer of an HIV test (6%); HIV risk activity was within the window period (5%); no new risks since last test (5%); and the patient of low perceived risk (4%).

The investigators found that patients attending for a routine sexual health screen were three times more likely to be offered an HIV test than those attending because they had symptoms of a sexually transmitted infection. (p < 0.01). An increasing number of partners increased the likelihood of an HIV test being offered (p < 0.01) as did a report of unprotected anal intercourse (p < 0.01).

Overall, the offer of an HIV test was accepted by 82% of men, including 84% of new patients and 79% of re-attenders.

Commonly reported reasons for refusing an HIV test were: HIV risk activity was within the “window period” (23%); low self-perceived risk (13%); anxiety about the result (11%); and deferral of testing to a later date (9%).

Patient characteristics significantly associated with accepting a test included routine attendance rather than seeking care for specific symptoms (p < 0.01), younger age (p < 0.01), increasing number of partners (p = 0.05), and shorter waiting time for results (p = 0.02).

Patients reporting unprotected anal sex in the previous three months were 81% more likely to request an HIV test than patients who reported never having unprotected anal sex. In addition, patients who had had unprotected sex more than three months ago were some 62% more likely to request a test than patients who had never had unprotected sex.

“This is the first national study of this kind and the aim was to aim was to examine rates of HIV testing and factors associated with offer an uptake of HIV testing among men who have sex with men. The data show that rates of offer and uptake are high”, write the investigators.

But the investigators do have concerns, particularly that patients with symptoms of sexually transmitted infections, which could indicate recent HIV risk activity, are less likely to be offered a test than individuals attending for routine screens.

The investigators are also concerned that patients were not being offered HIV tests because their risk activity was within the “window period.”

Both these reasons for not testing could, the investigators fear, lead to individuals with recent HIV infection, and a high risk of transmission to others, remaining undiagnosed.

Five recommendations are made by the investigators:

• All clinics should have written policy regarding HIV testing for gay men.
• All clinics should consider offering opt-out testing.
• Gay men re-attending clinics should be routinely offered an HIV test, at least annually.
• Patient attending with symptoms, reporting recent sexual risk, or within the “window period” should be encouraged to test at their first visit and be given appointments for retesting outside the window period.
• Waiting times for test results should be kept to a minimum.