HIV testing should be promoted in school sex education classes and on Facebook

In order to reach those Australian gay and bisexual men who have never tested for HIV, innovative methods will have to be developed, Martin Holt and colleagues write in the online edition of AIDS and Behavior. Health messages delivered through gay community outreach and by clinicians will tend to reach men who have already tested.

The researchers’ analysis of the demographic and behavioural characteristics of men who have never tested suggests school and college sex education classes could play an important role. Moreover internet interventions, especially on social networking sites, can reach men with fewer ties to metropolitan gay communities.

In order to have an up to date understanding of men who have never tested or not done so recently, the researchers included relevant questions in a national, online survey of gay and bisexual men in Australia in 2008. The e-male survey was promoted through a wide variety of methods (adverts and links on relevant websites; promotion by gay and HIV organisations; flyers in gay venues; adverts in the gay media; adverts in the personal, adult or classified sections of local newspapers).

A total of 3457 men took part in e-male. However the analysis that is reported here excludes men who have ever tested HIV-positive. Moreover as only half the participants were asked the full set of questions on testing (the other half were given questions on other topics), the data here is of 1770 participants.

How many men have tested?

HIV testing is generally considered to be far more common among Australian gay and bisexual men than among men in other countries, including the UK. However this understanding comes from surveys conducted at gay community events and gay venues. For example, in the 2009 Gay Community Periodic Surveys, 87% had ever been tested and 60% had done so in the past year.

Such surveys are likely to under-represent younger men, non-gay identified men and men living in rural or remote areas, whereas online surveys tend to recruit more of these men. Indeed, one in five e-male respondents identified as bisexual or heterosexual.

In this sample, 72% of the participants had ever been tested for HIV and 28% had never been tested. Around half the men (48%) had tested in the last twelve months.

To put this in context, back in 2001-2002, a representative survey of Australian adults had found that 77% of gay men and 71% of bisexual men had ever tested. Furthermore, the Gay Community Periodic Surveys have found testing rates to be stable over the past decade.

The rest of the analysis considered the profiles of the men who had never tested and recently tested in the e-male study.

Never tested

Men who had never tested, compared to men who had tested more than twelve months ago, tended to be younger and have lower levels of education.

Moreover, they had fewer gay male friends and were less likely to seek sexual health advice from a gay community or HIV organisation. This confirms previous findings which suggest that men who are more attached to the gay community are more likely to test.

Untested men were also much less likely to seek sexual health advice from a doctor or nurse.

The researchers believe that these findings suggest that the promotion of HIV testing through gay venues, gay social networks and clinicians will fail to reach men who have never tested. They argue for school and college based sex education as an alternative.

Untested men tended to spend more time using Facebook and other social networking websites. The researchers note that “The internet is particularly good at reaching those men who have not been tested for HIV and who may be geographically or socially distant from metropolitan centres of gay community activity.” They recommend that health promotion messages about testing should be placed on social networking sites, especially those which allow advertisers to target male and same-sex-attracted users.

Men who had had unprotected anal intercourse with a regular male partner in the past six months were more likely to have tested. The researchers consider that this is probably due to HIV testing being used to inform decisions about condom use in relationships.

Men who had never tested were more likely to agree with the idea that HIV-negative men should disclose their HIV status before sex. While more men expected HIV-positive men to disclose their status, this belief did not distinguish non-testers from testers.

Moreover other factors such as unprotected anal sex with casual partners or use of particular venues were not significantly associated with having been tested or not.

Recently tested

Men who had tested in the past year, compared to men who had tested more than a year ago, were more likely to have a larger numbers of gay male friends and to have attended a pool, beach or gym used by gay men in the past year, reinforcing the association of HIV testing and gay community attachment. On average, they also had more sexual partners.

Men testing in the past year were younger (mean age 35) than men who had tested more than a year ago (mean age 39). On the other hand, men who had never tested were younger still (mean age 30).

Recent testers were more likely to have ever sought advice or information on sexual health from a doctor or nurse.

Moreover these men were more likely to expect that HIV-negative men should disclose their status before sex. They were also more likely to report HIV disclosure to or from some of their casual male partners in the last six months. The researchers comment: “This appears to indicate that as HIV disclosure becomes more common between casual male partners in Australia, MSM who engage in HIV disclosure (or rely upon it as a way to assess HIV transmission risk) may be increasing the frequency with which they get tested for HIV”.

Other factors did not distinguish recent testers from other men in the multivariate analysis.

Comparison with the UK

In the 2008 United Kingdom Gay Men’s Sex Survey, 68% of respondents had ever tested, and 44% had tested in the past year. (These figures exclude men with diagnosed HIV).

Although there are important differences between the two samples, it remains possible that the numbers who have ever tested in the UK and Australia are not as dissimilar as is often thought.

In the UK survey, a number of the same factors are also associated with ever testing for HIV or having done so recently - older age, more education and more sexual partners.

In addition, the UK study found that men who had sex with both men and women were less likely to test. While a similar finding was initially found in the Australian study (and large numbers of bisexual men took part), this did not remain a significant factor in the multivariate analysis - which provides the most reliable results.

Moreover in the 2006 UK survey, men who had never tested were more likely to expect HIV-positive men to disclose their status before sex. Again, this was found in the Australian raw data, but not in the multivariate analysis.