A programme in which cheap, 30-minute HIV tests were offered in local pharmacy shops in three Spanish regions, diagnosed over 200 new infections, amounting to 10.6% of all HIV diagnoses in the three regions during the study period.
The programme was particularly successful at reaching heterosexual men, who amounted to nearly half of those who tested. Seventy per cent of the more than 50 heterosexual men who tested HIV-positive had never taken a test before, with HIV prevalence in heterosexual men higher in non-testers than previous testers.
HIV prevalence in the gay men who tested was 40% higher than in regional estimates of HIV prevalence.
The testing programme
Spanish pharmacy shops are small, usually family-run businesses with local catchment areas (legislation in Spain forbids pharmacies being owned by retail chains). It was thought that as trusted local professionals, pharmacists were in a good position to suggest and provide HIV testing.
A programme of pharmacy-based rapid testing (using the Determine1-2 fingerprick test) was therefore set up in three Spanish regions: the Basque country, Castilla y León and parts of Catalonia, mainly in suburban towns surrounding Barcelona and Tarragona.
The three regions are very different: the Basque country is densely populated and traditional urban working class, the Catalonian towns are low-income suburbs with a high immigrant density, while Castilla y León is rural and sparsely populated. The latter has no specific HIV testing services or clinics, with testing done in primary care.
Seventy-four pharmacies took part altogether. For a negative result, the test took 30 minutes: if it was reactive, people were sent to a local clinic or hospital for confirmatory testing (the Determine test used is over 99% specific, but this does imply some false-positives). To take a test cost €5 in Castilla y León and the Basque country and €10 in Catalonia.
The programme received widespread press publicity in advance and ran from 2009 to 2013.
Results
During this time, a total of 24,151 people took an HIV test at the pharmacies, of whom 226 (0.94%) were diagnosed with HIV.
Of those who tested, 46% were heterosexual men, 14% gay men and 27% women.
Of those who tested positive, 52% were gay men, 23% heterosexual men and 15.5% women with 2% classed as people who inject drugs and 9% not classified. This leads to an estimate of 3.4% prevalence in gay male testers and 0.5% in heterosexual men and women. Notably, gay men formed a higher proportion of those who tested positive – 40% more – than would have been anticipated by regional prevalence estimates.
Seventy-four per cent of the heterosexual men who were diagnosed, and 34% of the gay men, had never taken an HIV test before: conversely, 21.5% of the gay men had taken a previous HIV test within the last year.
Over a third of testers, and 43% in Castilla y León, were under 30 years old. A higher proportion of those diagnosed were under 30 in Catalonia than elsewhere. Castilla y León had a notably higher HIV prevalence among both gay men (4.6%) and heterosexual men (0.9%) than other regions. Castilla y León also had the highest proportion of people who had never tested before, at 59%.
Nearly 10% of testers were not Spanish citizens. Five per cent of testers were of Latin American origin, but they formed 15% of those who tested positive. Only 0.5% of testers were from sub-Saharan Africa and 1.5% of those who tested positive.
HIV prevalence in women who tested was also twice as high in Catalonia, at 0.8%, than in the other regions: this region may include a high proportion of poor or foreign-born women who use other health services less or simply find pharmacies more friendly.
Conclusions
This is by far the largest HIV testing programme ever conducted using local pharmacies. There have been pharmacy-based initiatives, such as one in the US where 22 Walgreens pharmacy stores offered free HIV tests to 900 people in the three days before national HIV testing day. However the researchers could not find more than 5000 people who had ever taken HIV tests in pharmacy-based programmes before.
The researchers comment that with nearly 11% of all diagnoses within the regions performed, and with especially high uptake in heterosexual men and young gay men, pharmacy-based testing offers a particularly valuable addition to other testing programmes, at least in the Spanish context, and may be particularly suitable in areas without large cities and with no specific HIV testing services.
Fernández-Balbuena S et al. Widening the access to HIV testing: the contribution of three in-pharmacy testing programmes in Spain. PLoS ONE 10(8): e0134631. doi: 10.1371/journal.pone.0134631. 2015.