Where would gay men prefer to take their next HIV test?

Among English gay men who have never previously taken a test for HIV, self-testing and self-sampling are the most popular options for a future HIV test, but a significant proportion would use a sexual health clinic, the best-established site of HIV testing in the country. Men with higher levels of sexual risk (who tend to test more often) would be most likely to return to a sexual health clinic, but there is interest in self-testing too.

The data are published this week in BMJ Open. Some of the same researchers have also published a qualitative study this week in PLOS One on the acceptability of self-testing, highlighting the importance of test accuracy when comparing different self-testing kits.

The first set of findings come from the 2014 Gay Men’s Sex Survey, focusing on men living in England who had never been diagnosed with HIV. There were 14,317 men included in the analysis.

While three-quarters of men had previously taken an HIV test, the researchers were particularly interested in men who did not test regularly. Analyses focused on the 26% of respondents who had never taken an HIV test and the 46% of respondents who had not tested in the past year.

Profile of men who do not test

Men under the age of 20 were less likely than men in their twenties or thirties to test. As age increased, the number of men who had never tested declined, but so did the frequency of testing. Men with lower levels of education were less likely to have tested recently or to have ever tested.

All participants were men who have sex with men, but men identifying as ‘straight’ or ‘bisexual’ were much less likely to test than men identifying as ‘gay’.

Rates of testing were lower in white men than in men of other ethnicities, and lower in men born in England than in men who had moved there from other countries.

The men who were most likely to have tested for HIV were men who had had sex without a condom with at least two non-steady sexual partners in the past year. In this group, 73% had tested in the past year. Nonetheless, only 60% had tested in the past six months, which may be a more appropriate frequency for men with this level of sexual risk.

Preferences for future HIV tests

Men were asked where they would most like to take an HIV test in the future. Only 1% of men who had never tested said that they will not test in the future, indicating that HIV testing is broadly acceptable.

Among men who had never tested, the most popular options were:

• Self-sampling or self-testing: 32%
• Sexual health clinic: 31%
• General practice: 22%
• Community testing service (in a bar, club, sauna or mobile unit): 8%
• Private practice: 6%

There was less diversity in preferences in men who had previously tested. Over half (56%) would attend a sexual health clinic, while 21% would prefer self-sampling or self-testing. Some men were also interested in community testing (10%), general practice (9%) or private practice (2%).

Benefits and drawbacks of self-testing

In a separate study, 47 men who have sex with men took part in focus group discussions on HIV self-testing, in late 2015. The researchers ensured that men living in rural areas, men who did not identify as gay, men who did not test regularly and men who had already used self-sampling or self-testing were among those taking part. During the focus groups, self-testing kits manufactured by OraQuick and BioSure were demonstrated.

Self-testing was acceptable to most participants. Its primary perceived benefit was to be appropriate for individuals concerned about privacy and confidentiality. Men often talked about it being useful for ‘other men’, especially men who were not open about their sexuality, rather than for themselves.

Men also appreciated the convenience of self-testing. The ability to test when and where they wanted was highly valued, especially by men living outside of large cities. A man living in Cornwall explained some barriers to attending a sexual health clinic:

“Well for me it’s an hour to drive here [Plymouth], and hour to go to Truro. Newquay is an option, and then that’s only certain mornings of the week and then it’s taking time off work to go, so it does get quite tricky.”

Many men thought that this convenience could allow men to test more frequently.

Some men worried about their ability to accurately perform a self-test and interpret the test result. Many felt that the written instructions provided with the self-testing kits were unnecessarily complicated. This generated some confusion and anxiety.

Men were also worried about handling a reactive/positive result on their own.

“If you do self-test and the results are positive, there’s the trauma as well of that, that person being by themselves having tested themselves and found out they’re positive.”

This was often a concern for men who took more sexual risks. Some men suggested that they would only use a self-test if they felt there was very little chance of getting a positive result.

A number of participants, particularly those with more sexual risk behaviour, expressed concerns about separating HIV testing from sexual health clinics. This could mean that sexually transmitted infections would not be promptly diagnosed and men would miss the advice and support that clinic staff provide.   

Preferences for self-testing kits

During the focus groups, men were also asked to consider several different potential characteristics of self-testing kits and interventions: sample type, window period, format for instructions, and how a kit could be obtained. It’s worth noting that participants may have been made aware of the potential importance of an issue by the researchers’ prompts.

Participants discussed their preferences and which were most important to them.

In all the focus groups, the window period was the most important element, with a 4^th generation test and a four-week window period seen as the gold standard. The fact that the OraQuick and BioSure devices are 2^nd generation tests and have a 12-week window period undermined the other benefits of self-testing for many participants.

“I guess you don’t want it to be ‘oh crap, things went a bit crazy last week and I'll get this now and do it and oh this is a negative’ and find that actually it’s much more like twelve weeks… I could imagine [using self-testing] but only if I could get a test [where the] window period was as good as a clinic test.”

In contrast to some other studies, most men preferred tests using blood samples – they were believed to be more accurate than saliva samples. The exception was a few men who had an aversion to blood or needles.

Other characteristics were considered less important than window periods and sample type. Having tests kits sent through the post was seen as more convenient than picking them up from a healthcare or retail setting. Most participants would be unwilling to pay for a self-test. There was a slight preference for video rather than written instructions on how to perform a test.

The researchers think that men are unlikely to use self-testing as their primary testing method, due to concerns about test accuracy and being disconnected from clinical services. “Therefore, when designing interventions, HIV self-testing should be considered a supplementary option which can increase the ability of individuals to test frequently while potentially diverting lower risk individuals from clinical services,” they write.