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The aim of improving uptake of HIV testing is threefold: to reduce the proportion of undiagnosed HIV infection within the community; to ensure early access to treatment for those found to be infected; and to limit further transmission.1 Little research has occurred within the United Kingdom to understand reasons why patients decline an offer of HIV testing. An aim of this study was to identify factors that would persuade patients who declined to have an HIV test, to test in an inner city sexual health clinic with a universal HIV testing policy.
We conducted a prospective questionnaire based survey of all patients of unknown HIV status presenting over a 2 month period. All patients who saw a doctor, except those attending for follow up, were invited to participate.
In all, 585 (49.4%) questionnaires were returned. There were no significant differences between responders and non-responders in terms of sex, age, STI, or HIV prevalence. Forty two per cent of all eligible patients reported that they were having an HIV test. Half (51.6%) of the patients who did not test for HIV reported that they felt at low risk of HIV as a reason for not testing. The second and third most common reasons were “being too scared of the result” (19.1%) and “not wanting to know” (14.2%). Reported sexual behaviours, previous STI diagnosis, and STI prevalence for patients who reported not testing because they considered themselves at low risk of HIV, were compared with patients who gave other reason(s) for not testing (table 1). In general, those who felt themselves to be at low risk of HIV tended to report fewer sexual risk behaviours.
In all, 198/225 who were not testing reported at least one situation that would make them consider testing. The main situations for which they would “very likely” consider testing were if a partner or ex-partner was HIV positive (97.1%, 95% CI: 93.2 to 99.1). Two thirds (63.6%, 95% CI: 52.7 to 73.6) of woman were “likely” or “very likely” to test if they became pregnant. The availability of medicines to treat HIV would make half (49.2%, 95% CI: 35.7 to 61.3) “likely” or “very likely” to test, while a cure for HIV would make two thirds (69.1%, 95% CI: 56.4 to 79.1) “likely” or “very likely” to test.
Overall, the analysis of reasons not to test and patient’s appreciation of risk suggests people test as a response to behaviour and are aware of the risks. However, a substantial proportion of patients perceiving themselves at low risk, the principal reason for not testing, did have significant risk factors (for example, 36.1% reported unprotected sex with two or more partners in the past year, 46.3% had a previous STI diagnosis, and 9.6% a current STI diagnosis). Although participants appeared to be largely aware of the risks associated with their behaviours they did not appear to be aware of many of the benefits of testing. A substantial proportion of patients appeared unaware of the benefits of testing in terms of pregnancy or the availability of medicines to treat HIV. In the age of effective antiretroviral therapies, approximately half of patients not testing were “likely” or “very likely” to test if medicines were available to treat HIV. Promoting the benefits of combination antiretroviral therapies may significantly increase uptake of HIV testing.
We thank RF and RP for help with design of the questionnaire; the authors acknowledge with considerable gratitude the efforts of staff at Archway Sexual Health Clinic for their enthusiasm in implementing this study.
Contributors FB and STS conceived and designed the study, helped to analyse and interpret the data, drafted and revised the article; CHM analysed the data and helped draft and revise the article; DM helped in study conception and design, and revision of the article; BC and PK helped in design of the study and final revision of the article.
Sources of support: Funding for data entry from Archway Sexual Health Clinic.
Conflict of interest: none.