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Health services research
Original article
Audit of HIV testing frequency and behavioural interventions for men who have sex with men: policy and practice in sexual health clinics in England
  1. Monica Desai1,3,
  2. Sarika Desai1,
  3. Ann Kathleen Sullivan2,
  4. Malika Mohabeer2,
  5. Danielle Mercey3,
  6. Margaret A Kingston4,
  7. Caroline Thng4,
  8. Sheena McCormack5,
  9. O Noel Gill1,
  10. Anthony Nardone1,
  11. On behalf of GUMNet
  1. 1HIV & STI Department, Health Protection Agency, London, UK
  2. 2John Hunter Clinic for Sexual Health, Chelsea & Westminster Hospital NHS Foundation Trust, London, UK
  3. 3Mortimer Market Centre, Central and Northwest London NHS Foundation Trust, London, UK
  4. 4The Manchester Centre for Sexual Health, Manchester Royal Infirmary, Manchester, UK
  5. 5Medical Research Council Clinical Trials Unit, London, UK
  1. Correspondence to Dr Monica Desai, HIV & STI Department, Health Protection Agency, 61 Colindale Ave, London NW9 5HT, UK; desai.monica{at}gmail.com

Abstract

Background National guidance recommends targeted behavioural interventions and frequent HIV testing for men who have sex with men (MSM). We reviewed current policy and practice for HIV testing and behavioural interventions (BI) in England to determine adherence to guidance.

Methods 25 sexual health clinics were surveyed using a semistructured audit asking about risk ascertainment for MSM, HIV testing and behavioural intervention policies. Practice was assessed by reviewing the notes of the first 40 HIV-negative MSM aged over 16 who attended from 1 June 2010, in a subset of 15 clinics.

Results 24 clinics completed the survey: 18 (75%) defined risk for MSM and 17 used unprotected anal intercourse (UAI) as an indication of high risk. 21 (88%) offered one or more structured BI. Of 598 notes reviewed, 199 (33%) MSM reported any UAI. BI, including safer sex advice, was offered to and accepted by 251/598 (42%) men. A low proportion of all MSM (52/251: 21%) accepted a structured one-to-one BI as recommended by national guidance and uptake was still low among higher risk MSM (29/107: 27%). 92% (552/598) of men had one or more HIV test over a 1-year period.

Conclusions In 2010, the number of HIV tests performed met the national minimum standard but structured behavioural interventions were being offered to and accepted by only a small proportion of MSM, including those at a higher risk of infection. Reasons for not offering behavioural interventions to higher risk MSM, whether due to patient choice, a lack of staff training or resource shortage, need to be investigated and addressed.

  • HIV
  • Behavioural Interventions
  • Prevention

https://doi.org/10.1136/sextrans-2012-050679

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    Introduction

    Men who have sex with men (MSM) account for the largest number of new HIV diagnoses acquired in the UK,1 and an increasing proportion report sexual behaviour at higher risk of HIV infection.2–4 There are no national longitudinal studies characterising the distribution and changes of HIV risk among MSM. There are limited data on which to base risk assessment and prediction models to identify those at the highest risk of HIV infection.5

    Over the past decade, several guidelines on interventions6–8 to reduce the risk of HIV acquisition, particularly among MSM, have been published. The National Institute for Health and Clinical Excellence (NICE) advocates 15–20 min one-to-one structured discussions by health professionals trained in sexual health (SH) to address risk-taking reduction with high risk individuals including all MSM.6 The guidance does not stratify MSM into risk strata for behavioural interventions. Furthermore, there has been no systematic assessment of uptake of these recommendations in SH clinics.

    National guidance recommends at least annual HIV testing for MSM.8 National audits examined the proportion of MSM offered and taking up an HIV test,9 ,10 and surveys have investigated the association between recent HIV testing and HIV infection.11 To our knowledge, there has been no national analysis of frequency of HIV testing or characterisation of behavioural interventions offered in SH clinics.

    We audited first HIV testing and behavioural intervention policies for MSM in a sample of SH clinics, and determined how clinics defined MSM at high risk of HIV infection. Second, we audited HIV testing and behavioural intervention practice for MSM through a note review in a sample of SH clinics.

    Methods

    All 26 GUMNet clinics in England were invited to contribute to this audit, in which 25 participated in the policy and 15 in the notes audit. GUMNet is a sentinel network of 29 SH clinics in England (26), Wales (two) and Northern Ireland (one) coordinated by the Health Protection Agency for public health monitoring of HIV and sexually transmitted infections (STIs). Questionnaires were developed inhouse using Select Survey and piloted in three clinics prior to rollout of the audit.

    Policy audit

    The policy audit surveyed clinical leads of all participating clinics in July 2011, and asked specifically about policies for MSM of a negative or unknown HIV status. An online questionnaire collected data about clinics’ behavioural intervention protocol, HIV testing protocol, formal risk assessment criteria and service provision (eg, HIV testing and behaviour change clinics). Missing data were then collected via telephone interview.

    Notes audit

    In all, 15 GUMNet clinics in England volunteered to take part in the notes audit (eight from London and seven from outside of London). Each clinic audited the records of the first 40 consecutive MSM who attended the clinics from 1 June 2010.

    Inclusion criteria were a new episode of care of an MSM (as defined by local clinic policy) aged 16 or over who was HIV negative or of unknown status at that clinic visit. Attenders known to be or who self-reported being HIV positive were excluded. Those attending follow-up appointments were excluded. The clinic extracted information from patients’ records on: sexual risk behaviours, the behavioural intervention offered and whether it was accepted, reason for offering HIV test and HIV testing frequency in the 12 months subsequent to the initial visit. No patient-identifiable information was collected, and all data were handled in line with Caldicott guidance.12

    Analysis

    Associations between behaviours and behavioural intervention offered were investigated using χ2 test. For the notes audit, men who had unprotected anal intercourse (UAI) in the last 6 months were considered to be at high risk for HIV infection. Data analysis was performed using Stata V.11 and MS Excel.

    Results

    Policy audit: risk assessment

    Responses were received from 24 of 25 (96%) clinics. A total of 20 clinics (83%) had a written HIV testing policy, 11 (46%) had a written behavioural intervention policy and 20 (83%) had a risk assessment pro forma.

    Six clinics did not categorise MSM into risk strata for HIV infection. Four of these clinics considered all MSM to be at higher risk of HIV infection and two had no documented criteria for categorising risk.

    Overall 18 (75%) clinics reported criteria to categorise HIV-negative/unknown status MSM as being at higher risk of HIV infection, of which 17 (94%) used a report of UAI to define those at higher risk of HIV infection (table 1). The time periods most commonly considered were ‘since last negative HIV test’ in 7 (41%) clinics and ‘within the last 3 months’ in 5 (29%) clinics.

    View this table:
    Table 1

    Criteria used by clinics to categorise MSM as at higher risk of HIV infection

    A quarter of clinics considered two partners or more over a 3-month time period as criterion for higher risk. In all 13 (54%) clinics considered previous STI infection as criterion for higher risk. The greatest proportion of these clinics looked at STI infection since last negative HIV test (9/13: 69%), followed by STI infection in the last 3 months (4/13: 31%).

    Policy audit: behavioural interventions

    The policy in all clinics was to offer safer sex advice to MSM regardless of risk and all doctors, nurses and health advisors were trained to provide this through either formal (15/24: 63%) or informal (24/24: 100%) training.

    In all 21 clinics (88%) offered at least one type of structured behavioural intervention, and 14 (58%) offered two or more interventions. A total of 20 (83%) clinics offered motivational interviewing (table 2), of which 14 (70%) only offered it to MSM they considered to be at high risk of HIV infection. In all clinics, health advisors were trained to provide motivational interviewing with fewer doctors and nurses trained in the technique. Formal training in motivational interview technique was provided in 18 (90%) clinics that offered motivational interviewing.

    View this table:
    Table 2

    Structured behavioural interventions offered to MSM by clinics inhouse

    A total of 13 clinics (54%) offered counselling to MSM inhouse and 11/24 (46%) of these clinics formally trained staff in counselling. Nine (38%) offered psychological therapy provided by formally trained specialists. Eight (33%) offered cognitive behavioural therapy (CBT) inhouse; in three of these clinics between 20% and 50% of health advisors were formally trained in CBT techniques; in six clinics CBT was provided by trained psychologists. No clinics reported offering peer education or structured group work.

    Policy audit: HIV testing

    In practice, all clinics offer 4th generation serology HIV testing8 to all MSM. A total of 10 (42%) clinics offer 3rd generation antibody only point of care testing (POCT), primarily to high risk groups without a risk exposure in the last 3 months (4/24: 17% clinics). Combined antigen-antibody POCT was offered as the first line test by one clinic. In the remaining nine clinics that offered combined antigen-antibody POCT, the test was offered in the main as an initial confirmatory test for a positive antibody only POCT.

    Almost all (23/24: 96%) clinics invited MSM back for a repeat HIV test if they had reported a recent risk behaviour in the last 3 months in addition to the baseline test. Overall 19 of these 23 clinics (83%) invited MSM back for the repeat HIV test within a 3-month period, 3/24 (12%) invited patients back 6 months later and 1/24 (4%) invited patients back after a year. A total of 13 (54%) clinics had dedicated HIV testing clinics; over half (7/13:54%) were available daily.

    Notes audit: risk behaviour

    A total of 598 notes were reviewed from 15 clinics. The average age of men whose notes were reviewed was 34 years (range 16–77, IQR 25–40), and 76% were of white ethnicity.

    In all, 33% (199/598) of men reported UAI in the last 6 months; 10% (62/598) exclusively receptive UAI, 7% (43/598) exclusively insertive UAI and 16% (94/598) both insertive and receptive UAI. Overall 10% of men had been offered postexposure prophylaxis (PEP) in the last year (59/598); 51 men had been offered PEP once and eight had been offered PEP twice in the past year.

    Notes audit: behavioural intervention

    The offer of any behavioural intervention (including giving advice) was recorded for 293 individuals (49%) and was accepted by 251 (86%) of those offered the behavioural intervention. Of those who were recorded as having been offered and accepted a behavioural intervention, 234/251 (93%) accepted advice. However, a much lower proportion (52/251: 20.7%) were offered and accepted a structured behavioural one-to-one intervention as recommended by NICE, the most common being counselling which was offered to and accepted by 37/251 (14.7%) of men (table 3). In the eight clinics with a written policy on behavioural interventions, only 7% of all MSM were offered and accepted a structured behavioural intervention. This proportion rose to 20% in the four clinics with an unwritten policy but was zero in the three clinics without a policy.

    View this table:
    Table 3

    Behavioural interventions taken up by MSM who did or did not report UAI in the last 6 months

    The commonest reasons for offering behavioural intervention was that all MSM should be offered a behavioural intervention according to clinic policy (159/293: 54%) and that the patient was considered to be high risk (118/293: 40%); other reasons included diagnosis of an STI (44 patients), at patient request (nine) or not recorded (24). Where men declined a behavioural intervention (38/293: 13%), the reason was not recorded for 15 men (18/38: 47%), three men reported they did not have time (8%) and 17 (45%) felt that they did not need it (17/38:45%). Of men in this last group, 6/17 (35%) reported UAI in the last 6 months.

    Significantly more higher risk MSM who reported UAI were offered and accepted behavioural intervention than MSM not reporting UAI (54% vs 36%, p=0.0013; table 3).

    Notes audit: HIV testing

    A total of 549 men (91.8%) were offered a HIV test, of whom 507 (92.3%) accepted; 99% of tests were negative. Overall 46 men (7.7%) were not offered an HIV test; the most common reason was that the patient was not considered by the healthcare worker to be at risk of HIV (12/46: 26%), although one of these patients reported insertive UAI with a casual partner in the last 6 months.

    Patients who were offered and accepted an HIV test had a mean of 1.6 HIV tests (median=1, range 0–10) over the 1-year audit period, which included the audited HIV test. Patients had an average of 0.6 further HIV tests in the subsequent year with 43% having one or more further tests. This was the same for higher risk men who had UAI in the last 6 months. However, significantly more men who did not report UAI in the previous year did not have a further HIV test.

    Discussion

    We report the first audit, in a subset of English SH clinics, of policies and practices in targeting of HIV testing and behavioural interventions to MSM including those at higher risk of HIV infection. The results indicate that although there is some agreement in assessment of risk behaviour by clinics, the offer of structured behavioural intervention does not always match the patient's risk of HIV infection and there is a low level of such interventions recorded as offered to and accepted by MSM, in particular to higher risk MSM.

    In the audit of medical notes, a third of all men reported UAI in the last year. This is higher than estimates from a community survey which found that 16% of HIV-negative MSM in London had UAI with one or more partner in the last 12 months,13 but lower than the UK Gay Men's Sex Survey 2010 in which 45% of MSM reported UAI in the last 6 months.14 This difference is likely attributable to differences in sampling frame—both surveys were carried out in the community—and the Gay Men's Sexual Health Survey sampled all MSM including HIV-positive men. Estimates suggest that between 18.6% and 41.7% of MSM have attended an SH clinic in the UK in last year, depending on the population sampled; notably higher reports of clinic use were found in samples of men attending gay men's bars.15 Men attending SH clinics have higher levels of self-reported sexual risk behaviour.16 ,17 Therefore, SH clinics afford an opportunity to target men engaging in high risk behaviours.

    In the policy audit, the commonest criterion considered by clinics for higher risk was UAI, most commonly in the period since last negative HIV test or in the last 3 months. Other factors, such as STI infection and alcohol use were less commonly considered. Our audit showed that risk assessment of MSM is not standardised across the UK, with some clinics not performing a formal risk assessment or treating all MSM as high risk. Several studies have identified a number of different behaviours associated with HIV infection including high risk sexual behaviour, previous history of STIs and drug and alcohol use.18 ,19 These factors have been used to develop prediction models.5 ,20 ,21 to identify those individuals at higher risk of infection and who might benefit from intensified prevention efforts. A standardised risk assessment is needed in UK SH clinics, and if validated as a tool predictive of HIV infection it could be used to target intensified interventions to men at the highest risk of HIV infection attending services.5 ,19

    Structured behavioural interventions for MSM attending SH services, one example being motivational interviewing, have been recommended by NICE and in 2012 by the British Association for Sexual Health and HIV and BHIVA.6 ,7 ,22 In the policy audit, the majority of clinics reported offering at least one structured behavioural intervention. However, the notes audit demonstrated that only a quarter of men who reported UAI in the last 6 months, and therefore considered to be at higher risk of HIV infection, were offered any structured behavioural intervention. Reasons for this difference may include lack of resources and training capacity and the short time period since publication of national guidance for significant changes in practice to be seen. Furthermore, the evidence for effectiveness of one-to-one interventions for prevention of STIs is mixed6 with often only a small impact observed;23 such interventions require intensive efforts and needed to be offered in combination for effective HIV prevention.24

    We found that a high proportion of the audited clinics had a written HIV testing policy and offered 3-month repeat testing. However, a sixth of clinics did not have a written HIV testing policy and almost a fifth of clinics did not invite men considered high risk for HIV infection for a repeat HIV test 3 months after risk behaviour. An audit of all SH clinics in the UK in 2008 reported only a quarter of clinics had a written HIV testing policy and a similar proportion had a system in place to recall MSM 3 months after last high risk sexual activity.10 This difference may be indicative of the major change in policy to increase HIV testing among MSM attending SH clinics and increasing evidence of the effectiveness of regular testing in identifying new diagnoses24 but may also reflect differences in sampling.

    In our notes audit, all MSM had an average of 1.6 tests per year regardless of risk. This complies with NICE guidance which recommends at least annual HIV testing for MSM to reduce undiagnosed HIV infection.8 Data returns to the Health Protection Agency from SH clinics show similar findings with 72% of MSM attending a SH clinic offered at least one HIV test per year and those that reattend SH clinics receiving on average 1.5 HIV tests per year (HPA unpublished).

    However, despite guidance for more frequent HIV testing,25 the little evidence there is on the acceptability, feasibility and effectiveness of increased recall frequency is conflicting.11 ,26 ,27 Therefore, further studies are required to determine optimal frequency of HIV testing.27

    Limitations

    The GUMNet clinics sampled may not be representative of SH clinics nationally and may have been more likely to offer repeat HIV tests and a wider range of behavioural interventions. This is reflected in the difference between our findings and those of Munro et al,10 who audited practice at all SH clinics in the UK and found a lower proportion of clinics with HIV testing policies and 3-month recall strategies.

    Low level documentation of the offer of behavioural interventions may have resulted in underestimating the provision of behavioural intervention. The policy audit suggests that advice is offered to all MSM; however, this was only recorded for 228/293 (78%) of men (table 3). We were unable to report refusal rates by intervention offered, and reasons for not offering or refusal were rarely recorded. However, the low recorded rate of offer of structured behavioural interventions suggests that even with under-reporting, there is a low level of provision of these behavioural interventions, in particular to higher risk MSM. We use uptake as a surrogate marker of acceptability, but a more indepth understanding of acceptability of structured behavioural interventions is needed.

    In the notes audit, we used UAI in the last 6 months as a marker of higher risk. This time period was selected in response to pilot study feedback and time intervals used in research literature.2 ,28 In light of our policy audit findings, it may have been better to determine risk of men in the last 3 months or since last negative HIV test. UK national guidance on sexual history taking recommends taking a 3-month history or noting the last time the patient had sexual intercourse if no partners are reported during the last 3 months.29

    In the notes audit, as detailed risk assessments were not consistent between clinics, we did not look in detail at types of UAI such as sero-adaptive behaviours, although such behaviours do have a high risk of HIV acquisition.30 We were unable to ascertain if perception of an individual's risk because of such sero-adaptive behaviours and subsequent offer of prevention services were properly matched.

    Conclusions

    The findings of our audit indicate that in 2010 the number of HIV tests performed met the national standard, there was some uniformity in risk assessment, but structured behavioural intervention was being accessed by only a small proportion of higher risk MSM. A standardised risk assessment based on a risk prediction model for the UK needs to be validated against HIV incidence data and could better allow interventions to be targeted to the highest risk groups. Reasons for not offering structured behavioural interventions to higher risk MSM need to be investigated and addressed.

    Key messages

    • In 2010, the number of HIV tests performed met the national standard of at least an annual HIV test for men who have sex with men (MSM).

    • Structured behavioural interventions were being offered to and accepted by only a small proportion of MSM, even those at higher risk of acquiring HIV infection.

    • Reasons for not offering behavioural interventions to higher risk MSM need to be investigated and addressed.

    • A standardised risk assessment in UK sexual health clinics could be used to target intensified interventions to men at the highest risk of HIV infection.

    Acknowledgments

    GUMNet clinics.

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    Footnotes

    • Collaborators On behalf of GUMNet: Alan McOwan (56 Dean Street), Liat Sarner (Barts and the London NHS Trust), Gillian Dean (Brighton and Sussex University Hospitals), Caroline Rae (Chelsea & Westminster Hospital NHS Foundation Trust), Gillian Wildman (Florey Unit Centre for Sexual Health), Sulaiman Zubayr (Gloucestershire Hospitals NHS Trust), Mayura Nathan (Homerton University Hospital), Linda Greene (Imperial College Healthcare NHS Trust), Melinda Tenant-Flowers (Kings College Hospital NHS Foundation Trust), Sarah Schoeman (Leeds Teaching Hospital NHS Trust), Thambiah Balachandran (Luton & Dunstable Hospital), Ashish Sukthankar (Manchester Royal Infirmary), Danielle Mercey (Mortimer Market Clinic), Nathan Sankar (Newcroft Sexual Health Centre), Tom McManus (Newham University Hospital), Lynn Riddell (Northamptonshire Healthcare NHS Foundation Trust), Chris Bignell (Nottingham University Hospitals NHS Trust), Siobhan Murphy (Patrick Clements Clinic), Christine Bowman (Royal Hallamshire Hospital), Philip Hay (St George's Healthcare Trust), Tariq Anjum (The Royal Wolverhamptom Hospitals NHS Trust), Judy Russell (Trafalgar Clinic for Sexual Health), Ken Mclean (West London Centre for Sexual Health), Christine Hardwick (Whittal Street Clinic), Emma Savage (Health Protection Agency, London) and Catherine Lowndes (Health Protection Agency, London).

    • Contributors MD: Devised and performed the audit, analysed the results and wrote and revised the drafts of the paper. SD: Involved in development of the audit tool, data collection, and reviewed and revised drafts of the paper. AS, MM, DM, MK, CT, SMcC, NG and AN: Involved in development of the audit tool and reviewed and revised drafts of the paper.

    • Funding No funding sought.

    • Disclaimer The views expressed are those of the authors.

    • Competing interests None.

    • Patient consent Not obtained as this is a clinical audit.

    • Ethics approval No ethical review was sought as this is a clinical audit.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing All data were handled in line with Caldicott guidance.