Objective Timely HIV testing among recently HIV-infected gay men may enable earlier access to clinical care and changes in behaviour that will reduce onward transmission. We investigated the testing practices of men recently diagnosed with HIV to identify factors associated with recent testing.
Methods In an online survey of men in Australia recently diagnosed with HIV, participants were asked about their HIV testing history, perceived impediments to testing prior to diagnosis, motivation for testing at the time of diagnosis and a range of demographic and behavioural characteristics. Descriptive statistics were used to compare those men who reported recent HIV testing with those men who had not tested for HIV in the 12 months before their diagnosis.
Results Of 187 men who provided information about their testing history and social connectedness, 6.4% were previously untested for HIV, whereas 65.8% had last tested within the 12 months prior to their diagnosis. Factors associated with having tested more recently were being more socially engaged with other gay men (OR 1.34; 95% CI 1.10 to 1.63; p=0.003) and having greater optimism about HIV health (OR 1.13; 95% CI 1.00 to 1.27; p=0.047). In multivariate analysis, only level of social engagement with other gay men remained independently associated (adjusted OR 1.30; 95% CI 1.07 to 1.59; p=0.003).
Conclusions Gay community plays a key role in the response to HIV in Australia. Building a sense of community through programmes that support social engagement between gay men may support earlier and more frequent testing.
- GAY MEN
- HIV TESTING
- HEALTH PROMOTION
- PUBLIC HEALTH
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Rates of HIV infection have increased significantly among gay men in Australia and internationally since the late 1990s.1 ,2 This has corresponded to a period of increases in rates of condomless anal intercourse with casual partners (CLAIC) among these men, which has been shown to be the strongest predictor of HIV incidence.2 HIV testing is critical to the control of HIV; early detection of infection enables timely access to appropriate care and support. Furthermore, successful viral suppression through the use of antiretroviral therapy (ART) has been demonstrated to reduce the risk of onward transmission to sex partners.3 Knowledge of HIV-positive status also provides men with the information they need to modify their behaviour to reduce the risk of infecting others.4
Australian guidelines recommend that all homo sexually active gay men test for HIV at least once every 12 months, whereas those men who engage in behaviours that might place them at higher risk of contracting HIV or other sexually transmissible infections should test more frequently.5 Data from Australia's behavioural surveillance among gay men show reasonably high rates of HIV testing, with almost nine in 10 (88.9%) men reporting having ever been tested for HIV.6 However, less than two-thirds (60.6%) of these men had tested in the previous 12 months.6 While these levels are higher than in some comparable settings, they still do not meet the recommended guidelines. A study of the rates of re-testing for HIV revealed that just one-third of men who, under the guidelines of the time, would be advised to retest each year were doing so, while only 15% of those men at greater risk, for whom the guidelines recommended six monthly testing, were doing so.7
For HIV testing to have a clear and direct impact on reducing new infections, men who engage in sexual risk behaviour should test frequently. Some men have adopted strategies to minimise the risk of HIV transmission, such as serosorting and strategic positioning during CLAIC.8 ,9 To be applied successfully, such strategies rely on accurate knowledge of HIV status.10 Men negotiating condomless sex on the basis of their last HIV-negative test result may be contributing to a significant proportion of new infections. Modelling estimates vary greatly, with anywhere between 40% and 90% of incident HIV being ascribed to transmission from those in the acute stage of HIV infection (during which high levels of viral load make an individual highly infectious). In many cases, an individual in acute infection is unaware of their HIV-positive status.11 ,12
Men who engage in potentially risky sexual practices, and men who are more socially engaged with other gay men have been shown to test at higher levels.13 Whereas younger men, those who live outside of metropolitan areas and those of non-European backgrounds are less likely to have been tested.14 In industrialised countries, including Australia, barriers to HIV testing reported by gay men include not believing they have exposed themselves to HIV, fear of receiving an HIV-positive result and lack of convenience.15–17
We investigated the testing practices of men recently diagnosed with HIV including their testing history, factors associated with a history of having ever tested or having recently tested. We also investigated the men's reasons for testing at the time of their diagnosis and any factors that may have contributed to the men delaying testing prior to their HIV diagnosis.
The HIV Seroconversion Study included an online survey of people in Australia who had been recently diagnosed with HIV.
Eligibility criteria for the study include: being over 18 years of age, living in Australia, and having been diagnosed HIV positive within the 2 years prior to enrolment. Prior to June 2010 participation was restricted to men. Enrolments occurred through four main sources: referrals from state and territory AIDS Council staff; referrals from state-based people living with HIV organisation staff; referrals from clinics, mostly sexual health services; or self-referral by individuals who found a link to the survey through a local gay community or HIV organisation website or through printed promotional materials available in sexual health clinics and community-based organisations.
In 2010, questions addressing testing prior to diagnosis, social connectedness to gay men and health optimism were introduced. From December 2010 to March 2013, the total number of respondents who reported that their HIV infection was due to homosexual contact was 259. Of these respondents, 187 provided complete information on the key variables described here (HIV testing history, social connectedness to gay men and health optimism). Analyses reported here were restricted to these 187 men for whom we had complete data. We compared these 187 men with the other 72 men in the sample who did not provide complete information on the items included in these analyses, on a range of demographic and behavioural indicators and found no statistically significant differences.
The questionnaire included demographic characteristics, time and place of participants’ HIV diagnosis and HIV testing history. Those who reported having a previous HIV test were asked how much time had passed between their last HIV-negative test and the test that returned their HIV-positive result. Those men who indicated that they had not previously tested for HIV and those whose previous test had been more than 12 months before their test at diagnosis were asked about reasons they had not tested in that time. All men were asked what had led them to test at the time they were diagnosed.
Several items from the online questionnaire explored beliefs about the consequences of an HIV infection; these were used to develop a scale to measure health optimism. These were based on earlier measures,18 with such items as ‘HIV is less serious than it used to be’ and ‘HIV treatments take the worry out of sex’. Responses were on a four-point scale ranging from ‘strongly disagree’ to ‘strongly agree.’ Scores were assigned where ‘one’ was least optimistic and ‘four’ was most optimistic. With this sample, an additional item ‘I'm less worried about HIV transmission than I used to be’ was included. With this added item, the scale was found to be more robust and reliable with an Cronbach α value of 0.711, a mean of 9.8 and an SD of 2.55.
We assessed men's degree of social connection to other gay men using two questions:6 how many of their friends were gay or homosexual men (‘None’, ‘a few’, ‘some’, ‘most’ or ‘all’) and how much of their free time was spent with gay or homosexual men (‘None’, ‘a little’, ‘some’, ‘most’ or ‘a lot’). Scores were assigned from zero to four, with responses added together to provide a scale with the range zero to eight. This scale has been used in Australian gay community research for more than 20 years6 ,19 and represents the extent to which the person's social life is lived in the company of gay male friends.
The quantitative data were analysed with SPSS software (IBM SPSS Statistics V.22.0, IBM Corporation, Armonk, New York, USA). Descriptive statistics were used to compare those men who reported recent HIV testing (within the 12 months prior to the test which led to their diagnosis with HIV) and those men who had not tested for HIV in the 12 months before their diagnosis. For univariate analyses, categorical variables were analysed using Pearson's χ2 test and ordinal variables were analysed using Spearman's correlation test. We used type I error of 5% for these analyses. To estimate statistical associations with prior HIV testing, we used logistical regression models and presented ORs and 95% CIs.
At the time of their HIV diagnosis the men ranged in age from 16 to 64 years old, with a mean of 34.4 years (table 1). The vast majority of the men identified as gay, and most were born in Australia. Over two-fifths (41.2%) reported that most of their friends were gay men and one-third (33.7%) reported spending most or all of their free time with gay men. Most men (93.6%) were able to identify the specific event that they believe had led to their HIV infection, with 71.7% reporting that this event involved condomless anal intercourse, including 62.6% who did so in the receptive position.
The vast majority of the men (93.6%) indicated they had had a prior HIV test which had returned a negative result, including two-thirds (65.8%) who had been tested within the 12 months prior to their HIV-positive diagnosis. Factors associated with having tested more recently were being more socially engaged with other gay men (OR 1.34; 95% CI 1.10 to 1.63; p=0.003), and having greater optimism in HIV health (OR 1.13; 95% CI 1.00 to 1.27; p=0.047). In multivariate analysis, only level of social engagement with other gay men remained independently associated (adjusted OR 1.30; 95% CI 1.07 to 1.59; p=0.003).
Those men who had not tested for HIV in the 12-month period before their diagnosis were asked why they had not been tested in that time. The two most common reasons men provided were being afraid of testing HIV positive and not having experienced any symptoms of seroconversion (table 2). Other men reported not testing because they did not believe they had put themselves at risk or they ‘didn't want to know’.
When asked about what had led them to be tested for HIV at the time of their diagnosis, men most commonly cited concerns about symptoms they were experiencing or they indicated that the test was part of their regular testing pattern (table 3). Few men, one in four men, reported that they were motivated to test due to concerns that they had engaged in behaviour that may have put them at risk of acquiring HIV, despite the fact that most of them reported having engaged in condomless sex on the occasion they believe had resulted in their HIV infection.
People who have been recently diagnosed with HIV potentially provide key insights into the reasons why those at risk might seek or avoid HIV testing. In this study, men who were more socially engaged with other gay men and those who were more optimistic about the health consequences of HIV infection were more likely to have been tested in the 12 months prior to their diagnosis with HIV. The men who had not recently tested were fearful of testing or were relying on symptoms of infection to prompt them to test. At the time of diagnosis, this test was most likely to be in response to symptoms, or as part of a regular pattern of testing.
Gay community has played an integral role in the Australian response to HIV; a history of engagement with the epidemic, combined with lived social experience has provided gay men with high levels of technical knowledge. Community ‘know-how’ and social practice play an important role in understanding and transforming technology into practice.20 Social support among and between gay men plays a role in shaping community norms around HIV, with men who perceive strong social support from their peers more likely to practice HIV-risk reduction behaviours and to consider regular HIV testing as part of their responsibility to the broader gay community.21 Being more socially engaged with other gay men, as indicated by the measure of social engagement used in these analyses, may facilitate transfer of knowledge about HIV, testing and the benefits of knowing one's HIV status.
In addition, greater social engagement with other gay men provides the opportunity for contemporary attitudes about testing and treatment to be considered and reinforced. Access to current information about developments in HIV treatments may be a precursor to developing and sustaining a more optimistic view regarding the health impact of living with HIV. Men with limited social engagement with other gay men have fewer opportunities to benefit from the knowledge and experiences of their peers. Their relative isolation from other gay men may inhibit them from gaining an understanding of the realities of what it means to live with HIV today, leaving them afraid to get tested and, consequently, delaying or avoiding testing.
The fact that few men reported having sought testing at the time they tested HIV positive because of concern that they had engaged in risk suggests a disjunction between many of the men's perceptions of HIV-risk practices and their actual sexual practices. Although educational tools are available to help men assess the risks involved in particular sexual practices,22 some men continue either not to access the information or alternatively to believe that it does not apply to them. Reminding men that symptoms do not always occur during early infection, as well as information that helps them recognise symptoms of HIV infection may increase testing rates.
From the outset, Australia's response to HIV has used community engagement and peer education to increase awareness of sexual health and use of sexual health services, playing a crucial role in community-based HIV prevention.23 ,24 These data support that approach, but suggest that additional support for HIV testing information targeting men with limited social contact with other gay men may be required to reduce the time between infection and diagnosis.
Until recently, HIV testing in Australia has typically involved venipuncture, with a 1-week waiting time for results.16 This need to return for a second visit to obtain results represents a barrier to some men: in a study conducted in one clinic in Sydney, over half of men tested did not return for their results.25 Recent policy changes now permit clinic staff to provide HIV-negative test results by phone, with, as yet, no adverse effects identified.26
Following a recent revision of Australia's national testing policy,27 rapid HIV tests have become available in a variety of settings, including clinics and community sites. A study of the use of rapid HIV tests in the USA revealed a 40% increase in testing rates.28 Modelling the predicted outcomes if rapid testing was widely used in the Australian context showed marginal benefit, when no adjustment was made for a change in testing frequency.29 However, gay men in Australia have expressed enthusiasm for access to rapid tests, citing their convenience as an incentive to test more regularly.30 Although self-testing has not been supported in the recent changes to HIV testing policy, the majority of a large sample of Australian gay men reported that they would likely test more often if they could test themselves at home.21
There are a number of limitations to these analyses. Due to the cross-sectional nature of the study, HIV testing and diagnosis data were gathered by self-report, and causal relationships cannot be determined. Although the men in this sample are similar to other samples of Australian gay men,14 ,18 there may be limited generalisability of these results outside of the Australian context, where rates of HIV testing may be different.
We sought to identify factors associated with recent previous HIV testing among a sample of recently HIV-diagnosed gay men. Our findings suggest that gay community peer networks continue to play an important role in the Australian response to HIV. The relationship between social engagement and HIV testing practices has implications for an engaged health promotion agenda. Interventions that reinforce positive attitudes to testing and treatment, highlight the improved health outcomes for PLHIV and establish more supportive environments for newly diagnosed individuals may encourage earlier and more frequent testing among men at risk for HIV infection, particularly those who with limited social contact with other gay men. The barriers to HIV testing described by the men in this study could be lessened to some extent through community development and peer education interventions.
Recently diagnosed men who were more socially engaged with other gay men were more likely to have had a recent HIV test, prior to their diagnosis.
Not experiencing symptoms and being afraid were the most common reasons for not having tested sooner.
Gay community continues to play a key role in the response to HIV among gay men.
The authors thank the participants for giving their time to the study. We also thank those who funded the study, the Health Departments of: New South Wales, Victoria, Queensland, Western Australia, South Australia, Tasmania, Northern Territory and the Australian Capital Territory.
Handling editor Jackie A Cassell
Contributors GP was the principal investigator. GP, ID, JE, KT and GB designed the study protocols and data collection instruments. ID analysed the data and wrote the first draft of this manuscript. All authors contributed to and approved the final manuscript.
Funding The HIV Seroconversion Study was funded by the health departments of New South Wales, Victoria, Queensland, Western Australia, South Australia, Tasmania, Northern Territory and the Australian Capital Territory. The research was conducted by a team of investigators at The Kirby Institute and The Australian Research Centre in Sex, Health and Society (ARCSHS). The Kirby Institute and ARCSHS receive funding from the Australian Government Department of Health and Ageing. The Kirby Institute is affiliated with UNSW Medicine, University of New South Wales. ARCSHS is affiliated with La Trobe University.
Competing interests None.
Ethics approval University of NSW and La Trobe University Human Research Ethics Committees.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data available at this time, due to ongoing nature of analyses.