Increases in new HIV infections among men who have sex with men (MSM) are now reported from nearly every industrialised country context,1 and the news from resource-poor settings is worse still—extremely high background prevalence, increases in new infections and only very limited access to care and prevention.2 3 With the weakening commitment of MSM to consistent condom use (at the population level),4 5 and with the growing popularity of different behavioural risk-reduction strategies (negotiated agreements, serosorting and strategic positioning),6 7 8 and the increasing uptake and enactment of pharmacoprophylaxis by MSM (pre and postexposure prophylaxis),9 10 it is little wonder public health and prevention practitioners are highly sensitive to changes in the HIV testing practice and patterns of MSM. From a public health perspective HIV testing rates are a factor in estimating the scale of the problem in this population group.

For MSM as individuals knowing their HIV status is something quite different. It is no longer important just because it permits them to maximise the benefits of early HIV treatment interventions (if it ever was?). Regular and repeated HIV testing are becoming increasingly understood as gateway behaviours that open a range of potentially effective HIV prevention options, which may not include condoms, but for which knowledge of HIV status is the essential starting point. Whether as public health and prevention practitioners this was our intention, whether we choose to acknowledge and support it, and whether we are willing to step up and work to support MSM who enact these practices to do so as effectively as possible is the point in question. Are we ready to take the next HIV testing test?

Efforts to increase MSM's knowledge of their HIV status have been impressive as have been the results. Testing initiatives include actively promoting individual health benefits of knowing one’s status, simplifying testing procedures and putting supportive policy and practice in place in both community and healthcare settings.11 12 All have had major impacts on the numbers tested, but none has so far been linked to measured reductions in new HIV infections—although several reports assume these benefits are still in the pipeline.13 However, for MSM on the ground, expanded testing opportunities are likely to be seen quite differently. More testing opportunities make the “testing” part of HIV testing easier—that was part of the intention in scaling up and expanding testing services. Rapid HIV antibody tests give results more quickly. Routinised opt-out testing in sexual health services helps avoid the “awkward” discussion with a healthcare worker potentially perceived as judgemental. Provider-initiated testing and counselling in community and primary healthcare settings reduces the need to discuss sexuality and other difficult personal issues. But for MSM it goes further. Learning one’s HIV status also has significant potential consequences.14

The paper by Williamson et al15 in this issue reporting HIV testing trends among MSM in Scotland between 1998 and 2005 is important to this discussion. Using a chain of repeated surveys sampling gay men attending bars and clubs in Glasgow and Edinburgh between 1996 and 2005, Williamson and colleagues15 found that almost half the men (47%) reported never having had an HIV test. Of those who had tested, few had done so recently (defined as testing within a year of the survey) giving little opportunity to benefit from treatment and monitoring that come with early diagnosis of HIV infection. Of particular concern is the observation that testing recently did not increase among ever-tested MSM in the sample, and in fact decreased with age (>34 years) suggesting that few men test repeatedly and that those in the age groups in which HIV incidence is high may be among those least likely to test more than once.

The results of Williamson et al15 are at one and the same time salutary—an ecological demonstration of what can be achieved rapidly through establishing supportive policy and clinical practice changes, and sobering—a reminder that achieving high levels of HIV status knowledge through voluntary and opt-out testing (and then maintaining them), and doing this repeatedly in the right population groups cannot be delivered by “healthy public policy” alone.

Healthy policy and practice changes to normalise HIV testing in different settings can make inroads—making HIV testing “normal” and just another aspect of comprehensive healthcare or sexual health screening. What it has so far not been able to do is alter the perceptions of MSM of what testing means and what an HIV-positive result means.14 16 The fear of a positive result is still a major barrier to HIV testing, even in this day and age. Receiving an HIV-positive test result can be a devastating experience for many men, and especially for those living outside major gay communities. No amount of supportive services and post-test counselling can protect one from the negative responses of peers, colleagues, family and perhaps most importantly, current and future sexual partners.14 The progressive approaches to testing in community and healthcare settings have not been matched by equally aggressive campaigns to tackle the barriers to testing and the stigma and discrimination that HIV testing and being HIV positive still attract in some gay communities.14 16 Not to be confused, the social and societal barriers are still huge. Employers, insurers and the criminal justice system all in various ways demonise and in some instances make criminal being HIV positive and the failure to disclose it.17 This is to say nothing of the prejudice that HIV-positive MSM encounter in their own communities.14 16 Little wonder, perhaps, that many gay men in Scotland opt to not undertake regular HIV testing or avoid it altogether.

The conclusions of Williamson et al15 are undoubtedly correct; additional effort is needed to increase regular and particularly repeat HIV testing. However, perhaps before launching into a discussion of what form these initiatives should take, we need to step back and openly discuss our objectives, and perhaps more importantly and especially in this context, we need to consider HIV testing from the perspective of MSM. What is in it for them? What would be the greatest selling point of HIV testing for Scottish and other MSM? For many, the greatest attraction of repeated HIV testing is likely to be the possibility of practising behavioural risk reduction that does not involve condoms more effectively; something clearly needed among MSM in Scotland, the UK and more widely.6 If we are prepared to accept this and to promote status-based risk-reduction strategies, then we need to do so openly, lest we find our prevention programmes once again playing catch-up to the norms of rapidly evolving communities. Several studies indicate that “practised perfectly” most status-based risk reduction can be effective.18 But like all prevention strategies they are rarely practiced perfectly.6 7 How the education about which risk-reducing condomless sexual practices are most effective and in what circumstances is developed and delivered is crucial. We must actively support health promoters to deliver education packages about testing and the effectiveness of risk-reduction strategies accurately. We must also be cautious not to contribute to the community stigma that prevention based on a “sero-divide” could create.9 14 16 HIV-positive MSM are our greatest allies in the prevention endeavour and need to be treated as such. They hold the key.

The stigma that still surrounds HIV testing and being HIV positive is as much, and probably greater, a challenge to increasing the uptake of testing than making testing opportunities more widely available. We must put equal energy into tackling the stigma and discrimination, real and perceived, if our project is to be a success.14 16 The challenge presented by research such as that presented by Wiliamson and colleagues15 is how we use it to inform the next generation of prevention education and testing policy and how imaginative and ambitious we are prepared to be. Are we prepared for the next HIV testing test?