HIV self-test boosts testing awareness among MSM

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Distribution of free HIV self-tests via the internet can increase testing for the disease by men who have sex with men (MSM) and boost awareness among members of their social networks, potentially limiting transmission of the disease, according to a study. The findings suggest that HIV prevention programmes should include an HIV self-testing mail distribution program to their portfolios of prevention services for high-risk populations.

In 2015, the US Centres for Disease Control and Prevention initiated a longitudinal study – called Evaluation of Rapid HIV Self-testing Among MSM Project, or eSTAMP – to examine the effectiveness of mailing HIV self-tests to MSM in the US, particularly in regards to frequency of testing, diagnoses of HIV infection, sexual risk behaviours, and the use of self-tests by social network members.

A total of 2,665 participants were recruited through advertisements placed on social network, music, and dating websites frequented by MSM. The study was limited to US males at least 18 years of age who reported engaging in anal sex with at least one man in the past 12 months, reported being HIV negative or unaware of HIV status, had never been diagnosed with a bleeding disorder, had never participated in an HIV vaccine trial, and were not taking antiretroviral medications to prevent HIV.

All participants received access to online HIV testing resources and telephone counselling on request, but half were randomly assigned a self-testing arm that were mailed two oral fluid HIV self-tests – OraSure TechnologiesOraQuick In-Home HIV test – and two fingerstick whole blood HIV self-tests – Chembio DiagnosticsSure Check HIV 1/2 assay. Individuals in the self-testing arm could also order additional tests to replace tests that were used or given away.

All study participants were asked to answer surveys every three months in exchange for payment throughout the study’s 12-month term, and all received self-tests at the end of the trial. The eSTAMP researchers found that those who received the self-tests reported testing more frequently than those who did not, with most reporting testing three times or more during the study period. Of the 36 newly identified HIV infections reported by all the trial’s participants, 26 were from those who received self-tests.

Notably, nearly half of the total number of infections reported were among participants who had not been tested in the preceding year, with nine infections diagnosed in individuals who had never been tested before. Additionally, study participants in the self-testing arm reported 34 newly identified HIV infections among members of their social networks with whom they shared the tests.

The investigators also observed a roughly 57% overall increase in annual HIV testing among those receiving self-tests. Specifically, 61% of trial participants in the self-testing arm received annual testing before enrolment in the study, but that figure climbed to 96% at the end of the study. The percentage of control arm participants who tested for HIV annual increased only 5% over the course of the study, to 63% from 60%. Moreover, nearly all of those receiving self-tests reported testing at least once during the study compared with fewer than two-thirds of control arm participants.

Based on these findings, the study’s authors wrote, “distribution of HIV self-tests provides a worthwhile mechanism to increase awareness of HIV infection and prevent transmission among MSM,” and should be considered for inclusion in prevention programs.

“Additional implementation research on HIV self-testing could provide information about the most cost-effective methods for online recruitment, optimal frequency of self-test provision, linkage of HIV-positive persons to care, and HIV behavioural messaging to improve operational expansion of HIV self-testing,” they added.

Abstract
Importance: Undiagnosed HIV infection results in delayed access to treatment and increased transmission. Self-tests for HIV may increase awareness of infection among men who have sex with men (MSM).
Objective: To evaluate the effect of providing HIV self-tests on frequency of testing, diagnoses of HIV infection, and sexual risk behaviors.
Design, Setting, and Participants: This 12-month longitudinal, 2-group randomized clinical trial recruited MSM through online banner advertisements from March through August 2015. Those recruited were at least 18 years of age, reported engaging in anal sex with men in the past year, never tested positive for HIV, and were US residents with mailing addresses. Participants completed quarterly online surveys. Telephone call notes and laboratory test results were included in the analysis, which was completed from August 2017 through December 2018.

Interventions: All participants had access to online web-based HIV testing resources and telephone counseling on request. Participants were randomized in a 1:1 ratio to the control group or a self-testing (ST) group, which received 4 HIV self-tests after completing the baseline survey with the option to replenish self-tests after completing quarterly surveys. At study completion, all participants were offered 2 self-tests and 1 dried blood spot collection kit.
Main Outcomes and Measures: Primary outcomes were HIV testing frequency (tested ≥3 times during the trial) and number of newly identified HIV infections among participants in both groups and social network members who used the study HIV self-tests. Secondary outcomes included sex behaviors (eg, anal sex, serosorting).

Results: Of 2665 participants, the mean (SD) age was 30 (9.6) years, 1540 (57.8%) were white, and 443 (16.6%) had never tested for HIV before enrollment. Retention rates at each time point were more than 54%, and 1991 (74.7%) participants initiated 1 or more follow-up surveys. More ST participants reported testing 3 or more times during the trial than control participants (777 of 1014 [76.6%] vs 215 of 977 [22.0%]; P < .01). The cumulative number of newly identified infections during the trial was twice as high in the ST participants as the control participants (25 of 1325 [1.9%] vs 11 of 1340 [0.8%]; P = .02), with the largest difference in HIV infections identified in the first 3 months (12 of 1325 [0.9%] vs 2 of 1340 [0.1%]; P < .01). The ST participants reported 34 newly identified infections among social network members who used the self-tests.
Conclusions and Relevance: Distribution of HIV self-tests provides a worthwhile mechanism to increase awareness of HIV infection and prevent transmission among MSM.

Authors
Robin J MacGowan; Pollyanna R Chavez; Craig B Borkowf; S Michele Owen; David W Purcell; Jonathan H Mermin; Patrick S Sullivan for the eSTAMP Study Group

360dx material JAMA Internal Medicine abstract

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