Young men who have sex with men have the highest risk for HIV infection, but only one in five has ever been tested for HIV, a much lower rate than testing for non-adolescents, reports a new national Northwestern Medicine study conducted in partnership with the Centre for Innovative Public Health Research. The greatest barriers to these teenage males getting tested are not knowing where to go to get an HIV test, worries about being recognised at a testing site and – to a lesser degree – thinking they are invincible and won’t get infected.
“Understanding the barriers to testing provides critical information for intervening, so we can help young men get tested,” said study first author Gregory Phillips II, a research assistant professor of medical social sciences at Northwestern University Feinberg School of Medicine and an investigator for the IMPACT LGBT Health and Development Programme at Feinberg.
“Rates of new HIV infections continue to increase among young gay and bisexual men,””said Brian Mustanski, principal investigator of the study, an associate professor of medical social sciences at Feinberg and director of IMPACT. “Testing is critical because it can help those who are positive receive lifesaving medical care. Effective treatment can also help prevent them from transmitting the virus to others.”
The findings suggest testing can be increased by providing young men with an easy way to find nearby testing sites via text messaging or online programs and by opening testing sites in high schools. “Providing in-school testing would normalise the process,” Phillips said. “If there is a constant presence of on-site testing at schools, testing would seem less stigmatised. It would also increase knowledge about the testing process and make it less scary.”
Online information explaining the testing procedure also can calm young men’s fears. Finger stick or cheek swabs are both options for testing, which teens may not realise. The IMPACT Program at Feinberg created a video that shows young people what it’s like to get an HIV test.
Between June and November 2014, the study enrolled a national sample of 302 gay, bisexual and queer males ages 14 to 18 years into a text messaging-based HIV prevention program (Guy2Guy). Questions about their HIV-testing behaviors were included in the study. The researchers found only 20% of the teenage boys had ever been tested for HIV, a rate that is much lower than what other studies have found with adult gay and bisexual men. A 2008 national Centres for Disease Control and Prevention-sponsored study of men who have sex with men found 75% of men ages 18 to 19 reported they had been tested for HIV, for example.
Michele Ybarra, an investigator at the Centre for Innovative Public Health Research, was the co-principal investigator on the study.
Adolescent gay and bisexual men (AGBM) are disproportionately affected by human immunodeficiency virus (HIV), but little is known about testing rates among men aged 18 years and under or about the barriers that they face when contemplating an HIV test. Therefore, we investigate here the testing behaviors and barriers among a diverse national sample of AGBM.
A total of 302 AGBM aged 14–18 years were recruited via Facebook ads to participate in an mHealth (text messaging-based) HIV prevention program. Recruitment was stratified to ensure approximately 50% were sexually inexperienced.
Only 30% of sexually active participants had ever been tested for HIV, and nearly half of them did not know where they could go to get tested for HIV (42.9%). Based on exploratory factor analysis, nine questions assessing potential barriers to HIV testing factored into three subscales: external factors, fear, and feelings of invincibility. Among sexually active participants, those who had never tested for HIV had significantly greater scores on the external factors (odds ratio, 1.63; 95% confidence interval, 1.01–2.66) and fear (odds ratio, 1.88; 95% confidence interval, 1.11–3.19) subscale. Older (16–18 years old) youth were especially likely to be affected by external factor barriers, and fear was associated with never testing among gay-identified individuals.
HIV testing rates were low among AGBM. Several modifiable barriers emerged, especially a lack of knowledge about the closest testing site. Interventions and programs that target high school–age adolescents could address external barriers by introducing HIV testing services into high schools.
And while adolescents and young adults are about as likely as older people to be linked to care after being diagnosed with HIV in the US, less than a third were retained in care or started antiretroviral therapy (ART). Only 7% reached undetectable viral load, much lower than the rate for older individuals, researchers reported at the recent Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention . Prompt referral to youth-friendly services, however, increased the likelihood of viral suppression.
Bill Kapogiannis of the US National Institute of Child Health and Human Development and fellow investigators with the SMILE Collaborative looked at the HIV continuum of care for young people with HIV. SMILE (Strategic Multisite Initiative for the Identification, Linkage and Engagement in Care of Youth with Undiagnosed HIV Infection) is a collaboration between the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN), the US Health Resources and Services Administration (HRSA) and the Centres for Disease Control and Prevention (CDC).
The continuum or cascade of care refers to the sequence of steps from HIV testing and diagnosis, to linkage into care, to starting treatment, to achieving viral suppression. Public health researchers track progress in addressing the epidemic by looking at how many people ‘get lost’ or fall out of care at each step. Approximately a quarter of all new HIV infections in the US occur among youth aged 13-24 years, the researchers noted, yet there are little youth-specific data on engagement in care.
The CDC estimates that 86% of the 1.2m people living with HIV in the US have been tested and know their status, falling to 49% among youth age 18-24, according to 2011 figures reported in the 28 November 2014 Morbidity and Mortality Weekly Report.
The SMILE study started at the next step of the continuum, looking at outcomes among 1,548 youth, age 12-24, who were diagnosed with HIV and identified by the collaboration between October 2012 and September 2014. Among the 733 participants with available data, 81% were male, 72% were black, 70% identified as gay or bisexual, the mean age was 20.6 years and the mean CD4 T-cell count was 463 cells/mm3.
The researchers determined the number of participants who were referred to care, linked to care (within 42 days after referral), engaged in care (defined as at least one additional visit within 16 weeks after linkage), retained in care (at least one additional visit within 52 weeks of engagement) and achieved viral suppression or undetectable plasma HIV RNA.
Of the 1,548 total participants diagnosed with HIV, 1053 (68%) were newly linked to care. Of these 839 participants (80%) were engaged in care, and among those 473 (56%) were retained in care. Looked at as proportions of the initial total diagnosed with HIV – not just those who had reached the previous step in the continuum – 54% were linked to care, 31% were retained in care, 31% started ART and 7% achieved undetectable viral load. Among the 358 people who were not successfully linked to care, the main reasons were repeated failure to attend appointments (34%), inability to locate the participant (32%), participant’s refusal of care (11%) and being out of the service jurisdiction (11%).
At the time of linkage to care, 38% of participants had a CD4 count above 500 cells/mm3, 29% had 350-500 and 34% had less than 350. As participants reached successive steps of the care continuum median viral load decreased progressively, while the proportion with undetectable HIV RNA increased.
Significant predictors of viral suppression in an adjusted analysis included lower viral load at the time of linkage to care, recent ART use (adjusted hazard ratio (HR) 3.10, or more than 3-fold higher) and a shorter interval between testing and referral for linkage to care (adjusted HR 1.64 for 0-7 days, 2.52 for 7 days to 6 weeks and 2.08 for 6 weeks to 3 months, compared to more than 3 months).
The 7% viral suppression rate seen in this analysis is surprisingly low – substantially lower than the approximately 40% figure for all age groups combined in the CDC’s Medical Monitoring Project (according to the July 2015 Supplemental Surveillance Report).
“The SMILE collaborative has demonstrated that HIV-infected youth had high levels of plasma viremia and advanced infection at diagnosis, which have implications for disease progression and transmission potential,” the researchers concluded. “While they linked to care at similar rates as adults, youth achieved disproportionately low rates of virologic suppression.”
“Prompt referral to youth-friendly linkage-to-care services after HIV testing is an independent predictor of viral load suppression,” they continued. “Recent developments affecting the urgency to start antiretroviral treatment for HIV-infected persons have direct implications for youth who would now have even less time for adjustment to their new diagnosis. This argues for more research and services to address such critical issues of treatment readiness and medication adherence among newly infected youth.”