Understanding HIV risk and addressing barriers to testing for men who have sex with men in Australia

Diagnoses of HIV among men who have sex with men (MSM) are increasing in many developed countries. In Australia, rising rates of HIV diagnoses among MSM have been attributed to increasing prevalence of unprotected anal intercourse, dramatic increases in the prevalence of other STIs including syphilis, gonorrhoea and chlamydia, and (following the introduction of ART) an expanding pool of healthy, sexually active, HIV positive MSM. Surveillance data also suggest a shift in the epidemiology of HIV within Australian MSM populations in recent years, with an increasing proportion of younger MSM being diagnosed with HIV and other STIs. Although identified in other developed countries as a key factor likely to be associated with increasing HIV transmission among MSM, local data on undiagnosed HIV (HIV positive individuals who are unaware of their HIV infection) in Australia is limited. Additional information regarding the prevalence and correlates of undiagnosed HIV among MSM is required to understand how undiagnosed infection may impact on transmission rates. In addition to initiatives to maintain and enhance awareness of risk and protective behaviours for HIV and other STIs, encouraging regular HIV and other STI testing among MSM is a central part of Australia’s HIV prevention response. Increasing the frequency of HIV and other STI testing among high risk MSM is considered particularly important to detect primary infections and undiagnosed infections. The benefits of testing are several. First, it provides an opportunity for the provision of education and counselling, regardless of the outcome of the test. Second, for those found to have infection, it represents a pathway into HIV care and treatment. Finally, the reduction in viral load that can be achieved through treatment can substantially lower the risk of transmission to sexual partners. Annual self-reported HIV testing rates among MSM in Australia are consistently high (60%-68%). Nevertheless, recent clinic data suggest that the proportion of MSM undergoing more frequent testing is falling well short of the 3-6 monthly recommendation for high-risk men, and a significant proportion with HIV infection may be undiagnosed or diagnosed late. Numerous barriers to frequent testing among MSM have been identified previously including low risk perception, difficulties getting an appointment, the requirement for multiple clinic appointments for specimen collection and for receiving results, and difficulties in finding a ‘gay-friendly’ doctor. This thesis provides estimates of the extent of undiagnosed HIV infection in MSM and then describes evaluations of the impact of a range of preventative approaches to increasing HIV and STI testing for MSM in Australia. Limitations of current HIV epidemiological approaches in Australia and the potential impact of undiagnosed infections (and, in turn, the importance of frequent HIV testing) on HIV epidemiology were highlighted in the ‘Suck it and See’ Study. Field-based HIV testing techniques used for the first time in Australia enabled measurement of the biological prevalence of HIV alongside behavioural data, revealing an undiagnosed HIV prevalence estimate of 31%, and confirmed the previously unrecognised impact of undiagnosed HIV on transmissions. These outcomes, combined with the known limitations of self-report measures for estimating HIV prevalence, as currently used in Australia, makes a strong case for the incorporation of biological measures into routine HIV and behavioural surveillance in Australia. A quantitative and qualitative evaluation of a national STI awareness campaign demonstrated the effectiveness of social marketing campaigns in encouraging HIV/STI testing. The campaign aimed to increase HIV and STI testing among MSM by improving awareness and knowledge of the importance of regular testing. The quantitative evaluation demonstrated the impact of the campaign on awareness and health-seeking behaviour. These findings were complemented by those of the qualitative evaluation, which identified key elements of campaign style, language and broadcast schedule, in particular the use of mainstream media channels that contributed to impact, reach, acceptability and engagement. The qualitative evaluation also identified campaign limitations, including its limited ability to reduce risk behaviour and encourage community dialogue or interpersonal communication. The lack of portrayal of negative consequences associated with not getting tested and the limited engagement with the campaign content were identified as a potential reason for these limitations. Web-based interventions offer a new and potentially more engaging approach to health promotion than traditional types of social marketing. In particular, newer Web 2.0 applications like social networking sites have interactive functions and rapidly increasing popularity, characteristic that can be exploited to provide a unique platform to deliver health promotion messages. “Queer as F**K” is an innovative sexual health program delivered to gay men via social networking sites. The evaluation of its pilot provided evidence of the feasibility and acceptability of health promotion delivered through social networking sites and other new media for reaching and engaging gay men in sexual health discussions. Increasing avenues to deliver sexual health promotion and helping to normalise sexual health discussions among MSM are important steps to help reduce stigma and other structural/societal barriers to testing. These new technologies can support or accompany existing mass media campaigns that have been shown to be effective at encouraging testing. Despite successful and innovative marketing approaches designed to enhance HIV and other STI testing among MSM, structural barriers to testing remain. Men currently need a second appointment to receive their test results, as conventional HIV serology results are not available for two or more days. Thus, for high-risk men, each HIV test could be associated with two visits to a clinic, meaning up to eight clinic visits per year for HIV testing alone. Rapid HIV testing could enable men to increase their testing frequency by halving the number of visits required In Australia, HIV testing is only available through clinical settings and until 2011 HIV rapid testing was not supported through the Australian National HIV Testing Policy. To inform changes to HIV testing policy and practice in Australia, and demonstrate the benefit of alternative testing models, a systematic review of community-based models of testing for MSM, with a focus on rapid testing was undertaken. The review provides evidence that community models attract a significant proportion of high-risk MSM and reach a high proportion of men who have never tested before, supporting the diversification of testing strategies in Australia to increase HIV testing rates among MSM. In summary, while improving access to HIV testing for MSM in Australia is recognised as key to reducing new diagnoses and onward transmission, achieving this outcome requires complementary and supporting strategies, including biomedical, behavioural and structural interventions. As these new strategies are implemented, it is imperative that effective and ongoing evaluations measure the impact of the overall strategy and identify the most effective components. This information in turn informs the ongoing refinement of the prevention strategies that will ultimately help reduce the number of HIV infections among MSM and the burden on the health system and the community. This thesis contributes greatly to our understanding of the impact of undiagnosed HIV in driving the HIV epidemic among MSM in Australia. It provides strong evidence for the need to diversify testing strategies in Australia to reduce the prevalence of undiagnosed HIV, including the introduction of rapid HIV testing into both clinical and community based settings. Findings presented in this thesis suggest that the introduction of new testing strategies need to be accompanied by engaging sexual health promotion interventions that encourage and increase the uptake and frequency of HIV testing among MSM populations.