Evaluation of HIV self-testing as a strategy to increase HIV testing in higher risk gay and bisexual men in Australia

Abstract

Gay and bisexual men (GBM) account for the majority of new HIV infections in Australia. Regular testing provides a pathway to prevention and treatment; however testing remains suboptimal in some GBM. One aim of this thesis was to understand in more detail the HIV testing practices among a retrospective cohort of 25,000 HIV-negative GBM attending 32 sexual health clinics (SHCs) in New South Wales (NSW) between 2009 and 2015. The analysis was conducted at a time when a range of clinic-based initiatives were introduced to promote HIV testing and showed a significant annual increase in HIV tests conducted (23–31%) and testing frequency (4–6%) in high-risk GBM, yet 54% did not meet the minimum recommended frequency. HIV self-testing, an appealing new technology, has the potential to improve testing uptake and frequency by reducing barriers to clinic attendance. At the commencement of this PhD, no trial evidence on effectiveness of self-testing in increasing HIV testing existed. To address these gaps, a randomised controlled trial (FORTH) was conducted; 362 high-risk GBM from NSW, Victoria and Queensland were randomised (1:1) to the intervention (free oral fluid self-tests) or standard care alone. A chapter in this thesis describes the rationale and design of the FORTH trial. At baseline, a survey was conducted among FORTH trial participants to examine the factors, including self-efficacy, associated with past HIV testing frequency and the future likelihood of self-testing. In multivariate analyses, self-efficacy was independently associated with both outcomes assessed: ≥3 HIV tests in the past year and the future likelihood of self-testing, suggesting improvement in self-efficacy and enhancement of knowledge and testing skills may facilitate frequent testing. The FORTH trial intention-to-treat results showed that HIV testing frequency increased two-fold in recently tested (past two years) GBM and nearly four-fold in non-recent testers (not tested in the past two years or never-tested) over 12 months (both significant), without a decline in facility-based HIV or STI testing frequency. Follow-up surveys conducted during the trial showed that HIV self-testing was acceptable and did not increase sexual risk behaviour. Together, these results highlight the improved targeting of HIV testing to high-risk GBM in NSW and support wider availability of HIV self-testing in Australia to improve testing uptake.