This article by Roger Pebody first appeared on aidsmap.com here. Republished with permission.
With health services and HIV prevention organisations now having relentlessly focused on HIV testing for several years, new data suggest that more English gay men have recently taken an HIV test, have good knowledge of HIV testing and were happy with testing services. But the data, from the 2014 Gay Men’s Sex Survey, also include signs of decreases in basic knowledge of safer sex and of poorer access to condoms.
“Are we putting all our prevention needs in one testing basket?” Ford Hickson of Sigma Research asked the HIV Prevention England conference in London yesterday.
Over the last decade, HIV testing has become a public health priority and many more clinical services have invited gay and bisexual men to test. An increasing proportion of HIV prevention campaigns have focused on testing and many local HIV prevention services have offered testing as part of their outreach work. But some feel that some of the other ‘bread and butter’ issues of HIV prevention may have been neglected.
The data presented were the first to emerge from the 2014 Gay Men’s Sex Survey, which recruited a large convenience sample of men through dating websites and apps, Facebook promotion and HIV organisations.
The data are cross-sectional, but comparisons are made between the surveys conducted in 2010 and 2014. In order to improve the validity of these comparisons, only men recruited through dating websites and apps are included (the other recruitment methods weren’t used in 2010). Moreover, there was statistical adjustment for observed differences between the samples (geographical area, average age, level of education, employment and identifying as ‘gay’). The comparison is of 11,519 men in 2010 and 6784 men in 2014.
The proportion that had ever taken an HIV test rose, from 72% in 2010 to 77% in 2014.
But the biggest changes were in how recently the test had been taken. Across the sample, the proportion that had tested for HIV in the past year jumped from 43% in 2010 to 56% in 2014. Amongst those who had ever tested, the proportion who had done so in the past year increased from 66 to 75%.
The differences between 2010 and 2014 were statistically significant after adjustment for confounding factors.
But as more men were tested, a lower proportion were diagnosed with HIV at that test. Moreover those diagnosed reported similar CD4 cell counts in the two surveys, suggesting that the increase in the frequency of HIV testing may have primarily occurred in men who remained HIV negative.
The increase in testing volume was not at the expense of service quality. In 2014, 80% of those testing negative and 84% of those testing positive were ‘very satisfied’ with the way the service kept their confidentiality; and 79% of those testing negative and 82% of those testing positive were ‘very satisfied’ with the respect they were treated with. These figures were actually higher than they had been in 2010. Fewer men testing negative received counselling in 2014, but this did not affect men’s satisfaction.
On indicators of basic knowledge about HIV testing, there were no changes between the surveys. Only 3% did not know that you can’t work out someone’s HIV status from their appearance, 1% did not know that testing exists and 10% were not aware that tests have window periods. Men remained confident that they could get an HIV test if they wanted one.
The proportion of men expressing some degree of doubt or uncertainty about their own HIV-negative status increased. This is in keeping with the aims of health promotion – people who have taken a sexual risk since their last HIV test should not take their HIV-negative status for granted.
More worryingly, gaps in knowledge of safer sex appear to be widening. These changes were small but statistically significant. Compared to 2010, more men did not know that sexually transmitted infections increase the risk of HIV transmission (up from 39 to 42%), that the insertive sexual partner (‘top’) can acquire HIV during anal sex (up from 10 to 15%) or that HIV cannot be passed on during kissing (up from 19 to 21%).
And more men reported problems getting hold of condoms. In the past month, 7.7% of men had wanted a condom but did not have one and 5.2% had had unprotected sex for that reason. (The 2010 figures were 6.5 and 3.8% respectively.)
Ford Hickson suggested that health organisations’ singular focus on HIV testing – sometimes to the expense of education around safer sex or condom distribution programmes – may be having an impact. While HIV testing has improved, needs around safer sex have got worse.
HIV testing: comparison with other data
Since 2001, data from successive Gay Men’s Sex Surveys have shown increases in the proportion of respondents who have ever taken an HIV test. A previously published comparison showed that 46% had ever tested in 2001 and 66% had done so in 2007. While the most recent edition had somewhat different recruitment methods (making comparisons problematic), it showed that 77% had tested.
But men who are recruited through dating websites and apps do not represent the whole population of men who have sex with men (MSM). The National Survey of Sexual Attitudes and Lifestyles (Natsal) recruited a large, representative sample from households throughout Great Britain, making it more likely than other studies to give representative data. The proportions of MSM testing are much lower in this survey than described above, although it has recorded a rise over a twenty-year period, from 34% in 1990, to 39% in 2000 and 52% in 2010. Moreover, concerning testing in the past year, this was only reported by 27% of gay men in 2010 (compared to 43% in that year's Gay Men’s Sex Survey).
And while the vast majority of gay men attending sexual health clinics do take an HIV test, the number of clinic attendees is much lower than the estimated population of gay men, also suggesting that many men test infrequently. While we don’t have figures for tests conducted in GP surgeries, other medical settings, community settings or at home, this is unlikely to make up the shortfall.
Hickson F et al. HIV prevention objectives among MSM in England: Data from Gay Men's Sex Surveys 2010 and 2014. HIV Prevention England conference, London, 19 February 2015.