NIHR DC Discover

NIHR Signal Self-testing kits increase overall HIV testing uptake in men who have sex with men

Published on 6 February 2018

doi: 10.3310/signal-000550

Frequency of HIV testing in men who have sex with men may be increased by one additional test in a six month period when self-testing kits are used. Self-testing kits allow people to collect their finger-prick or saliva sample, perform the test and interpret the result themselves.

This global study found that first-time testers made up around a tenth of all self-testers in high-income countries such as the US or UK, but about a third of those in resource-limited countries. About a third of self-testers had not had a recent test in either setting.

For men testing positive, most (88%) went on to seek professional care in the UK, but rates were lower in other countries. Counselling and support following an HIV diagnosis are of great importance and should include partner notification. 

Self-testing kits are available in the UK online from www.freetesting.hiv and are recommended by Public Health England.

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Why was this study needed?

An estimated 89,400 people in the UK are living with HIV according to 2016 figures. The annual rate of new diagnoses is starting to decline, falling from 6,286 in 2015 to 5,164 in 2016. Over half of cases are in men who have sex with men (MSM).

A previous Signal reported on research demonstrating that most men would be willing to use home kits to test for sexually transmitted infections. GPs, pharmacies and sexual health clinics were deemed to be acceptable places to collects these kits. These differ from self-testing in that the sample is sent to the lab or clinic rather than being performed by the individual. In 2016, 26,723 self-testing kits were obtained in the UK. There are some concerns that after testing people do not alert health professionals to positive results, leaving people to face a positive diagnosis alone.

This study investigated the ability of self-testing to increase overall HIV testing in MSM globally.

What did this study do?

This systematic review and meta-analysis pooled data from 23 studies looking at how effective HIV self-testing is in increasing overall HIV testing in MSM.

Only two randomised controlled trials were included. The others were 14 quasi-experimental studies, cross-sectional and one mixed methods design; these were all included in the various analyses. Three large studies were UK-based, with 9,104 participants. Ten studies were conducted in the US and four in Europe with nine conducted in resource-constrained countries including eight from China. Studies from resource-limited and high-income countries were separated in the analysis.

There was a wide variety in study size, design and type of self-test which reduces the reliability of the combined results. Studies were assessed using standard appraisal tools for the study design. For a question of prevalence, they provide reliable evidence.

What did it find?

  • HIV self-testing increased overall HIV test frequency in MSM by one extra test over a six-month time slot (mean difference 0.88, 95% confidence interval [CI] 0.52 to 1.24; 2 randomised controlled trials, 540 participants).
  • HIV self-testing was used as the first test in 9.9% of MSM in high-income countries (95% CI 7.4 to 13.8).
  • Of those undertaking HIV self-testing, the proportion of non-recent testers was 32.9% (95% CI 28.1 to 38.3).
  • The proportion of MSM who were ever or currently married to a woman and used a self-test was 16.7% (95% CI 14.5 to 19.4).
  • Of studies looking at onward referral to a health professional, the "linkage” rates ranged from 31.3% to 100%. One large UK-based study found a linkage rate of 88%.

What does current guidance say on this issue?

NICE guidelines in 2016 recommend offering and recommending HIV testing in different settings depending on local prevalence and different groups within the community. Possible settings include GP surgeries, community settings, secondary and emergency care and sexual health services. The guideline recommends considering providing self-testing kits to people in areas of high HIV prevalence.

Public Health England 2017 guidance recommends high-risk groups such as MSM who have sex without condoms to have a test every three months if they have new or casual partners, or annually if in a stable relationship.

What are the implications?

This study found HIV self-testing increased the frequency of overall testing by one per six months in MSM. Given the high proportion of HIV infected people who are MSM, particularly in the UK, increasing testing uptake is of great importance. It may be more convenient, particularly for those at high risk who are recommended testing every three months.  

Outcomes from high-income and resource-limited countries were analysed separately for most comparisons. However, the data on married men came largely from China studies and may not be directly applicable to the UK given the differences in service provision, health promotion campaigns for HIV testing and stigma between countries.

Self-testing may overcome some of the barriers of receiving tests in formal health care settings and ensuring linkage to care for those testing positive is important.

Citation and Funding

Zhang C, Li X, Brecht ML, Koniak-Griffin D. Can self-testing increase HIV testing among men who have sex with men: A systematic review and meta-analysis. PLoS One. 2017;12(11):e0188890.

The study was funded by a Fogarty International Center Award (D43 TW009579), and partially funded by the National Social Science Fund (15CSH037).

Bibliography

Brown AE, Kirwan PD, Chau C, et al. Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK –2017 report. London: Public Health England; 2017.

House of Lords. No Vaccine, no cure: HIV and AIDS in the United Kingdom. Select Committee on HIV and AIDS in the United Kingdom: 1st Report of Session 2010-12. Published 1 September 2011.

Nash SG, Furegato M, Gill ON, et al. HIV testing in England: 2017 report. London: Public Health England; 2017.

NICE. HIV testing: costs and savings. LGB21. London: National Institute for Health and Care Excellence; 2014.

NICE. HIV testing: increasing uptake among people who may have undiagnosed HIV: context. NG60. London: National Institute for Health and Care Excellence; 2016.

NICE. HIV testing: increasing uptake among people who may have undiagnosed HIV: recommendations. NG60. London: National Institute for Health and Care Excellence; 2016.

NIHR DC. Men find self-testing acceptable to test for sexually transmitted infections. Southampton: National Institute for Health Research Dissemination Centre; 2017.

WHO. Guidelines on HIV self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. Geneva: World Health Organization; 2016.

Why was this study needed?

An estimated 89,400 people in the UK are living with HIV according to 2016 figures. The annual rate of new diagnoses is starting to decline, falling from 6,286 in 2015 to 5,164 in 2016. Over half of cases are in men who have sex with men (MSM).

A previous Signal reported on research demonstrating that most men would be willing to use home kits to test for sexually transmitted infections. GPs, pharmacies and sexual health clinics were deemed to be acceptable places to collects these kits. These differ from self-testing in that the sample is sent to the lab or clinic rather than being performed by the individual. In 2016, 26,723 self-testing kits were obtained in the UK. There are some concerns that after testing people do not alert health professionals to positive results, leaving people to face a positive diagnosis alone.

This study investigated the ability of self-testing to increase overall HIV testing in MSM globally.

What did this study do?

This systematic review and meta-analysis pooled data from 23 studies looking at how effective HIV self-testing is in increasing overall HIV testing in MSM.

Only two randomised controlled trials were included. The others were 14 quasi-experimental studies, cross-sectional and one mixed methods design; these were all included in the various analyses. Three large studies were UK-based, with 9,104 participants. Ten studies were conducted in the US and four in Europe with nine conducted in resource-constrained countries including eight from China. Studies from resource-limited and high-income countries were separated in the analysis.

There was a wide variety in study size, design and type of self-test which reduces the reliability of the combined results. Studies were assessed using standard appraisal tools for the study design. For a question of prevalence, they provide reliable evidence.

What did it find?

  • HIV self-testing increased overall HIV test frequency in MSM by one extra test over a six-month time slot (mean difference 0.88, 95% confidence interval [CI] 0.52 to 1.24; 2 randomised controlled trials, 540 participants).
  • HIV self-testing was used as the first test in 9.9% of MSM in high-income countries (95% CI 7.4 to 13.8).
  • Of those undertaking HIV self-testing, the proportion of non-recent testers was 32.9% (95% CI 28.1 to 38.3).
  • The proportion of MSM who were ever or currently married to a woman and used a self-test was 16.7% (95% CI 14.5 to 19.4).
  • Of studies looking at onward referral to a health professional, the "linkage” rates ranged from 31.3% to 100%. One large UK-based study found a linkage rate of 88%.

What does current guidance say on this issue?

NICE guidelines in 2016 recommend offering and recommending HIV testing in different settings depending on local prevalence and different groups within the community. Possible settings include GP surgeries, community settings, secondary and emergency care and sexual health services. The guideline recommends considering providing self-testing kits to people in areas of high HIV prevalence.

Public Health England 2017 guidance recommends high-risk groups such as MSM who have sex without condoms to have a test every three months if they have new or casual partners, or annually if in a stable relationship.

What are the implications?

This study found HIV self-testing increased the frequency of overall testing by one per six months in MSM. Given the high proportion of HIV infected people who are MSM, particularly in the UK, increasing testing uptake is of great importance. It may be more convenient, particularly for those at high risk who are recommended testing every three months.  

Outcomes from high-income and resource-limited countries were analysed separately for most comparisons. However, the data on married men came largely from China studies and may not be directly applicable to the UK given the differences in service provision, health promotion campaigns for HIV testing and stigma between countries.

Self-testing may overcome some of the barriers of receiving tests in formal health care settings and ensuring linkage to care for those testing positive is important.

Citation and Funding

Zhang C, Li X, Brecht ML, Koniak-Griffin D. Can self-testing increase HIV testing among men who have sex with men: A systematic review and meta-analysis. PLoS One. 2017;12(11):e0188890.

The study was funded by a Fogarty International Center Award (D43 TW009579), and partially funded by the National Social Science Fund (15CSH037).

Bibliography

Brown AE, Kirwan PD, Chau C, et al. Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK –2017 report. London: Public Health England; 2017.

House of Lords. No Vaccine, no cure: HIV and AIDS in the United Kingdom. Select Committee on HIV and AIDS in the United Kingdom: 1st Report of Session 2010-12. Published 1 September 2011.

Nash SG, Furegato M, Gill ON, et al. HIV testing in England: 2017 report. London: Public Health England; 2017.

NICE. HIV testing: costs and savings. LGB21. London: National Institute for Health and Care Excellence; 2014.

NICE. HIV testing: increasing uptake among people who may have undiagnosed HIV: context. NG60. London: National Institute for Health and Care Excellence; 2016.

NICE. HIV testing: increasing uptake among people who may have undiagnosed HIV: recommendations. NG60. London: National Institute for Health and Care Excellence; 2016.

NIHR DC. Men find self-testing acceptable to test for sexually transmitted infections. Southampton: National Institute for Health Research Dissemination Centre; 2017.

WHO. Guidelines on HIV self-testing and partner notification: supplement to consolidated guidelines on HIV testing services. Geneva: World Health Organization; 2016.

Can self-testing increase HIV testing among men who have sex with men: A systematic review and meta-analysis

Published on 1 December 2017

Zhang, C.,Li, X.,Brecht, M. L.,Koniak-Griffin, D.

PLoS One Volume 12 Issue 11 , 2017

BACKGROUND: Globally, four out of ten individuals living with HIV have not been tested for HIV. Testing is especially important for men who have sex with men (MSM), among whom an increasing HIV epidemic has been identified in many regions of the world. As a supplement to site-based HIV testing services, HIV self-testing (HIVST) provides a promising approach to promote HIV testing. However, evidence is scattered and not well-summarized on the effect of HIVST to improve HIV testing behaviors, especially for MSM. METHODS: Seven databases (PubMed, Web of Science, Cochrane Library, PsycINFO, CINAHL Plus, WanFang, and China National Knowledge Internet) and conference abstracts from six HIV/sexually transmitted infections conferences were searched from January 2000-April 2017. RESULTS: Of 1,694 records retrieved, 23 studies were identified, 9 conducted in resource-limited countries and 14 in high-income countries. The pooled results showed that HIVST increased HIV test frequency for MSM by one additional test in a 6-month period (mean difference = 0.88 [95% CI 0.52-1.24]). The pooled proportion of first-time testers among those who took HIVST was 18.7% (95% CI: 9.9-32.4) globally, with a rate 3.32 times higher in resource-limited country settings (32.9% [95% CI: 21.3-47.6]) than in high-income countries (9.9% [95% CI: 7.4-13.8]). The pooled proportions included non-recent testers, 32.9% (95% CI: 28.1-38.3); ever or currently married MSM, 16.7% (95% CI: 14.5-19.4); and HIV positive men, 3.8% (95% CI: 2.0-5.7) globally; 6.5% [95% CI: 0.38-12.3] in resource-limited country settings; and 2.9% [95% CI: 2.0-5.0] in high-income countries). The rates reported for linkage to care ranged from 31.3% to 100%. CONCLUSIONS: HIVST could increase HIV testing frequency and potentially have capacity equivalent to that of site-based HIV testing services to reach first-time, delayed, married, and HIV-infected testers among MSM and link them to medical care. However, more rigorous study designs are needed to explore the specific self-testing approach (oral-fluid based or finger-prick based) on improving HIV testing for MSM in different social and economic settings.

Expert commentary

Testing and diagnosing HIV followed by antiretroviral therapy improves the health of individual patients but also helps to control the spread of HIV at a population level. This is because effective treatment reduces the viral level so effectively that the patient is rendered virtually non-infectious.

It is therefore important to make testing as easy and accessible as possible. This study looking at HIV self-testing can be combined with other testing options such as home sampling, outreach testing and improving access to sexual health clinics, to reduce the proportion of individuals who remain undiagnosed and untreated.

Jonathan Ross, Professor of Sexual Health and HIV, University Hospitals Birmingham NHS Foundation Trust