HIV Testing Correlates: U.S. and Foreign Born High-Risk Black Heterosexual Men.

Uptake of HIV testing is critical to halting the spread of HIV. Our study aimed to examine the coverage of HIV testing and self-testing and the individual-level, household-level and community-level factors associated with HIV testing and self-testing awareness. We analysed data of 12 312 men and women from 2016 SADHS and used multilevel mixed-effects models to examine the factors associated with uptake of HIV testing and self-testing awareness. About 80% of participants had ever tested for HIV, and 64% had tested in the past year. Only 49% of adolescents aged 15-19years had ever tested for HIV compared with over 80% of adults. Self-testing awareness was low (22%), and only 2.9% of respondents had ever self-tested for HIV. The odds of having ever tested for HIV were significantly higher among respondents who were aged 25-29 (AOR: 4.02; 95% CI: 3.27-4.95), had a higher level of education (AOR: 3.18; 95% CI: 2.19-4.61), were married (AOR: 1.63; 95% CI: 1.36-1.94), had high media exposure (AOR: 1.23; 95% CI: 1.06-1.44) and had ever had sex (AOR: 5.57; 95% CI: 4.67-6.64), but lower among men (AOR: 0.39; 95% CI: 0.35-0.44). In conclusion, HIV testing coverage is high in South Africa relative to most countries in sub-Saharan Africa, but falls short of the UNAIDS first 95. We found no evidence of socioeconomic and geographic inequalities in access to HIV testing. However, adolescents had a lower level of HIV testing uptake, suggesting a need for interventions to expand testing in this age group.

BackgroundDespite remarkable success in the fight against HIV, HIV prevalence in many countries remains high among key populations including men who have sex with men (MSM), and HIV testing rates is relatively low among this hard-to-reach population. This cross-sectional study explores factors associated with recent HIV testing among MSM in Cambodia.MethodsThis study was conducted in 2014 and included 384 MSM randomly selected from two provinces of Battembang and Siem Reap, using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect data on socio-demographic characteristics, HIV testing history, sexual behaviors, HIV testing attitudes, and HIV knowledge. Multivariate logistic regression analysis was performed to identify factors independently associated with recent HIV testing.ResultsMean age of the participants was 23.4 (SD = 5.2). Of total, 83.6 % had been tested for HIV at least once in their lifetime, and 65.1 % had been tested for HIV in the past six months. After controlling for other covariates, MSM who had been tested for HIV in the past six months were significantly more likely to regard themselves as female (AOR = 2.29, 95 % CI = 1.06-5.37), have received some form of HIV education in the past six months (AOR = 3.97, 95 % CI = 1.91-8.26), perceive that they were at higher HIV risk compared to the general population (AOR = 2.48, 95 % CI = 1.14-4.86), have been diagnosed with an STI in the past six months (AOR = 3.19, 95 % CI = 1.02-9.24), report using a condom at last sexual intercourse with a man or woman (AOR = 2.24, 95 % CI = 1.06-3.13), and report using a condom at last sexual intercourse with a boyfriend (AOR = 2.17, 95 % CI = 1.04-5.31).ConclusionsThis study highlights the common practices of risky sexual behaviors and relatively low rate of recent HIV testing among MSM in Cambodia. HIV education and social marketing should be expanded and tailored for MSM, specifically addressing the risk of unprotected anal intercourse and the importance of regular HIV testing for early enrolment in the care and treatment cascade.

Background The intersection of foreign-born (FB) status and HIV among transgender women (TW) presents public health challenges, especially unmet healthcare needs (UHN). FBTW often encounter barriers like immigration status, language difficulties, and institutional distrust, which may be compounded for those living with HIV. Understanding how FB status and HIV intersect with UHN can guide health equity policies tailored to FBTW.Prevalence of unmet healthcare needs among US-born and foreign-born transgender women by HIV status in 7 U.S. Cities from June 2019 – February 2020Notes: aPR – adjusted prevalence ratios; CI – confidence intervals; * - significant at p<0.05, Models were adjusted for respondent-driven sampling design and confounding factors, including age and racial categories stratified by Hispanic/Latina ethnicity Methods TW in 7 US cities were recruited via respondent-driven sampling, consented, interviewed, and offered HIV testing. Data from people who were ≥18 years, assigned male/intersex at birth, self-identified as women or TW, spoke English/Spanish, and who had valid responses to variables of interest were included. Participants were grouped by FB status: US-born vs. FB. Log-linked Poisson regression models estimated the association between FB status and past-year UHN due to cost. HIV test results and FB status were assessed for effect modification. Models generated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI). Results Among 1561 TW, 1152 (74%) were US-born and 409 (26%) were FB. 520 (42%) US-born TW and 139 (34%) FBTW tested HIV-positive. Overall, FBTW reported higher prevalence of UHN compared to US-born TW (22.2% vs 19.4%; aPR 1.15, 95%CI 1.01-1.46). There was a significant interaction between HIV test result and FB status (p< 0.05) (Figure). Among those HIV-negative, FBTW reported higher prevalence of UHN compared to US-born (29.3% vs 21.4%; aPR 1.34, 95%CI 1.06-1.69); whereas among those HIV-positive, FBTW reported lower prevalence of UHN’s compared to US-born (8.6%; vs 16.9% vs 8.6%; aPR 0.54, 95%CI 0.32-0.89). Conclusion This finding challenge assumptions that HIV-positive FBTW, often at greater risk of comorbidities and requiring more medical care, would face more barriers to healthcare. Instead, HIV-negative FBTW having higher UHN’s may suggest lack of access to HIV prevention. This raises critical questions on underlying factors contributing to these UHN’s and suggests a complex interaction between HIV status and gender identity and its implications on healthcare access. Status-neutral, comprehensive care approaches must be prioritized for FBTW. Disclosures All Authors: No reported disclosures

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

BackgroundUndiagnosed HIV infection remains substantial in key population subgroups including adolescents, older adults, and men, driving ongoing transmission in sub-Saharan Africa. We evaluated the impact, safety, and costs of community-led delivery of HIV self-testing (HIVST), aiming to increase HIV testing in underserved subgroups and stimulate demand for antiretroviral therapy (ART).Methods and findingsThis cluster-randomised trial, conducted between October 2018 and July 2019, used restricted randomisation (1:1) to allocate 30 group village head clusters in Mangochi district, Malawi to the community-led HIVST intervention in addition to the standard of care (SOC) or the SOC alone. The intervention involved mobilising community health groups to lead the design and implementation of 7-day HIVST campaigns, with cluster residents (≥15 years) eligible for HIVST. The primary outcome compared lifetime HIV testing among adolescents (15 to 19 years) between arms. Secondary outcomes compared: recent HIV testing (in the last 3 months) among older adults (≥40 years) and men; cumulative 6-month incidence of ART initiation per 100,000 population; knowledge of the preventive benefits of HIV treatment; and HIV testing stigma. Outcomes were measured through a post-intervention survey and at neighboring health facilities. Analysis used intention-to-treat for cluster-level outcomes.Community health groups delivered 24,316 oral fluid-based HIVST kits. The survey included 90.2% (3,960/4,388) of listed participants in the 15 community-led HIVST clusters and 89.2% (3,920/4,394) of listed participants in the 15 SOC clusters. Overall, the proportion of men was 39.0% (3,072/7,880). Most participants obtained primary-level education or below, were married, and reported a sexual partner. Lifetime HIV testing among adolescents was higher in the community-led HIVST arm (84.6%, 770/910) than the SOC arm (67.1%, 582/867; adjusted risk difference [RD] 15.2%, 95% CI 7.5% to 22.9%; p < 0.001), especially among 15 to 17 year olds and boys. Recent testing among older adults was also higher in the community-led HIVST arm (74.5%, 869/1,166) than the SOC arm (31.5%, 350/1,111; adjusted RD 42.1%, 95% CI 34.9% to 49.4%; p < 0.001). Similarly, the proportions of recently tested men were 74.6% (1,177/1,577) and 33.9% (507/1,495) in the community-led HIVST and SOC arms, respectively (adjusted RD 40.2%, 95% CI 32.9% to 47.4%; p < 0.001). Knowledge of HIV treatment benefits and HIV testing stigma showed no differences between arms. Cumulative incidence of ART initiation was respectively 305.3 and 226.1 per 100,000 population in the community-led HIVST and SOC arms (RD 72.3, 95% CI −36.2 to 180.8; p = 0.18). In post hoc analysis, ART initiations in the 3-month post-intervention period were higher in the community-led HIVST arm than the SOC arm (RD 97.7, 95% CI 33.4 to 162.1; p = 0.004). HIVST uptake was 74.7% (2,956/3,960), with few adverse events (0.6%, 18/2,955) and at US$5.70 per HIVST kit distributed. The main limitations include the use of self-reported HIV testing outcomes and lack of baseline measurement for the primary outcome.ConclusionsIn this study, we found that community-led HIVST was effective, safe, and affordable, with population impact and coverage rapidly realised at low cost. This approach could enable community HIV testing in high HIV prevalence settings and demonstrates potential for economies of scale and scope.Trial registrationClinicaltrials.gov NCT03541382.

High HIV infection rates in the United States are increasingly due to heterosexual risk behaviors, with increased rates in blacks and women. A survey of HIV knowledge and attitudes about HIV testing was conducted in an inner-city public housing population that included a convenience sample of residents of South Side Chicago Housing Authority facilities. The questionnaire addressed knowledge about HIV transmission and disease, health care options, condom use, prior HIV testing, and preferred places for HIV testing and education. Five hundred residents, ages 13-50 years completed the survey, during the period from November 2002 until April 2003. Eighty-three percent of the respondents were female and 50% of those surveyed were from 18-30 years of age. Race/ethnicity was not questioned in order to improve response rate. A comparable sample conducted earlier showed that population was 99% black race. Most respondents were knowledgeable about HIV transmission risk factors, although misinformation about transmission, treatment and prevention existed. Knowledge that HIV therapy is available was high (71%), while 25% thought an HIV vaccine was available and 13% thought there was a cure for HIV. Two thirds of sexually active respondents reported condom use in the past year. Three quarters reported previous testing for HIV and 90% of those tested returned for results. Most respondents wanted to learn more about HIV risk factors, testing and treatment but preferred primary care clinics to specialized places for HIV testing. Targeted HIV education interventions in the public housing facilities or primary care clinics are warranted.

Research documents the link between traditional ideologies of masculinity and sexual risk among multi-ethnic male adolescents and White male college students, but similar research with Black heterosexual men is scarce. This exploratory study addressed this gap through six focus groups with 41 Black, low- to middle-income heterosexual men aged 19 to 51 years in Philadelphia, PA. Analyses highlighted two explicit ideologies of masculinity: that Black men should have sex with multiple women, often concurrently, and that Black men should not be gay or bisexual. Analyses also identified two implicit masculinity ideologies: the perception that Black heterosexual men cannot decline sex, even risky sex, and that women should be responsible for condom use. The study's implications for HIV prevention with Black heterosexual men are discussed.

To the Editor: We recently published our findings from the HIV Testing Survey (HITS),1 a study designed by the Centers for Disease Control and Prevention to assess the potential effect that HIV infection reporting might have on delaying or deterring high-risk persons from seeking HIV testing.2,3 HITS has been conducted among the traditional HIV risk groups of men who have sex with men, injection drug users, and high-risk heterosexuals. Missing from these evaluations have been male-to-female (MTF) transgenders, a population at high risk for HIV infection. Transgenders are persons who are born one sex but identify as either the opposite sex or as transgender. Previous studies have demonstrated high rates of HIV infection and risk behaviors among MTF transgenders, those born male but who later identify as female or transgender.4,5 In San Francisco, previous studies of MTF transgenders have found an HIV prevalence rate of 35%6 and incidence rates of 7.8 per 100 person-years7 and 12.5% per year.8 We conducted a modified version of HITS among MTF transgenders in San Francisco to determine knowledge of HIV reporting regulations and the potential effect that HIV reporting might have on deterring or delaying HIV testing in this population. Females or MTF transgender-appearing persons were recruited from 8 transgender-focused social service agencies, 6 bars, 7 street locations, and 4 community event that were known to be frequented by MTF transgenders between June 26 and October 18, 2002. Persons aged ≥18 years who had resided in California for at least the past 6 months and who were born male but currently identified as female or who identified as transgender currently or at some time in their lives were eligible to participate. Those who provided verbal consent were administered an anonymous face-to-face interview immediately following recruitment or the following day at a nearby agency or the San Francisco Department of Public Health. Participants were compensated $25 for their time. Of a total of 181 eligible persons, 153 (85%) participated. Two were enrolled prior to July 1, 2002, the day that HIV reporting using a non–name code was implemented in California, and were excluded from analysis of knowledge of reporting regulations. Fourteen percent of subjects were white, 37% Latina, 22% African American, and the remainder predominantly Asian and Pacific Islanders. Fifty percent had monthly incomes of ≤$1000. Thirty-four percent were commercial sex workers and 8% sold illicit drugs. Forty-eight percent lacked health insurance. One hundred forty (92%) of the subjects had been HIV tested and 34 (22%) knew they were HIV infected. Among the 13 subjects who had never been tested for HIV infection, 3 noted that fear of having their name reported to the government if they tested positive was one reason they had not tested for HIV infection, but none of these subjects cited this as their most important reason for not testing. Subjects who did not report being HIV infected were presented with several, not mutually exclusive, descriptions of HIV reporting in California. There were 52 participants (44%) who correctly noted that California HIV reporting regulations require reporting using a unique identifier. However, only 5 (4.3%) of subjects were able to correctly identify California HIV reporting system as using a unique identifier reporting and to correctly note that California does not use any of the other HIV reporting systems presented (Table 1).Table 1: HIV Testing and Knowledge of HIV Reporting Regulations Among Male-to-Female Transgenders, San Francisco†Consistent with our prior study,1 HIV testing rates were high and fear of having their name reported to the government was an infrequent reason for not testing. The proportion of participants who correctly answered the reporting system questions was similar in the transgender and traditional HITS, suggesting that knowledge of reporting regulations is limited. Information obtained so far suggests that HIV reporting does not appear to be a substantial deterrent to HIV testing. Sandra Schwarcz, MD, MPH Susan Scheer, PhD, MPH Department of Public Health, San Francisco, CA

Sexually transmitted infections (STIs) are a common reason for evaluation in the emergency department (ED). Given the overlapping risk factors for STIs, patients screened for gonorrhea and chlamydia should be tested for syphilis and HIV. Syphilis and HIV testing rates in the ED have been reported to be low. The study objective was to examine whether collaboration between emergency medicine (EM) and infectious disease (ID) providers improved syphilis and HIV testing in the ED. A multidisciplinary team of EM and ID providers was formed to identify and address barriers to syphilis and HIV testing in the ED. Syphilis, HIV, chlamydia, and gonorrhea testing and infection rates were calculated and compared during 2 time periods: preintervention (January 1, 2012-December 30, 2017) and postintervention (November 1, 2018-November 30, 2019). We also extracted clinical and laboratory data from patients with positive syphilis and HIV results during the study period. The most commonly cited barrier to syphilis and HIV testing was concern about follow-up of positive results. Compared with the preintervention period, syphilis and HIV testing rates increased significantly in the postintervention period (incidence rate ratios, 30.70 [P < 0.0001] and 28.99 [P < 0.0001] for syphilis and HIV, respectively). The postintervention period was also associated with a significant increase in the identification of patients with positive syphilis and HIV results (incidence rate ratios, 7.02 [P < 0.0001] and 2.34 [P = 0.03], respectively). Collaboration between EM and ID providers resulted in a significant increase in syphilis and HIV testing and diagnosis in the ED.

Less data exist on HIV testing rates among male couples. By using dyadic data from 142 male couples, we found that less than a quarter of the men had been tested for HIV in the previous 3 months. Few factors also were associated with their most recent HIV test.

A cross-sectional survey among 550 randomly selected 16–19-year-olds in Ndola, Zambia, assessed the influence of individual (e.g., HIV knowledge), relational (e.g., discussed HIV testing with family), and environmental factors (e.g., distance) on adolescents’ use of HIV counseling and testing. A multivariable logistic regression analysis comparing respondents who have taken an HIV test to respondents who have not found that at the relational level believing that one’s family would not be upset if the youth has taken an HIV test (adjusted odds ratio [AOR] = 5.08; 95% confidence interval [CI] = 1.16–22.35); and having discussed with a family member whether or not to take an HIV test (AOR = 3.51; 95% CI = 1.08–11.47) were significantly related to adolescent testing. At the individual-level, having ever had sex (AOR = 6.43; 95% CI = 2.14–19.30) and being out-of-school (AOR = 2.95; 95% CI = 1.32–6.59) were also strongly associated with HIV testing. Environmental measures were not found to be significantly related to HIV testing. These findings support the need to examine not only individual characteristics but also relational level factors, particularly the role of families, when implementing and evaluating adolescent HIV testing strategies. Programs to increase communication about HIV testing and counseling within families should be tested in a prospective design in order to assess the impact on young people’s decisions to learn their HIV status and subsequent health seeking and protective behaviors.

The continuum of HIV care among black men who have sex with men (BMSM) continues to be the least favorable in the United States. BMSM are disproportionally HIV-infected-but-unaware, despite expanded HIV testing efforts among this subgroup. We meta-analytically analyzed various HIV testing patterns [lifetime, after 24 months, after 12 months, after 6 months, and frequent (every 3-6 months) testing] among BMSM using the PRISMA guideline. PubMed, MEDLINE, Web of Science, and PsycINFO were searched for relevant articles, reports, conference proceedings, and dissertations published between January 1, 1996, and April 25, 2018. Two independent investigators reviewed and abstracted data into a standardized form. We used the DerSimonian-Laird random-effect model to pool the HIV testing prevalence and I-square statistics to measure heterogeneity. Funnel plots and Egger tests were used to assess for publication bias. We also performed subgroup and meta-regression analyses to explore aggregate-level characteristics that explain the heterogeneity across studies. Our meta-analysis includes a total of 42,074 BMSM pooled from 67 studies. Lifetime HIV testing prevalence was high, 88.2% [95% confidence interval (CI): 86.2% to 90.1%], but recent (after 6 months = 63.4%; 95% CI: 59.3% to 67.4%) and frequent (42.2%, 95% CI: 34.1% to 50.3%) HIV testing prevalence was low. Meta-regression suggests that younger age (borderline significant), lower annual income, and homelessness were correlated with lower lifetime/recent HIV testing prevalence; while ever having condomless insertive/receptive sex, alcohol consumption, and illicit drug use were associated with higher lifetime/recent HIV testing prevalence. Recent and frequent HIV testing remains suboptimal among BMSM. Future testing programs should prioritize strategies to enhance self-initiated, regular HIV testing among BMSM.

Although the Chinese government provides free-of-charge voluntary HIV counseling and testing, HIV testing rates among men who have sex with men (MSM) are reported to be extremely low. This study examines the association of structural and psychosocial factors and social network characteristics with HIV testing behaviors among "money boys" and general MSM in Shanghai. Overall, 28.5% of "money boys" and 50.5% of general MSM had never tested for HIV despite high rates of reported HIV risk behaviors. Factors associated with not testing for HIV included: not knowing of a testing site, limited HIV knowledge, low perceived HIV risk, concern about HIV testing confidentiality, being a closeted gay, not using the Internet, and having a small social network or network with few members who had tested for HIV. Future efforts to promote HIV testing should focus on outreach to general MSM, confidentiality protection, decreasing the stigma of homosexuality, and encouraging peer education and support through the Internet and social networks.

BackgroundSuboptimal HIV testing rates through available testing approaches such as HIV counselling and testing have directed research efforts toward recognizing the potential of HIV self-testing as an additional testing method. However, HIV self-testing is not readily available within HIV testing facilities and data on how HIV self-testing and HIV counselling and testing will co-exist within HIV testing facilities is limited. Therefore, this study sought to fill this knowledge gap.MethodsForty consenting adults were exposed to HIV counselling and testing and HIV self-testing using a cross-over study design between February 2016 and February 2017 resulting in 80 (20,20) interviews. Participants were randomly exposed to HIV counselling and testing first, followed by self-testing, or HIV self-testing first, followed by counselling and testing. In-depth interviews were conducted at baseline, and after each testing exposure, using a semi-structured interview guide. Interviews were transcribed and translated prior to doing the framework analysis.ResultsSupport through counselling played a central role in the HIV testing process for some participants who desired support or were not confident to perform unsupervised HIV self-testing. The complementary relationship between HIV self-testing and HIV counselling and testing requires a combination of benefits such as availability of counselling, confidence, convenience and confidentiality (4 Cs) derived from HIV self-testing and HIV counselling and testing. Implementation of the 4 Cs will depend on the availability of unsupervised HIV self-testing and/or supervised self-testing with support from HIV counselling and testing.ConclusionsAs treatment and prevention efforts expand, the reasons for and frequency of testing is changing and there is a need to develop differentiated models for providing HIV testing services to meet client’s needs. HIV self-testing is an important addition to enhance HIV testing efforts and should be offered in combination with HCT.

Exploring the role of healthcare affordability in lifetime HIV testing among young adults in Tennessee, United States