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MSM Testing Drive Works Well in Australia-Except for One Thing
  AIDS 2020: 23rd International AIDS Conference Virtual, July 6-10, 2020
Mark Mascolini
In Australia’s state of New South Wales, a statewide drive to expand HIV testing in men who have sex with men (MSM) has met with success, according to an analysis at Sydney’s Kirby Institute [1]. Although increasing HIV testing probably contributes to an overall decline in estimated undiagnosed HIV infection, undiagnosed HIV is rising in one group: overseas-born MSM.
Since 2012 New South Wales has formulated two sets of HIV strategies with goals for upcoming years. Both strategies prioritize HIV testing among MSM. Kirby Institute investigators set out to determine whether the state has achieved this goal by answering two main questions: Has HIV testing increased among MSM in New South Wales? Over the same period, has the proportion of MSM with undiagnosed HIV dropped? The researchers also wanted to know if these and other results differ between MSM born in Australia and those born overseas and now living in Australia. About 40% of overseas-born MSM come from Europe, 33% from Asia, 7% from Central and South America, and the rest from Oceania, North America, Africa, the Middle East, and Central Asia.
In New South Wales, the institution largely responsible for promoting HIV testing in MSM is ACON, the largest community-based HIV service organization in the state. Strategies to increase HIV testing in these men include phone text testing reminders, express testing clinics, rapid HIV testing, blood-spot testing, and community-based peer-led HIV testing. The state Ministry of Health funded private primary-care clinician training in HIV testing.
The Kirby researchers gathered 2010-2018 data from three sources: the New South Wales denominator data project, a sentinel surveillance system (ACCESS) that collects data from 25 clinics serving MSM, and the New South Wales HIV notification database. They used Poisson regression to estimate trends in HIV testing and join point models to assess possible changes in these trends. To estimate the proportion of MSM with undiagnosed HIV, the investigators used back-projection modeling of CD4 counts at diagnosis.
Total number of HIV tests conducted in New South Wales rose from 205,237 in 2012 to 291,210 in 2018, an annual average percentage change (AAPC) of 5.8%. The researchers also determined that the number of MSM attending ACCESS HIV testing clinics rose by an AAPC of 14.3% from 2010 to 2018 in Australia-born MSM and even more among overseas-born MSM, 19.2%. Overall the number of MSM attending those clinics jumped from about 5000 in 2010 to over 16,000 in 2018.
The proportion of MSM who got an annual HIV test (recommended for sexually active MSM) rose from 2010 to 2018 by an AAPC of 1.6% in Australia-born men and by 1.1% in overseas-born men. And testing frequency in high-risk MSM climbed in the same period by 9.0% in Australia-born men and by 8.7% in overseas-born men. (High risk is denoted by injecting drug use, rectal sexually transmitted infections, more than 20 partners per year, or PrEP use.)
In addition, the proportion of MSM diagnosed with an STI who got tested for HIV within 30 days before or 60 days after the STI diagnosis jumped from 2010 to 2018, by 2.6% in Australia-born men and by 2.7% in overseas-born men. Over the same period, the rate of HIV test positivity dwindled by 6.5% in Australia-born MSM and by 7.6% in overseas-born men.
Finally, New South Wales achieved the goal of lowering the overall proportion of undiagnosed HIV in MSM from 9.5% in 2010 to 7.7% in 2018. But that rate dropped only in Australia-born men, from 7.1% to 2.8% (AAPC 11.1%), while rising from 15.3% to 16.9% in overseas-born men (AAPC 1.2%). The undiagnosed HIV estimate is about 6 times higher in overseas-born men than in Australia-born men. About half of HIV diagnoses in the overseas group are late diagnoses.
The Kirby Institute team believes this last finding indicates a need for more programs outside the clinic to encourage overseas-born men to get tested, perhaps via self-testing or mail-in testing. The researchers also think barriers to PrEP must be addressed more strenuously in MSM born outside Australia. But the other findings all indicate that expanded HIV testing by MSM can by attained by vigorous promotion of effective testing strategies.
1. Patel P, Keen P, McManus H, et al. Increased targeted HIV testing and reduced undiagnosed HIV infections among gay and bisexual men in New South Wales, Australia 2010-2018. AIDS 2020: 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract OAC0205.