If you’ve ever had to wait two agonising weeks for a HIV test result, you’ll be pleased to hear that rapid HIV tests can now give an equally accurate result in just 30 minutes. The problem is, these tests aren’t available in Australia. Not yet, anyway.
While HIV tests are obviously an essential tool for timely diagnosis, the contact with health professionals is equally important because it facilitates discussions about prevention.
Or, if the result is positive, counselling can focus on behaviour modification to reduce the risk of onward transmission.
Services in the United States and Europe have been offering rapid point-of-care HIV testing in community settings for the past ten years. But current Australian HIV testing policies and other restrictions preclude the use of such devices except in very restricted circumstances.
The Australian Society of HIV Medicine (ASHM) is currently reviewing these guidelines and is likely to recommend the widespread availability of rapid HIV tests.
Reducing HIV transmission
Like many other developed countries, Australia has seen a substantial increase in HIV diagnoses over the past decade. Around 85% of these new infections are from sexual contact between men.
The rise has been attributed to more risky sexual behaviours among gay men and dramatic increases in other sexually transmitted infections (STIs) that are known to increase HIV transmission risk.
To reduce onward HIV and STI transmissions, we need to increase diagnostic testing. And the best “bang for our buck” will come from testing high-risk individuals more often.
Current testing guidelines recommend three to six monthly HIV testing for “high risk” gay men (those visiting sex-on-premises venues or reporting high numbers of sexual partners). This classification would apply to around half of the men completing annual national gay community behavioural surveys.
But research shows the proportion of high risk gay men in Australia adhering to such guidelines is as low as 15%.
Mathematical modelling suggests people who aren’t aware of their HIV positive status are disproportionately contributing to new HIV transmissions – again, a factor that can be addressed through more frequent testing.
With extensive health promotion campaigns encouraging regular testing, why don’t gay men have more frequent HIV tests?
Reducing the testing barriers
Finding the time to visit a GP clinic or sexual health service and the availability of appointments is a key barrier to regular testing.
The requirement for a return visit to receive the results adds to this burden. For high risk men, this may mean four to eight clinic appointments a year.
Just how realistic is this expectation of eight appointments a year?
Technical advances in rapid HIV testing over the past decade mean rapid tests perform just as reliably as traditional tests, offering a valuable alternative to overcome these barriers.
There are many advantages to rapid testing at the point-of-care:
It’s non-invasive and most commonly uses a finger-prick blood specimen;
Results are available within 30 minutes;
Testing can take place almost anywhere (night clubs, cruising beats, sex-on-site venues, festivals, among other places.);
Testing can be done by non-clinical (but well-trained) staff; and
Individuals are only required to return for another visit if their rapid test is “preliminary positive”, which only accounts for a small proportion of tests.
A recent Burnet Institute systematic review of community models for rapid HIV testing in the US, Europe and New Zealand showed the services have attracted significant proportions of high-risk gay men and men who have never been tested for HIV.
The testing included pre- and post-test counselling, support and referral processes. Clients reported high rates of satisfaction with the non-clinical staff (usually peer educators and counsellors), who were empathic and fitted in well in the community setting.
Who should provide rapid tests?
If and when rapid HIV testing is approved, we’re likely to see some robust discussion about who should provide these tests.
Clinicians have resisted the idea of having non-clinically trained staff undertake rapid HIV tests. But this seems to based on notions of professional boundaries and overestimates the ability of clinically-trained staff like doctors and nurses to deliver culturally appropriate health services to at-risk groups on the ground.
A clinic-based GP who requires booking days or weeks in advance and allocates ten minutes for an appointment, for instance, isn’t going to have the same reach as allied health care staff.
Peer educators, on the other hand, may provide more appropriate services to test and counsel men who engage in risky sex, for example in outreach settings such as at nightclubs or sex-on-premises venues. This involvement of “affected” communities has been widely recognised as an essential part of the effectiveness and appropriateness of the HIV response.
With the rest of the world making progress in reducing barriers to testing and providing greater access to health services, Australia can’t afford to be left behind.
The current ASHM review, which is expected to be submitted to the Commonwealth Department of Health and Ageing, must enable non-clinicians to undertake rapid HIV tests where they’re needed.