When the HIV epidemic first appeared in the 1980s, there were few apparent benefits to being tested for this virus, as there were no effective treatments. Also, fear and ignorance about a person’s HIV status sometimes led to discrimination.
Now, as we have entered the fourth decade of what has become the HIV pandemic, a range of effective and tolerable therapies is widely available, particularly for people who are initiating therapy. Researchers in high-income countries now predict that a young HIV-positive adult who begins therapy today and takes this therapy exactly as directed and who had no pre-existing health issues will likely live a near-normal lifespan. Such is the tremendous benefit of potent combination anti-HIV therapy (commonly called ART or HAART) in the present era.
After the introduction of ART, in the late 1990s researchers noticed that there was an increase in reports of high-risk sexual behaviour among men who have sex with men (MSM) - unprotected anal sex. This has led to a resurgence of HIV infections in Canada, Australia, Western Europe and the United States. Not surprisingly, there has also been an increase in sexually transmitted infections (STIs) such as syphilis, gonorrhea and hepatitis C virus.
To try to reduce the spread of HIV, public health authorities in high-income countries are encouraging the normalization of HIV testing. That is, rather than restrict HIV testing to special populations or certain situations, HIV testing should be done routinely (with a person’s consent) in community testing sites, offices of family physicians, across most departments of hospitals and, particularly in the U.S., available at home.
Through these efforts, public health officials hope to demystify HIV testing and help more people know their HIV status so they can receive care and treatment and take precautions to not pass on the infection. More widespread HIV testing should also incite awareness of the need to know one’s HIV status and discussion of ways to reduce the risk of transmission.
However, breaking down perceived barriers to HIV testing will not be easy. Research in the European Union has found that barriers to HIV testing can be grouped into three main categories, as follows:
- personal level
- healthcare provider level
- institutional or policy level
At the level of the person, key barriers to HIV testing can include the following:
- a perception of being at low-risk for HIV infection
- fear of HIV disease
- fear of HIV disclosure and its consequences (discrimination and rejection)
- lack of accessibility to health services for testing
Researchers in Scotland have been assessing changes in HIV testing behaviour among men who have sex with men over the past decade. In surveys of more than 1,600 men, a research team in Glasgow has found that what it calls a “partial normalization of HIV testing” seems to have occurred. The researchers also found that while some barriers to testing have been reduced, “other key barriers remain important.” The barriers identified in the Scottish survey are somewhat unique to HIV disease and so are likely applicable to other regions in high-income countries and could inform programs that seek to encourage HIV testing that leads to care and treatment.
The research team surveyed men at “commercial gay venues” in Scotland at two points in time: in the years 2000 and 2010. Overall, 1,625 men were interviewed.
Results - Behaviours
More men who completed the survey (14%) in 2010 reported having unprotected anal intercourse with two or more partners in the past year than in the 2000 survey (9%).
The researchers found that HIV testing behaviours changed as follows:
Proportion tested in the past 12 months
- Year 2000 – 27%
- Year 2010 – 57%
Proportion never tested for HIV
- Year 2000 – 50%
- Year 2010 – 20%
Results - Changes to testing barriers
People surveyed in 2010 were significantly more likely to view HIV testing as beneficial and routine compared to a decade earlier.
However, the survey found that a) there were no significant differences in the fear of having an HIV-positive test result, and b) attitudes toward HIV-positive people had not changed.
Researchers took many factors into account (including age and year surveyed) and found that people who had never been tested (compared to people who had been tested in the past year) felt this way:
- had “a greater fear of an HIV test result”
- were less likely to see HIV testing as a routine test
- had “more negative attitudes to sex with HIV-positive partners”
- had “weaker perceptions of the benefits of HIV testing”
Although people who had been tested for HIV in the past year in 2010 were still afraid of a positive test result, the degree of fear appeared to have been somewhat diminished compared to that in 2000.
The present study’s results are limited due to built-in issues around its design. It was a cross-sectional study; that is, analogous to a snapshot taken with different people at one point in time. It may have been more useful to have recruited a large group of volunteers in 2000 and retained them for a decade and then re-surveyed them. However, such a longitudinal study would have been very expensive, complex and time consuming.
Another drawback is that researchers relied on volunteers’ self-reporting of their HIV status rather than confirming their status with a blood test.
Another potential drawback is that, according to the researchers, there were campaigns in the Scottish media between 2008 and 2010 that “promoted both sexual health and HIV testing every six months among those at risk of acquiring HIV infection and other STIs.” So it is possible that these campaigns could have affected the results of the study, though the researchers suggest that this is not certain.
Focus on change
Whatever the cause(s) for the increase in HIV testing behaviour, the researchers say that the findings from the Scottish study suggest that “the perceived benefits of [HIV] testing have changed at the community level.” The researchers note that this change is “perhaps indicative of the increased acceptability of HIV testing.”
Despite these promising results, there remains much work to be done normalizing HIV testing in Scotland and elsewhere. The research team has found that some barriers to testing continue, such as the following:
- fear of a positive test result (although this appears to be somewhat diminished)
- perceptions of testing availability and convenience of access to clinics offering HIV testing
- negative attitudes toward sex with HIV-positive men
The Scottish team calls for “multifaceted public health initiatives that address biomedical aspects of HIV testing, including the psychological, social and cultural contexts of testing and its consequences.”
Other countries need to study issues around HIV testing so that the needs of MSM and other populations, such as women and people who inject drugs, are met and so that HIV testing, prevention and treatment become routine.
- Sean R. Hosein
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