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Testing times:Home testing and testing initiatives in Sexual Health & HIV
Dr Michael BradyMedical Director, Terrence Higgins Trust
Consultant, Sexual Health and HIV
Content
Context: the case for a dramatic increase in HIV testing
HIV home sampling
HIV home testing
STI home testing
HIV: the story in 2015
• 107,800 people were living with HIV by the end of 2013
• People living with HIV can expect a near normal life expectancy if diagnosed early
• Late diagnoses (42%) and undiagnosed infections (24%) remain the biggest challenge
3
SOPHID
Treatment cascade of adults living with HIV: United Kingdom, 2012
4 Treatment cascade of adults living with HIV: United Kingdom, 2011
HIV infected (n=98,400) HIV diagnosed Retained in care On treatment Undectable VL0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%100%
79%
73%
69%
62%
Undiagnosed
UK MSM: High proportion with viral suppression,but high and probably rising incidence of HIV
~600,000 MSM in UK
~45,000 living with HIV
~25% undiagnosed
~95% of ART experienced men are on ART
~95% of men on ART have viral suppression
~60% of HIV positive men have viral suppression
Sources: NATSAL, Public Health England (PHE)See also Birrell et at; Lancet Infect Dis 2013
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 1 2 3 4 5 Years from infection
base test rate(currentsituation)
test rate +
test rate ++
Probability of having been diagnosed
Potential increases in testing: Probability of diagnosis by time from infection For those infected after 2015
Phillips A et al 21st CROI, Boston 2014HIV in MSM in the UK: Prevention effects of ART in perspective
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 1 2 3 4 5 Years from infection
test rate ++ ART 350
base test rate ART at diagnosis
test rate + ART at diagnosis
test rate ++ ART at diagnosis
test rate + ART at 350
base test rate ART at 350
Probability of having started ART
Potential increases in testing & change in ART initiation criteria: Initiation of ART by time from infection For those infected after 2015
Phillips A et al 21st CROI, Boston 2014HIV in MSM in the UK: Prevention effects of ART in perspective
0
1000
2000
3000
4000
5000
Number of new infectionsper year (95% CI)
2015 2020 2025 2030 Year
HIV incidence
% reduction in 2030
32%32%
54%
64%
80%
test rate ++ ART at 350
base test rate ART at diagnosis
test rate + ART at diagnosis
test rate ++ ART at diagnosis
test rate + ART at 350
base test rate ART at 350
Phillips A et al 21st CROI, Boston 2014HIV in MSM in the UK: Prevention effects of ART in perspective
0
20000
40000
60000
80000
100000
2015 2020 2025 2030
Number of men with HIV (age 15-65)
Year
Numberofmen
test rate ++ ART 350
base test rate ART at diagnosistest rate + ART at diagnosis
test rate ++ ART at diagnosis
test rate + ART at 350
base test rate ART at 350
Phillips A et al 21st CROI, Boston 2014HIV in MSM in the UK: Prevention effects of ART in perspective
Cost effectiveness analysis
- Incremental cost-effectiveness ratio for moving from current scenario to test rate ++ ART at diagnosis assuming future generic drug costs
= £1,500 per QALY gained.
- Incremental cost-effectiveness ratio for scenario test rate ++ assuming future generic drug costs
= £9,500 per QALY gained.
- These low values mean that there is scope for considerable expenditure on projects to promote higher rates of testing.
Phillips A et al 21st CROI, Boston 2014HIV in MSM in the UK: Prevention effects of ART in perspective
Consequences of late presentation
Mortality Morbidity Treatment response Transmission Cost
The impact of HIV testing
Individual benefit – access to treatment & care
Population benefit – impact on transmission
HIV prevention strategies depend on knowledge of status
Challenge: how to deliver the volume of testing that will have maximal impact?
HIV testing
Normalising testing Non sexual health
settings Testing those at risk
‘Opt-out testing’• > 2:1000
prevalenceRisk groupsClinical settingsIndicator illnesses
Barriers to HIV Testing
Clinician
Time Confidence Knowledge Fear of stigmatising Concerns around
“counselling”
Patient
Stigma Lack of knowledge Fear of disclosure Lack of perceived risk Access to health-care Fear of positive result
Solutions……
Empower people to self-manage their HIV test
Build capacity by taking HIV testing out of the clinic
Develop systems that encourage not just uptake of testing but regular testing
Ensure this process is integrated with ‘traditional’ services not isolated from them
HIV testing strategies
Impact of ‘new’ testing technology
Online home HIV sampling
Home HIV testing
HIV testing technologies
Point of care testingLaboratory testing (postal)
Alere determine 4th generation
INSTI3rd generation
Orasure3rd generation
The Doctors Laboratory – ‘Tines’
Dried blood spot testing
• HIV tests ordered on-line • 4th generation dried
blood spot / ‘tiny’ vial • 3rd generation oral swab
• Samples posted to laboratory
• Individual informed of result• Negatives by text• Positives by phone
• Referral to HIV service recommended / facilitated
HIV Self-Sampling Services
Home sampling experience (THT and Dean Street)
Service ActivityReturns
(%)Positivity
(%)
Jan – Sep 2013Nov 2013 – March 2014
17,701 requests
11,488(64.9%)
171(1.49%)
Nov 2011 - Aug 2013
4,838requests
2,901(59.9%)
68(2.3%)
PHE supported two services for 5 months of operation (Nov 13 – March 14) which delivered:
− 12,485 test requests
− 6,593 returned (53%)
− 92 new diagnoses (1.4% positivity) 26
Self-reported HIV testing history
27
Never tested Over a year ago Within the last year
n=3270
33%
41%
25%MSM
Black African Heterosexuals
20%
36%
37%
5%
3%
How many sexual partners have you had unprotected (anal or vaginal) sex with in
the last 12 months?
0
1
2-5
6-12
13+
Sexual partners in last year and testing history, MSM
02
04
06
08
01
00P
erc
enta
ge o
f clie
nts
ord
erin
g a
kit
Never tested Over a year ago Within the last year
None 1 2-5 6-12 13+
(n=1088) (n=1350) (n=832)
Geo-demography of users (MSM)
30
Geo-demography of users (MSM)
31
User Satisfaction with the National HIV Self-Sampling Services
ServiceHPE/THT (N=861)
Dean Street (N=229)
Would you recommend the service to a friend expected to test negative
97% 96%
Would you recommend the service to a friend expected to test positive 65% 58%
I would use the service again 97% -
32McOwan et al BASHH/BHIVA conference 2014
“I was really grateful that this existed as I don't think I would have gone to a clinic. I would have taken a lot of courage. an anonymous postal service made it so much easier. I would be really happy if this existed for other sexual health screening.”
Major issues highlighted from pilot phases:
− High volumes can be easily managed through the internet
− Users are different to clinic populations (younger and more rural)
− Used by those at high risk due to testing history and sexual behaviour
− Linked to care− Positive user satisfaction
33
Promoted by HIV prevention campaigns and through social media
Relationship to marketing
18th Nov 2013Dec-13 Jan-14 Feb-14 Mar-14 30th March0
200
400
600
800
1000
1200
1400
1600
1800
2000
MARKETING PUSH
National HIV testing week
Reactives via marketing method
Dating apps Facebook THT staff Health services
It Starts with Me Campaign Leaflet Other social media THT Newsletter
Twitter Word of mouth Other
Reactive test result Negative test result
n=20 n=1,733
20%
30%15%
40%
21%9%
Cost per returned kit via marketing
• Cost per returned test on Twitter:
• Cost per returned test on dating sites:
• Cost per returned test on Facebook:
£19.08
£10.75
£1.87
Cost per reactive via marketing
• Cost per reactive on Twitter:
• Cost per reactive on dating sites:
• Cost per reactive on Facebook:
£1,450
£1,854
£108
Home HIV testing Legal in the UK since April 2014 Currently no testing kit with a CE mark in the UK Unknowns around:
Acceptability Test performance Cost Information, support and access to care
Studies in both developed and developing countries have shown home testing to be highly acceptable (22 – 87%), accurate and adequately done1
1Krause et al BMC Public Health Acceptability of HIV self-testing: a systematic literature review 2013, 13:735 www.biomedcentral.com/1471-2458/13/735
Home HIV tests
Home STI testing…..
Conclusions
We need a dramatic step change increase in HIV testing
Home HIV sampling, and perhaps home HIV testing, has the potential to be a ‘game changer’
Better use of on-line services and social media is the ‘key’
We must truly integrate home sampling and testing in a ‘combination prevention’ approach with sexual health services
Acknowledgements…..
Terrence Higgins Trust Fizza Qureshi, Emmanuel Buenavuntura Dominic Edwards, Peter Kelly, Cary James
Public Health England Samantha Westrop, Anthony Nardone, Noel Gill
PHE Laboratory (Manchester) Ken Mutton, Dave Ellis
Chelsea & Westminster (Dean Street) Dr Alan McOwan
michaelbrady@nhs.net
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