Rapid HIV tests did not result in a sustained increase in testing, although the rate of initial HIV testing increased by a third in a study of men who have sex with men (MSM).

This non-blinded randomised control study was based in the Melbourne Sexual Health Centre. The men were aged >18, reported having sex with a man within the previous year, had had a negative HIV test within the previous two years, and were attending for clinical care.

A total of 400 MSM were randomised in a ratio of 1:1 to either on-going access at the health centre to rapid finger-prick point of care tests (intervention group) or conventional serological HIV testing (controls).

The intervention group received their results in 20 minutes whereas those in the conventional testing arm received theirs in a week. Recruitment took place between September 2010 and March 2011.

All men were offered screening for other STIs. They were sent text messages at months 3, 9 and 15 recommending regular HIV testing and offering either an HIV test or a rapid HIV test according to their allocation. They were also emailed at 6, 12 and 18 months with a link to an online questionnaire.

Primary outcome was the incidence of HIV testing over the 18 months of follow-up – this included tests at the study clinic or elsewhere. As no other rapid tests for HIV were approved in Australia at that time, tests at other sites would have been on serological samples. Men who stated that they had had HIV testing in other clinics had this verified by researchers.

Secondary outcome was incidence of testing for STIs such as chlamydia, gonorrhoea and syphilis to determine if rapid HIV testing would result in a decrease in testing for other STIs.

Among 200 men assigned to rapid testing, five were diagnosed with HIV (two at baseline), six were lost to follow-up and 189 completed 18 months’ follow-up (94.5%). In the control group there were five HIV diagnoses of which three were at baseline, and 181 completed follow-up (90.5%).

The incidence of HIV testing in the rapid and conventional HIV testing arms over the 18 months of follow-up was 1.63 and 1.42 tests a year respectively; this represents a rate ratio (RR) of 1.15 (95% CI:0.96-1.38, P = 0.12). If only the first HIV test after enrolment were included, the rate was 1.32 in the rapid arm and 1.01 in the conventional arm; RR 1.32 (95% CI:1.05-1.65, P = 0.02). When the first HIV test after enrolment was excluded, the rate was 1.86 tests a year in the rapid test arm and 1.83 in the conventional arm; this represents an RR of 1.01 (95% CI:0.86-1.20, P = 0.90).

False-positive tests were more common with rapid tests than with conventional serology (1.5% vs 0.2%). The rate of testing for other STIs did not vary greatly between study groups.

Most of the men in the intervention arm said they preferred the rapid tests over conventional tests 88%.

Men in that group were also more likely than those in the control group to report that obtaining their HIV test result was convenient (74% vs 41%). Men with access to only conventional serology were more likely  than those in the intervention group to: feel that the wait for the result was too long (59% vs 9%), report anxiety because of the wait (63% vs 44%) and delay their next test because of this anxiety (24% vs 13%).

Apart from an initial increase in the frequency of HIV testing by a third in the rapid test arm compared with the conventional test arm, the study has not demonstrated a sustained increase in testing frequency over the follow-up period of 18 months.

A Department of Health/Health Protection Agency evaluation of HIV testing pilots in general practices in high prevalence areas in London and Brighton using POCTs found them to be acceptable with high uptake rates in different demographics but the incidence of new HIV diagnoses was low.

An accompanying editorial noted a persistent 25% of HIV-positive MSM who remain undiagnosed despite efforts made in HIV prevention and expanded access to testing in this group. There was a suggestion that there is a cohort of the undiagnosed population that do not respond to current interventions for HIV testing and many different strategies need to be considered to promote HIV testing to this group, this may include access to home testing.

There is clearly a need to consider novel strategies to increase the uptake of HIV testing especially in high-risk groups. NICE has already published guidance to encourage expanded testing for MSM and Black Africans.

Any novel approach needs to consider testing beyond conventional settings such as GUM clinics in order to improve coverage and access for

high-risk groups; such an approach will need to mobilise general practice, secondary care, internet and home testing. With any strategy, this needs to be linked to effective post-test counselling and referral for confirmatory HIV testing and treatment.

Dr Richard Ma