Original ResearchPreferences for oral fluid rapid HIV self-testing among social media-using young black, Hispanic, and white men-who-have-sex-with-men (YMSM): implications for future interventions
Introduction
In the United States (US), black, Hispanic, and white young (18–24 year-old) men-who-have-sex-with-men (YMSM) are disproportionately affected by the HIV epidemic,1, 2, 3, 4, 5, 6 as exhibited by increasing HIV incidence rates,1, 5, 7, 8 high HIV prevalence, and high levels of undiagnosed HIV infections2, 8, 9, 10 among this population. Although HIV testing rates appear to be improving among YMSM, they are relatively lower than for other MSM, which limits their chances of receiving appropriate treatment and impedes efforts to reduce the occurrence of new infections among their sexual or injection drug-using contacts.2, 8, 11, 12 Barriers such as lack of access to and availability of testing centers, healthcare insurance, medical providers, and transportation options, as well as concerns about confidentiality might prevent some YMSM from being tested at medical facilities and community organizations.13
Despite obviating some of the concerns and inconveniences of traditional venue-based HIV testing, the sole commercially available home-based conventional (i.e. non-rapid) mail-in blood sample collection HIV test (Home Access® HIV-1 Test System, Home Access Health, Hoffman Estates, IL) available in the US is used infrequently by MSM.14 A major limitation of this test is that users must collect a blood sample on a gauze pad, mail it to the testing center, and then telephone the laboratory several days later before obtaining the results.13, 15, 16 The cost of testing also might be a barrier to its use. Given the lower than critically needed testing rates observed among black, Hispanic and white YMSM in the US and the limits of current testing options, other means of increasing HIV testing appear to be necessary.
In 2012, the US Food and Drug Administration approved the OraQuick® In–home rapid HIV test (OraSure Technologies, Bethlehem, PA) for oral fluid self-testing as an over-the-counter test.17 A prime motivation for the oral fluid HIV self-test has been to increase the availability and convenience of HIV testing. The test is provided in a kit with step-by-step instructions on how to obtain the oral fluid sample, conduct the test, and read the results. The company provides free telephone-based assistance to those with queries about conducting the test, interpreting the results, and how and where to seek help if concerns arise or the test result is positive. The OraQuick® In–home rapid HIV test is a re-packaging of the company's oral fluid rapid HIV test (current version is the OraQuick® ADVANCE rapid HIV-1/2 antibody test) which is performed by a clinician or other test provider. The company's original oral fluid rapid HIV test became commercially available in the US in 2004 and subsequent iterations of the test have been used in clinical, nonclinical, and community outreach testing. Per the manufacturer's package insert information, the OraQuick® In–home rapid HIV test sensitivity is 91.7% and specificity is 99.9%,18 whereas the OraQuick® ADVANCE Rapid HIV-1/2 antibody test sensitivity is 99.3% and specificity is 99.8%19 (although some post marketing studies have reported lower values).20 In addition to this commercially available oral fluid rapid HIV self-test, over-the-counter fingerstick blood sample rapid HIV self-tests are under consideration for home-based use, although they are not yet offered in the US.21
Because the oral fluid rapid HIV self-test is widely accessible for purchase in stores or via the internet in the US, is considered easy to use, involves an oral swab instead of a blood sample, is private, and provides test results within 20 min, it is possible that this testing method might be employed in public health outreach campaigns to increase testing utilization among black, Hispanic, and white YMSM. Before such potentially costly public health approaches can be recommended, it is crucial first to assess YMSM willingness to use oral fluid rapid HIV self-testing as compared with other currently readily available HIV testing options. Given the widespread popularity among and the ubiquity of social media outlets for this population, it would be particularly useful to measure willingness to use the test among social media users, since these venues could be used to access this hard-to-reach population quickly and confidentially. Although prior research indicates interest by MSM in using the oral fluid rapid HIV self-test,22 it is more revealing to gauge testing preferences in context to the myriad of testing choices available to YMSM. YMSM might indicate they are interested in the oral fluid rapid HIV self-test, but when asked which test they would actually use, they might choose another testing option. In such a scenario, distributing the tests to YMSM in community outreach campaigns might not increase testing more than encouraging these men to use other HIV testing options. It also would be helpful to know which factors (e.g. demographic characteristics, HIV testing history, sexual HIV risk-taking behaviors, and aspects about oral fluid rapid HIV self-testing) might influence YMSM willingness to use the oral fluid rapid HIV self-test over other HIV testing options. Such factors could be incorporated into the design of interventions aimed to increase oral fluid rapid HIV self-testing among this high HIV risk population.
The primary objective of this investigation was to assess the extent to which social media-using black, Hispanic, and white YMSM are willing to use oral fluid rapid HIV self-testing, as compared with other readily available HIV testing options (testing at medical facilities or community organizations and home-based mail-in blood sample collection HIV testing). The secondary objective was to identify factors that influence willingness to use the oral fluid rapid HIV self-test, as compared with other HIV testing options. We also examined if consideration of the costs of oral fluid rapid HIV self-testing and if the potential future availability of fingerstick blood sample rapid HIV self-test influence testing preferences.
Section snippets
Study design
This cross-sectional study involved an anonymous, internet-based survey of social media-using black, Hispanic, and white YMSM across the US from August–December 2014. Participants answered questions about their demographic characteristics, HIV testing history, and injection-drug and sexual HIV risk-taking behaviors followed by the main study questionnaire about HIV testing preferences and opinions. To avoid influencing responses, participants were not informed, and no part of the questionnaire
Participant characteristics
Of the 1975 YMSM participants (Fig. 1), the median age was 22 years (IQR 20–23); 19% were black, 36% Hispanic, and 45% white; 70% had a primary health care provider or clinic; and 76% were covered by health care insurance. Few had ever injected drugs (2%), the majority had condom-less anal sex with another man within the past six months (64%), and many reported having had two or more casual condom-less insertive (40%) or receptive (41%) anal sex partners. Most had been tested for HIV (89%).
Discussion
This investigation provides insight into the HIV testing preferences among social media-using black, Hispanic, and white YMSM in the US, as well as implications for future efforts to increase HIV testing among this high HIV risk population. Despite the widespread availability of oral fluid rapid HIV self-testing in the US and its perceived advantages over other currently available HIV testing options, few social media-using YMSM had ever used this test or anticipated using it in the future.
Ethical approval
Lifespan-Rhode Island Hospital Institutional Review Board 1 approval, (Ref No: 014713).
Funding
This research was supported by a grant from the National Institute of Nursing Research (R21 NR023869). ClinicalTrials.gov Identifier: NCT02369627.
Competing interests
None declared.
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