testing times: home testing and testing initiatives in sexual health & hiv dr michael brady...

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


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





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





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.


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

[email protected]

testing times: home testing and testing initiatives in sexual health & hiv dr michael brady...

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