By Andrew Burry, CEO WA AIDS Council
It seems logical to say that if you increase the rate of HIV testing within a target community, you will be hoping to see an increase in diagnoses among that population. The aim of testing is to identify infection and without an increase you may well conclude that your testing program is misdirected or otherwise unsuccessful. But how do you respond when there is a significant rise in HIV notifications and the media conclude that the safe sex message has been lost? How can you show this is due to increased detection and not infection?
HIV Notifications by Mode of Transmission
HIV Notifications by Mode of Transmission
HIV Notifications among MSM by Clinic
In 2014, Western Australia recorded a total of 139 new diagnoses. This represented an overall increase of 16% compared to 2013 and was driven almost entirely by a 27% increase among gay and other homosexually active men (GHAM).
Significantly, the 2014 result was double the rate of 2009 and the highest annual total since 1991. On January 24 2015, the West Australian reported the increase under a headline: ‘HIV rise points to safe sex decline’, and quoted health authorities as being worried that the safe sex message has fallen off the radar in WA. The rise (among gay men) was labelled as alarming. Interviewed for the same article, the WA AIDS Council had a different take on the latest epidemiology: we said it would have been much more alarming if there hadn’t been a rise, given the significant investment that has gone into testing over recent years. As we have come to expect, our view of the situation was inadequately reported and readers were once again left with an impression of irresponsible gay men discarding their condoms with an air of ‘complacency’.
In arriving at a position that differs somewhat from the more commonly reported view, we were not indulging in a process of wishful thinking. Far from it, as in fact the available evidence provides strong support for our view.
The first significant indicator is the notification data itself. As Figure 1 shows, there is a very clear rising trend of rising HIV notifications among gay men and other homosexually active men while all other categories are trending downwards or stable. During the five years prior to 2010, the notifications for this group of men were relatively stable, at around 35–40 in each year. So what happened in 2010/11 to trigger such a significant and ongoing increase in diagnoses in this category?
In July 2010, we opened M Clinic for business. M Clinic is a sexual health screening service specifically (and only) for gay and other homosexually active men. It operates five full days per week and includes two evening sessions for those unable to make appointments during normal business hours. The clinic offers a full suite of tests for HIV and sexually transmissible infections (STIs) including hepatitis, and provides treatment for those diagnosed with the exception of HIV.
The testing offered by M Clinic is entirely additional to the testing services already available in Perth, and so the immediate impact was a dramatic increase in specialist testing availability. Not only has the clinic operated at capacity from day one, it was necessary to relocate to larger premises within 18 months of opening. M Clinic now has 3,300 clients.
The other sexual health clinics continue to report that they are operating at full capacity, so the conclusion has to be that since the advent of M Clinic there are now more GHAM testing, and testing more often.
There is further evidence for this: Although this graph only includes data through the end of 2013, it shows the trend of male testing over a five-year period. From 2010 (when M Clinic opened) when the testing rate per 1,000 men was 40, the rate rose steadily until by 2013 the rate was 50; an increase of 25%. Over the same period, the rate of positive test results (as measured per 1,000 tests conducted) stayed constant at 1.5. So what does this mean? If you test more men and increase diagnosis numbers at the same rate of positivity, wouldn’t this suggest that the prevalence of undiagnosed existing HIV is declining – or alternatively that the additional tests are targeted where they are not needed?
One observation over the last year is the increase in the number of homosexually active men diagnosed in general practice. As Figure 3 demonstrates, the proportion of total diagnoses in general practice has remained constant at just over one third. However, when General Practitioner (GP) data is further examined as shown in Figure 4, something interesting emerges.
Of significance here is the change in the reason for an HIV test. In absolute numbers, those presenting with symptoms suggestive of HIV where a positive diagnosis was subsequently made was the same in both years (10). The big changes are in the positive diagnoses where the patient reported risk behaviour with an HIV infected person (a fivefold increase) and as a result of STI screening (a threefold increase).
Whilst we have long been encouraging GPs to proactively encourage their patients to consider sexual health screening, we have no evidence that they have been doing so. The two categories of HIV notification increase are thus seen as resulting from patient initiation or requests. Why would so many more GHAM be requesting tests from their existing or new GP? One possible explanation is onward referral from M Clinic. The popularity of the clinic means that increasingly it is impossible to offer appointments when a client wants one. In such circumstances, those clients are strongly encouraged to try another sexual health service or general practice rather than wait until they can be seen at M Clinic. It is acknowledged that the GP data covers only two years and further work needs to be done here, but it nonetheless provides fairly strong circumstantial evidence in support of believing that detection rather than infection is driving recent epidemiology.
If the rise in HIV notifications among gay and other homosexually active men is a result of increased testing rates, can we conclude that there has not been a decline in safe sex? No!
A rise in risk behaviour – even a significant one – is completely compatible with a conclusion that rising notifications are resulting from increased testing. In reality, the increase in the effectiveness of modern treatments and greater ease of adherence together with the increased proportion of diagnosed HIV positive men on treatment who are maintaining an undetectable viral load means that it has never been ‘harder’ to acquire HIV. Even if the number of men living with HIV continued to grow, community infectivity can still be declining. Even if the number of serodiscordant sexual interactions was increasing, new infections/transmission could still decline.
Increased testing rates that result in new diagnoses reduces the level of undiagnosed HIV amongst the GHAM population. This leads to less undiagnosed and infectious HIV in the community and a declining acquisition/transmission risk overall.
Moreover, the more GHAM that know their HIV status (as at their last test), the more accurate status disclosure is, if made. This then results in improved effectiveness of other risk reduction strategies, including sero-sorting and strategic positioning. However, an increase in risk behaviour
undermines the benefits that increased testing offers, and if the increase in risk behaviour was extreme, this could entirely negate the positive effects of increased testing. There is no suggestion that efforts to promote safer and better-informed sexual behavioural choices can be relaxed.
What is important is that there seems to be very clear evidence both from within WA, as well as nationally and internationally, that of all the behavioural changes we ask GHAM to consider, increasing testing and frequency of testing is the most likely to occur. It is also clear that peer-based testing, particularly in community settings, is effective in achieving increased testing rates. This leads to an additional advantage of providing (in the case of Perth) 7–8,000 risk conversations that may well encourage other better-informed choices.
And so …
It is not unusual for there to be differences of opinion between those that comprise the partnership response to HIV in WA or in Australia generally. A range of perspectives is surely one of the points of
partnerships. One thing we are all agreed upon, though, is our commitment to a variety of targets in the Seventh National HIV Strategy and the United Nations 2011 Political Declaration. Principally, we are all dedicated to the notion of substantially ending HIV by 2020.
As a community organisation rather than a scientific one, the WA AIDS Council perhaps has a luxury of greater freedom in interpreting and acting on the evidence it sees. The Council also has the benefit of sourcing information, evidence and other insights from a richer variety of sources.
For example, we have almost 8,000 direct and individual face-to-face interactions with GHAM each year and can claim a better understanding of the current living experiences of GHAM in our jurisdiction and beyond.
Our view of the immediate challenge may seem simplistic. As long as we diagnose at a faster rate than new infections occur, we will reduce prevalence, increase the proportion of those with HIV on effective treatments and sooner or later we will see epidemiology reflecting falling rates of new HIV diagnoses.
We asked homosexually active men to step up and get tested or get tested more often and they have responded. The increase in diagnoses is an encouraging sign. It would be at the least unfortunate to ‘blame’ these same men for HIV data that may be politically difficult and then to accuse this community of being complacent.
Nobody can now doubt the impact of peer-based sexual health services for GHAM. They require some investment; indeed M Clinic absorbs $750,000 each year excluding the costs of pathology and treatment.
But our four years’ experience in WA should encourage other jurisdictions to recognise the importance of further increasing investment in peer-based testing programs in support of achieving our 2020 targets.
Some may believe that the jury is still out, but we think the verdict is in. It’s detection not infection in Western Australia.