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Seroconversion Study Presentation May 2014
1. The HIV Seroconversion Study
What we've learnt so far,
and what we're planning next
Presented by Ian Down
Kirby Institute, UNSW
Australian Research Centre in Sex,
Health and Society, La Trobe University
Grace Vaughan House
Friday, 23rd May 2014
3. Study history!
• There have been studies of this kind on-and-off in Australia since
1992!
• The first studies were clinic-based with a nurse administering the
questionnaire & were largely restricted to Sydney!
• The current version began in late-2007 & was the first to be
conducted online, meaning it could be conducted nationally!
4. Study aims!
• Interview individuals recently diagnosed with HIV about the factors
they believe led to their infection, and their experiences since
diagnosis;!
• Inform HIV organisations and state and territory health departments
about the contexts of risk behaviours and motivations for these; !
• Consider current gaps in policy and program development and
implementation, including in the research base. !
5. Eligibility criteria!
• Being over 16 years old!
• Living in Australia!
• Having been diagnosed with HIV within the previous two
years!
!
! Until December 2013, only those aged 18 years and over were
eligible to participate!
! Until 2010 there was an additional eligibility criteria of being male!
6. Enrolment!
Enrolment began in December 2007!
• current funding allows recruitment to continue until end of
June 2015!
Recruitment occurs mainly through community sources!
Participants enrol into the study through the study website!
• Online survey, takes about 20-30 minutes to complete!
• Option to volunteer for a face-to-face interview!
12. Relationship to source person!
58%
62%
68%
61%42%
38%
32%
11%
23%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Kippax et al., 2003 Volk et al., 2006 Jin et al., 2009 Current data
Fuckbuddy
Boyfriend
Casual partner
13. Knowledge of source person’s status!
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Casual partner Fuckbuddy Boyfriend
I thought he was HIV-negative
I didn't know his status
I thought he was HIV-positive
18. Comparing differences in UAIC!
Seroconversion Study!
• 200 newly positive men!
• Describe a UAIC event
as their HRE!
PASH!
• 343 HIV-negative men!
• Describe a recent
occasion of UAIC!
?"
19. SCS
n (%)
PASH
n (%)
P Value
Age in years (mean, SD) 34.1 (9.1) 36.8 (12.2) P=0.012
Sexual identity
Gay/homosexual 188 (94.0) 290 (84.5) P=0.006
Bisexual 10 (5.0) 32 (9.3)
Other 2 (1.0) 21 (6.1)
Education
No university 93 (46.5) 153 (44.6) P=0.219
Uni - undergraduate 68 (34.0) 103 (30.0)
Uni - postgraduate 39 (19.5) 86 (25.1)
Demographic characteristics!
20. SCS
n (%)
PASH
n (%)
P Value
Anglo-Australian background 164 (82.0) 231 (67.3) P<0.001
Regular relationship at time 70 (35.0) 153 (44.6) P<0.001
Prior HIV test
Within 12 months prior 125 (62.5) 279 (81.3) P<0.001
More than one year prior 60 (30.0) 58 (16.9)
Not previously tested 15 (7.5) 0
Demographic characteristics!
21. SCS
n (%)
PASH
n (%)
P Value
Participant’s home 38 (19.0) 120 (35.0) P<0.001
Partner’s home 57 (28.5) 116 (33.8)
Sex club/Sauna 56 (28.0) 45 (13.1)
Beat/other public place 18 (9.0) 21 (6.1)
Other 30 (15.0) 41 (11.9)
Location of UAIC event
22. SCS
n (%)
PASH
n (%)
P Value
Met for first time at this event 140 (70.0) 136 (39.7) P<0.001
Had sex with previously 41 (20.5) 156 (45.5) P<0.001
Knowledge of HIV status
Believed HIV-positive 29 (14.5) 13 (3.8) P<0.001
Believed HIV-negative 53 (26.5) 232 (67.6)
Didn’t know 110 (55.0) 95 (27.7)
Familiarity with UAIC partner
23. SCS
n (%)
PASH
n (%)
P Value
UAIC in the context of group sex 74 (37.0) 40 (11.7) P<0.001
UAIC highest risk practice
Receptive UAIC 170 (85.0) 216 (63.0) P<0.001
without ejaculation 64 (32.0) 106 (30.9) P=0.599
with ejaculation 106 (53.0) 110 (32.1) P<0.001
Insertive UAIC 72 (36.0) 203 (59.2) P=0.021
Reciprocal UAIC 42 (21.0) 85 (24.8) P=0.041
Sexual practices at UAIC event
25. PEP Knowledge: GCPS!
62%"
58%" 58%" 56%"
43%"
65%"
0%
10%
20%
30%
40%
50%
60%
70%
80%
Queensland
(2013)
Melbourne
(2013)
Sydney
(2012)
Adelaide
(2012)
Perth
(2012)
Canberra
(2011)
Column1(
Proportion of HIV-negative men who had heard of PEP, Gay Community Periodic Survey
"
26. PEP Knowledge: SCS!
• 48% of men had heard of PEP at time of the high-risk event!
Sales(
Not heard of PEP
Heard of PEP
27. Prior use of PEP!
• 28% of those who had heard of PEP had accessed PEP
previously!
13%"
Sales(
Not heard of PEP
Heard of PEP
Prior use of PEP
28. Reasons for not using PEP!
• Most common response for not having accessed PEP
following HRE was not having been aware of it!
• Among those who were aware of PEP, almost half said they
didn’t attend for PEP after the HRE because they not believe
the risk was sufficient to warrant it!
29. Barriers to PEP: Accessibility!
“I didn’t really think about it because I was not aware it was
generally available (i.e., I thought the process of getting PEP
would be too difficult)”!
“Until now I didn't know PEP was available for everyone in sex
clinics; I didn't now it was easy to get it”!
“I didn't know where to get it”!
“Not convenient enough as it was just before a weekend”!
30. Barriers to PEP: Ongoing nature of risk!
“As I had regular bareback sex with people, it wasn’t worth
going to the doctor’s weekly to get this treatment.”!
31. Barriers to PEP: Timing!
“By the time the P-n-P session had finished the first
incidence of cum in my bum was greater than 72 hours
past.”!
!
“Because I was interstate, and was still 'coming-down' after
the session. By the time my head was clear again, it was
too late for PEP”!
32. Barriers to PEP: Perception of being judged!
“The last time I had asked about taking PEP at the local hospital
I was met with attitude and condescension. This made me feel
like asking for PEP was a crime and that I was taking up
valuable resources by asking.”!
!
“I had taken it before - somewhat embarrassed to ask for it again
- hoped it would not be a problem - felt that I had already had my
'chance' with PEP and that if I got infected now I deserved it.”!
33. Barriers to PEP: Having to justify!
“On my previous two occasions I was grilled to a point I felt like I
was begging; I would rather have just bought them over counter
even if $400”!
!
34. Barriers to PEP: Making it an ordeal!
“Obtaining PEP was horrendous and one of the worst
experiences of my life. [It’s] easier just to accept getting HIV,
hence my decision not to go a third time”!
36. Undiagnosed infection!
• It is estimated that around one in five new infections are
transmitted by men in primary infection
– About 3% of all men with HIV are in primary infection
• And that almost a third are transmitted by men with
undiagnosed HIV
– About 10% of positive men were undiagnosed in this
model
Wilson et al., 2009
37. HIV testing in GCPS!
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Ever tested Non-HIV-positive men tested in previous 12 months
38. SCS: Prior HIV testing!
• 77% of men clearly reported ever having previously tested!
– 53% had tested within the twelve months prior to their
diagnosis!
39. Univariate analysis Multivariate analysis
OR P Value aOR P Value
Identifying as gay 2.58 (1.38-4.80) 0.003
University education 1.07 (0.75-1.52) 0.706
Age (mean, SD) 0.99 (0.97-1.01) 0.200
Engagement with gay men 1.29 (1.01-1.51) 0.001 1.28 (1.09-1.50) 0.002
Health optimism 1.16 (1.05-1.28) 0.003
Transmission optimism 1.17 (1.01-1.36) 0.031
Viral load optimism 1.37 (1.00-1.87) 0.046
Likelihood to have recently tested
40. Reasons for delaying testing!
n (%)
I had no illness which made me worry 23%
I was afraid to get tested 23%
I did not do anything risky 17%
I didn't want to know 14%
My doctor did not suggest it 13%
" Just over half of men weren't aware of experiencing a seroconversion illness
41. Reasons for testing!
N=506 n (%)
I had an illness which made me worry 32%
It was part of my regular testing pattern 27%
I did something risky 18%
My doctor suggested it 10%
I wanted to know my HIV status 8%
42. Overcoming fear of testing!
“I was always too scared to go for a test. And the … first couple
of experiences with going for a test was through my family GP
that I’d been seeing since I was a teenager, and they didn’t know
much about HIV. And they were kind of, I can remember some of
the things they’d say to me, like, ‘You're playing Russian
roulette.’ I didn’t feel comfortable. And it wasn’t until … I actually
did a test through M Clinic, when I actually felt more comfortable
knowing the support would be there.”!
44. Providing a referral!
“He just seemed pretty ignorant to a lot of things. He said it
wasn't good and … it's gonna be hard to get used to it, and blah,
blah, blah. He was ignorant on medications and treatment …
Which wasn't good for me 'cause I was ignorant to everything. I
didn't know. Hey, I just thought I was gonna die type stuff. I
thought, "Shit, what'll I do for the next two years? I'm gonna be
dead soon. So I was really lucky because I, I got to speak to
[AIDS Council staff member] within maybe two days, two or three
days after. [How was that?] Really good. He's awesome.”!
45. Sex since diagnosis!
N=259 n (%)
Reduce the number of partners I have sex with 111 (43%)
Stop having sex altogether 100 (39%)
Avoid sex with HIV negative partners 80 (31%)
Tell people my HIV status before sex more often 68 (26%)
Reduce my drug use 40 (15%)
Avoid sex with HIV-positive partners 23 (9%)
Avoid telling people my HIV status before sex more 22 (8%)
I have become more of a bottom 20 (8%)
Increased my drug use 15 (6%)
I have become more of a top 14 (5%)
46. Disclosing!
• Men were most likely to disclose to regular partners and gay
friends, though:!
– 17% had not disclosed to their regular partner;!
– 27% had not disclosed to any of their gay friends; and!
– 54% had not told any of their immediate family!
48. The Treatment Cascade in Australia!
0%
20%
40%
60%
80%
100%
People living with HIV Diagnosed HIV-positive On treatment Have suppressed viral load
Undiagnosed
infection
About 25%
Estimated
33,000
Diagnosed,
not yet on
treatments
About 34%
Estimated
pool of
untreated
HIV infection
About 62%
24,7500
(70-80%)
11,523
(54-70%
of those
diagnosed)
10,560
(90-95%
of those on
treatments)
49. Treatment as prevention!
• Growing evidence of benefits of early initiation of treatments!
– Improve the health of people with HIV!
– Prevent the onward transmission of the virus!
!
• Scaling up of treatment may face challenges!
50. Historical context of HIV medicine!
When to start:!
• Hit early, hit hard!
• More cautious approach!
• Treatment breaks!
Discourses around HIV medicine of scepticism and doubt!
51. Ben, 45: To be honest, I did not believe that you could give
somebody a pill and that they would survive this virus that is, as
far as I’m concerned, very much a death sentence. I don’t trust it.
I’ll be honest – I don’t trust it. I mean scientists don’t know
enough about the medication. I research the medication every
single day so there’s not a day goes by that I don’t check and
see what information is available on, like all the different types of
medication … and I mean there is no, no research on the
longevity of the taking of the medication as yet. So, therefore, I
have doubt!
52. Derek, 44: At the moment, I have no idea how infectious I am.
But if I’m on medication, I have a feeling that I can keep it in
control rather than it keep jumping around, up and down. And I
know they’re gonna have side-effects, but I’m ready to deal with
that rather than. . . like if something goes wrong, I don’t wanna
be the one responsible because I wasn’t taking care of myself. I
know I have to be very careful from now on. I just don’t want it to
be more serious than what it should be.!
53. Corey, 24: Medication, I thought was always a given. It was
always going to happen and I was quite prepared to, you
know, to take medication. However, it was sort of like being
diagnosed all over again when she said, “I’ve got your
bloods back. We really, really need to start talking about
medication and treating it.”!
55. Summary: high-risk event!
• Seroconverters are fairly typical gay men!
• Little evidence of use of use of risk reduction strategies!
56. Summary: PEP!
• Half of men who seroconvert were not aware of PEP!
• History of PEP use is high among men who seroconvert!
• The experience some men have requiring PEP appears to put
some off accessing PEP following subsequent exposures!
57. Summary: HIV testing!
• Men who seroconvert appear to test at levels slightly lower
than seen in behavioural surveillance !
• Men want testing options that are convenient, appropriate and
sensitive!
• Structural barriers are being addressed … what about fears?!
58. Summary: since diagnosis!
• Receiving an HIV diagnosis is still difficult for many,
and results in significant changes!
• Changes in sexual behaviour in the short term, are the
sustained?!
• Low levels of disclosure, make it a very isolating experience!
59. Summary: treatments!
• Little knowledge or trust of advances in treatments!
• Discomfort in accepting illness, adherence, commitment!
• Difficulty in accessing reliable advice!
61. NHMRC Partnership Grant!
• Current funding ends in June 2015!
• In the process of applying for NHMRC Partnership Grant!
• Partners will be: state & territory health departments, and HIV
community organisations!
• NHMRC match contributions provided by the partners!
• Funding will be for 2015-2018!
62. Evaluating the impact of programs for newly diagnosed!
• Continue to recruit participants, but before they participate in
newly diagnosed programs!
• Interview both before and after program, and again twelve
months later!
• Have a comparison group of people who choose not to
participate in the program!
• Measure uptake of ART, HIV risk reduction, disclosure, social
engagement and other well-being indicators!
64. Thanks & acknowledgements!
All the study participants who gave of their time
The many community organisation staff and clinicians who
have assisted with promotion and recruitment for the study
The study team:
Garrett Prestage, Ian Down, Jeanne Ellard, Graham Brown,
Kathy Triffitt, Asha Persson (CSRH) and Chris Gianacas
The Seroconversion Study was funded by the Health Departments of:
New South Wales, Victoria, Queensland, Western Australia,
South Australia, Tasmania, Northern Territory & the Australian Capital Territory!
