The document discusses the need to scale up rapid HIV testing in order to meet UNPD targets and increase testing coverage, as current testing rates among at-risk groups like MSM are low. It reviews evidence that rapid HIV testing can increase testing rates and yield higher proportions of undiagnosed cases. The document also examines issues around introducing rapid HIV testing services and the policy changes needed to support expanded access to rapid testing.

1. Rapid HIV Testing
&
Scaling Up Testing
Phillip Keen
phillip@napwa.org.au
May 2012

2. Overview
• Why rapid HIV testing?
• Where to now on rapid HIV testing
• National HIV Testing Policy Review
• Scaling up testing

3. UNPD Targets
• Need to scale up testing coverage and
frequency:
 New technologies (eg. rapid HIV testing)
 Reorienting existing testing services
 New models for marketing & providing
testing
Community/peer-based
Outreach
(Home?)

4. Testing Coverage among MSM
• There is still scope for benefit from increased testing
coverage and frequency
o Testing coverage low in broad-based MSM samples:
• e-Male Survey (2008)
– 23.8% never tested
– Among men who had tested, 31% had not tested in previous
year
• PASH Survey (2009)
– 15.2% never tested
• Adam (2012), NCHSR

5. Testing Frequency
• Real testing frequency v’s self-report data
o Guy et al (2010):
• Less than 40% of MSM retested after I year
• Less than 20% of highly sexually active men retested after six
months
• Late HIV diagnoses
o Approximately 14% of diagnoses among MSM are late
diagnoses
• Most have never previously tested, others have not
tested for a long time.

6. Rapid HIV Testing in other Settings
• Pedrana (2011): Rapid HIV Testing & Community-
Based Testing services:
o High proportion of never previously tested
o High positive yields
o High consumer satisfaction with rapid HIV testing
o High workforce satisfaction with rapid HIV testing
o Staffing models incorporating non-clinical staff in
community based testing services

7. Rapid Testing at NZAF

8. HIV Testing Policy Review
•Support for rapid HIV testing for use at point of care:
• Limited to use as screening tests
• Confirmatory testing required for reactive rapid test results
• May be considered for:
• High risk populations (eg. gay men)
• Hard to reach populations and individuals (who are resistant to
conventional testing) and

9. False Positives to True Positives
Test Specificity
Positive Yield 99.5% 99.8%
1.5% 1:3 1:7.5
(MSM in VPCNSS)
(5 FP per 1000 tests) (2 FP per 1000 tests)
1.0%
(Males @MSHC, 2009) 1:2 1:5
0.1%
(Females @MSHC, 2009) 5:1 2:1
0.025%
(All females tested in Victoria, 20:1 8:1
2004)

10. Community based testing
• Scope for non-clinical staff to administer rapid
tests:
• If State/Territory health department endorses organisation
• Staff must attend accredited training and achieve certification
• Service must have access to clinical support and
venepuncture, and a relationship with a laboratory approved by
the National Association of Testing Authorities (NATA)

12. What Now?
• Policy support for rapid testing at POC, but:
• No TGA licensed tests
• No Medicare funding for rapid test kits or
procedures

13. Community Organisations
• What models for rapid testing make sense locally?
• Establish a new community based testing service?
• What planning needed?
• Partner with other services to offer rapid testing?
• Incorporate peer-based workers to some parts of testing
services?
• Identify services well-placed to introduce rapid HIV testing
and start talking to them
• Liaison with funders and other stakeholders to plan for the

14. HIV Educators & Counsellors
• Peer Educators & TreatAware Officers:
• Community Awareness about rapid HIV testing
• Limitations and benefits of rapid testing
• Participate in rapid testing service delivery
• Very different role for most
• What selection & training?
• Counsellors:
• Different issues in context of rapid HIV testing – e.g. anxiety while

15. Reorienting Services
• Opening hours
• Location
• One-stop testing
 Providing results by phone/email

16. Marketing
• Increasing HIV testing rates will be needed to
reach new HIV Prevention and Targets
• Introducing rapid HIV testing represents an
opportunity to re-frame HIV testing

23. Home Testing
• Home testing was not supported in the recent
Australian HIV Testing Policy review
• UK: House of Lords Select Committee on HIV
in the UK recommendations:
o Legalise home testing
o Establish a quality control system
o THT supports the above

24. Home Testing
• USA:
 Orasure application to FDA for home sales
 Study of home users found 93% sensitivity
v's 99.3% when used by trained testers
 Expert panel unanimously supported
approving home sales
 FDA decision expected soon

25. Outreach Testing
• Was not considered in detail in policy review
• Outreach testing trial may start soon in
Sydney
• Community HIV sector doesn't have a well-
developed position on outreach testing.

26. Thanks

27. Clinical Staff
• Should rapid testing be introduced?
• New procedures
• Training & staffing – clinicians or nurses?
• Relationship with NATA-approved laboratory

28. Policymakers
• Planning
• How and where should rapid testing be introduced to complement
existing testing services?
• NSW Health Model - Point of Care Testing Working Group:
• ASHM
• Clinical & social research
• Community orgs
• Sexual health clinic director
• Counsellor

29. Policymakers II
• Funding
• Public sexual health clinics and specialist community based testing
services may be best placed to offer rapid HIV testing - but
State/Territory funding covers most costs of public sexual health
clinics and would need to for new community based testing services
• Cost barriers to introducing rapid testing in all
settings until there is Medicare funding
• Public clinics: Currently some HIV testing costs recouped from
Medicare

30. Policymakers III
• Funding support for trials of rapid HIV testing
• Trials are underway in public sexual health
settings
• Test performance (sensitivity, specificity, NPV & PPV)
• Acceptability to clients
• Feasibility issues in clinics
• Any impact on testing frequency?

31. Researchers
• Tracking changes in testing patterns in the
context of rapid testing
• Understanding the impact of rapid HIV testing
on gay men’s sexual cultures

32. CD4 at start of cART (closest CD4
with 6 months prior)
Prior to 1 Jan
2006
1 Jan 2006
onwards Overall
Total 1882 427 2309
Mean 327.9 324.0 327.1
SD 242.4 193.5 234.1
Median 288.5 294 290
25th 150 200 160
75th 450 422 445
n (%) n (%) n (%)
250-349 347 (18.4) 101 (23.6) 448 (19.4)
<250 787 (41.8) 161 (37.7) 948 (41.1)
>=350 748 (39.7) 165 (38.6) 913 (39.5)

33. CD4 Decline Following
Seroconversion
• CASCADE Study (Europe n. = 18,495)
CD4 Level Median time following
Seroconversion
500 1.19 years
350 4.19 years
200 7.93 years

34. Treatments Uptake Needed
• Rapid increases in treatments uptake occurred
1996-1998 (20% > 70%)
Year Estimated Proportion Population Additional
Population on ARVs not on ARVs needed if
90%
2010 21,391 70% 6,417 4,278
2011 22,391 70% 6,717 4,478

35. Challenges
• Costs of access
• Costs of multiple medications / management
interventions
• Complexity of access to prescriber / dispensing
arrangements
• Dr concerns re adherence
• Dr concerns re lifelong treatment commitments
• Concern re impact of side effects
• Other Patient barriers

36. Increased cost sharing
• 1. Lower rates of drug treatment / selective Rx
• 2. Diminished adherence among existing pts
• 3. More frequent discontinuation of therapy
• 4. Affect likelihood of pt to seek care
• Summary point
• For each 10% increase in cost
sharing, prescription drug spending decreases

37. Issues – Pt involvement
• 35% started treatment within a year of
diagnosis
• Majority waiting more than a year btwn
diagnosis and initiating
• Reasons
• 47% - Dr’s decision to wait*
• 27% - Pt Unsure about starting
• *Age split: Under 50 – 52% / Over 50 - 18%

38. Issues - Access
• Access has costs
• PBS drugs have pt contributions $35.40 /
$5.80 per script
• Safety net $1281.30 / $324.00
• Pt experience survey – PCR (ABS) 2009
• 9.7 % delay or reject filling a script (general
pop)

39. HIV population
• 30% live below poverty line
• 40% rely on a govt benefit
• Chronic disease management increasingly
complex within the ageing population
• Medicare not covering cost of most non
medical treatments, or increasingly newer
procedures

40. Issues - Access
• Chronic Illness
• - regardless of income levels spending up to
30% of household income on medications
• Plhiv (Futures 6) (n = 1100)
• - 42% report major source of income as Govt
support
• 31% report living below poverty line levels

41. Issues - Access
• BGF Survey (2010)
• PLHIV respondents struggling to access
treatment
• 46% - HIV medications
• 60% - Other prescribed medications
• Hardship requires people to make decisions
between care and basic living expenses

42. Patient Concerns
• Concern about side effects
• Lifelong treatment
• Lack of readiness
• Pt perception ARV are bad for you
• Dislike of taking (Reminder)
• Commencing Rx means health has declined
• Impact on lifestyle

43. Issues – Pt Attitudes
• 70%(ATLIS) to 80% (Futures) of treating
population believe that ARVs mean better
prospects for themselves
• 39% (ATLIS) & 30% (Futures)- Negative beliefs
such as “harmful” and impacts outweighing
benefit to QOL.
• Reminder of status / fear of disclosure
(includes access issues to care / drugs)

44. Psychological barriers
“Commencing was terrifying. I was scared and the night before I
started I was a mess. Initial physical reaction was minimal so that was
a relief. Changing meds is also a scary thought which I am trying to
avoid” (ARCSHS Tracking Changes, 2011)
“I had thought it would be difficult for me to commence meds since this
would be an acknowledgment of the progression of my HIV. However
since starting my meds I have found that a lot of small irritating
conditions have cleared up and my overall health is significantly
improved. I'm just grateful every day that the meds exist!” (ARCSHS
Tracking Changes, 2011)

45. What are the outcomes
• Therapeutic Treatment coverage and
maintenance will improve individual health
• Secondary prevention impacts will follow
• Dynamics across other Strategies and within
the BBVSS framework benefits shared
• As fast as knowledge is acquired it must be
applied (NHMRC Research Translation goal)

46. ROI
• Base policy options on evidence base of
current data + the value of treatments to
community
• Environment of community acceptability with
drive to resolve barriers or disincentives for
individuals
• National Strategy could be adapted to this
expansive vision

47. Economic analysis
• NSW – 50% Gay + men initiated Treatment at
diagnosis then minimum 10 % - up to 22% of
new infections would be averted
• $14,000 annually on HIV therapy
• One infection over a lifetime costs Govt
$700,000
• Data build to show nationally if a program
targets people who would otherwise have not
received therapy, it would be cost effective,

48. Success of Test and Treat in San Francisco? Reduced Time to Virologic
Suppression, Decreased Community Viral Load,
and Fewer New HIV Infections, 2004-2009
M Das, P Chu, G-M Santos, S Scheer, W McFarland, E Vittinghoff, G Colfax
Minimum, Most Recent, Maximum CVL and Newly
Diagnosed and Reported HIV cases

49. Where can we do more?
Testing
Treatments uptake
Community Mobilisation
PrEP + PEP
Targeting Primary Infection
Targeting Late HIV
Diagnoses
Specific actions to reduce
heterosexual transmissions

50. HIV diagnoses, 2006 --
2010, by HIV exposure
category
Source: State and Territory health authorities

51. Newly diagnosed HIV among men who report an exposure other than
sex with men, 2001 – 2010, by year and HIV exposure category
80
60
Num be r 40
20
0
Y ear
Source: State and Territory health authorities

52. Newly diagnosed HIV among women, 2001 – 2010, by year
and HIV exposure category
Source: State and Territory health authorities

53. Reducing Heterosexual
Transmissions
• Diagnosing
o Expand ASHM mentoring project
o Clinical markers (eg oral candidiasis)
o Populations focus – people from high prevalence
countries & partners
o Clusters (swingers)
• Serodiscordant couples

54. Peer base
• Community information
• Informed by community
• Drivers / influence
• Nuances
• Sophisticated (Persistence/ Resilience)
• Strength of peer ownership / partnership
• Acceptability / thresholds of tolerance &

55. Community Mobilisation
• Gay community
o High profile social marketing initiatives to suggest a period
of concerted community action
o Seek support from gay community leadership
• Disproportionate contributions to new diagnoses
from:
o Men in serodicordant relationships
o Sexually adventurous men

56. Targeting Late HIV Diagnoses
• NAPWA believes there is scope to reduce late
HIV diagnoses among MSM, heterosexuals
and CALD.

57. CD4+ cell count at HIV diagnosis,
2001 – 2010, by year
 Click to edit the outline
text format
 Second Outline
Level
Third Outline
Level
 Fourth Outline
Level
Fifth
Outline
Level
Source: State and Territory health authorities

58. What proportion of ‘late’ HIV
diagnoses are MSM?

59. Late HIV Diagnoses Actions
• Reduce structural and psychological barriers
to testing
• Encourage primary health services to offer
testing to populations at increased risk.
o Low caseload GPs in areas of high HIV prevalence
– offer testing to MSM
o GPs and community health services working with
CALD populations at increased risk

60. Need data for targets
• Variable treatment patterns across sub groups
• Attitudes and beliefs are wide ranging and
complex
• Motivations and drivers critical
• Campaigns need to be diverse and different
mediums – websites, blogs and social media

61. Should we expect an initial
increase in HIV Diagnoses?
Population Undiagnosed Click to edit the outline
 Undiagnosed
Size (10%) text format
(20%)
22,391 (1) 2,239  Second Outline
4,478
Level
Third Outline
•
Level
(1) Estimate of the number of people living with HIV in Australia as at
31/12/2010 plus 1,000 (estimated number of new diagnoses in 2011)
 Fourth Outline
• Level
The estimates of the proportion of the PLHIV population that are
undiagnosed are from Mapping HIV Outcomes: Geographical and clinical
Fifth
forecasts of numbers of people living with HIV in Australia (NCHECR/NAPWA,
2010)
Outline
• If testing coverage and frequency increase, there may be anLevel
initial spike in

62. A package
• Targets disease prevention
• Targets access inequities
• Targets continuity of care

63. Targets are a package
• They bring other dynamics and roll on effects
• National HIV strategy links
• The momentum brings energy and focus
• Forward to future yrs and see results
• Health and well being of a population is what
fosters other secondary benefits, such as
prevention and broader BBVSS health
maintenance

64. Setting Targets
• Set targets based on the number of people it
will positively affect.
• Planning should be optimistic and lead with
positive frameworks for what you can do and
what potentials there are to truly transform

65. Targets and Reduced Diagnoses
Exposure Category 2010 Diagnoses 50% Reduction
 Click to edit theReduction
80%
outline
MSM + MSM & IDU 621
text format
(311) 124
Heterosexual 289 Second Outline
 145
IDU 25 Level
13
All Categories 1,043 Third Outline
Level
• An 80% reduction in MSM diagnoses and a 50% reduction
 Fourth Outline
in heterosexual, IDU and other categories would result in
Level
approximately 335 annual diagnoses, which is a 68%
reduction overall on the 1,043 diagnoses in 2010.
Fifth
Outline
Level

66. Opportunities
• Emerging combination prevention options offer the best
chance in thirty years to drive infections down
• We have to seize the moment – ‘wait and see’ isn’t an option
• Signing up to ambitious (but not unrealistic) 2015 targets will
provide the galvanising factor

67. Thanks

68. End here?
• End?
• Jo, following slides are in case you want to
keep them and move them back up into the
presentation

69. Implications
• Targeted sub groups may require varied
interventions
• Health maintenance not just understood as
clinical benefits
• Must be peer driven and focused
• Need to measure national against state
analysis

70. Treatments Uptake
• Reducing barriers to treatment
o Dispensing arrangements
o Co-payments
• Difficulties obtaining medication and co-payments
associated with stopping ARVs (ARCSHS Tracking
Changes, 2011)
• ATRAS and other Medicare Ineligibles
• Addressing Psychological barriers to initiating treatment

71. Self reporting
• Actual utilisation vs self reported levels
• - Both testing – but also treating, and
maintenance