Letter to the Editor
To the Editor:
In many countries, men who have sex with men (MSM) comprise the largest risk group for HIV.1 – 3 Most HIV transmission between men is via unprotected anal sex.4
Guidelines5 – 7 recommend that MSM are tested annually for HIV irrespective of reported sexual risk. However, in a study we conducted, individual clinicians had substantially varied rates of HIV testing among MSM, with testing of MSM reporting protected intercourse being lower (64.9%) than testing among MSM reporting inconsistent condom use (81.5%).8 We aimed to determine the proportion of HIV diagnoses among MSM that would have been missed if HIV testing was based on self-reported risk.
We reviewed the sexual histories from MSM newly diagnosed with HIV between October 2002 and March 2011 at the Melbourne Sexual Health Centre, Victoria, Australia, using 2 different methods for obtaining the history. Before June 2008, sexual histories were obtained by clinician interview using standardized questions that included the frequency of condom use with anal sex. Men were also asked if they had tested for HIV before and, if so, when. From June 2008, computer-assisted self interview (CASI) was used to ask the same standardized questions. In addition, CASI asked “Have you had unprotected anal sex since your last HIV test?” Ethical approval for this study was granted by the Alfred Hospital Ethics Committee.
During the study period, 255 MSM tested positive for HIV. Of these, 91 men were clinician interviewed and tested for HIV within the preceding 12 months. Among men interviewed using CASI (n = 53), 32 had been HIV tested within the preceding 12 months. The median time since their last HIV test for all HIV-positive men who had received a prior test was 7 months (range: 1–164). Combining clinician- and CASI-interviewed men, of the 123 men who reported testing for HIV in the prior 12 months, 16 (13%; 95% CI: 8%–21%) reported that they always used condoms for anal sex. One man reported penile-anal contact without penetration.
Of the remaining 21 men interviewed using CASI, who received their last HIV test >12 months ago, 5 (24%) reported condom use always with anal sex since their last HIV test. Only one man reported injecting drugs, but >12 months previously.
There are a number of possible reasons why men may have acquired HIV in the absence of reported unprotected anal sex including feelings of embarrassment or stigma over reporting risk behavior, differences in understanding of what “anal sex” refers to,9 and impaired awareness or recall of unprotected sex because of drug or alcohol use.10 – 13
Our study shows that 1 in 8 MSM newly diagnosed with HIV would have been missed if men reporting consistent condom use had not been tested for HIV. The findings support US Centers for Disease Control and Prevention and Australian guidelines that recommend routine testing of MSM for HIV irrespective of reported risk.5 – 7 Universal testing of MSM for HIV coupled with an opt-out approach to testing is likely to improve HIV testing among MSM.14,15
Lenka A. Vodstrcil, PhD
Christopher K. Fairley, PhD
Marcus Y. Chen, PhD
Melbourne School of Population Health
The University of Melbourne
Melbourne Sexual Health Centre
Ian Denham, FRACP
Melbourne Sexual Health Centre
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15. Hamill M, Burgoine K, Farrell F, et al.. Time to move towards opt-out testing for HIV in the UK. BMJ 2007; 334:1352–1354.