In high-income European countries, men who have sex with men (MSM) remain the group at highest risk for human immunodeficiency virus (HIV) transmission. An increase in the rate of MSM who report unprotected anal intercourse has been reported,1,2 and recurrent outbreaks of syphilis, gonorrhea, and hepatitis C in several major European cities support this trend toward increased sexual risk-taking behavior among the MSM population.3–5 It has been estimated that nearly a third of infected individuals in Europe are unaware that they are HIV positive.6 Promoting HIV testing has the potential to reduce the proportion of undiagnosed infections and improve individual health/quality-of-life outcomes. Early diagnosis is also crucial for implementing the strategy of treatment as prevention, which aims primarily at reducing community viral load.7,8 Testing may also be of value in raising awareness of HIV more broadly and in engaging MSM with sexual health services.9 Community-based testing initiatives may provide services that reach groups of MSM who are traditionally less likely to seek the established health care setting. This idea is in line with a recent shift toward expanding HIV testing into a greater variety of health care and nonclinical community settings10,11 and is parallel to the HIV Prevention Trials Network 065 study recently launched in the United States, which aims to assess feasibility and linkage to care from community-level testing projects.12 In this article, we report the experiences of 5 years of Checkpoint, a community-based rapid HIV testing and counseling project in the heart of the MSM community in Copenhagen, and evaluate its capacity for reaching MSM and successfully linking patients to care.
As of December 31, 2012, Denmark had a population of 5.6 million13 with an estimated HIV prevalence of 0.09%14 and fairly liberal attitudes toward sexual issues in general.15 Denmark’s tax-funded health care system provides free HIV testing in a variety of health care settings such as general practitioners, hospital-associated sexually transmitted infection (STI) clinics, and infectious disease departments across the country. In the health care setting, testing is performed by standard venous puncture followed by antibody and antigen measurement. Testing is generally not anonymous, and the standard waiting time for an HIV result is approximately 5 days (range, 1–7 days), mainly due to the logistics of sample transportation and laboratory/clinic opening hours. All HIV-positive patients are referred to 1 of 8 specialized HIV care centers, where they are seen on an outpatient basis at intended intervals of 12 to 24 weeks. HIV care and antiretroviral therapy is free of charge. Forty-five percent of 4745 HIV-positive patients in Denmark report being MSM.16 The total size of the MSM population in Denmark has previously been estimated to be 54,723 to 88,900 of 2.2 million adult men (2.5%–4.0%).17 Most HIV-positive MSM live in Copenhagen, but the HIV prevalence among MSM in the city is unknown. National criteria for highly active antiretroviral therapy (HAART) initiation is the presence of an HIV-related disease, acute HIV infection, pregnancy, or a CD4 cell count below 350 cells/μL. Age greater than 50 years, rapid CD4 decline, chronic viral hepatitis, and the wish to protect an HIV-negative partner are relative indications for HAART.18 From 2008 to 2012, 65% (range, 54%–76%) of all new HIV-positive patients in Denmark were on HAART within a year of diagnosis14 consistent with a 94% adherence to national guidelines for start of HAART.18
Checkpoint: A Community-Based Walk-in Clinic and a Mobile Test Unit
A walk-in clinic placed in the heart of the MSM community was created in 2007 by the nongovernmental organization STOP AIDS19 and funded by the Danish National Board of Health. The project was targeted exclusively at MSM, and a continuous, comprehensive recruitment campaign was initialized via gay community outlets such as magazines and Internet resources and by using sauna masseurs and volunteer bar patrons as peer recruiters for referral to the walk-in clinic. The clinic was staffed with a receptionist and a group of specially trained counselors, predominantly with a non–health care background. Free, anonymous HIV testing and counseling with no requirement for preceding appointments were offered. The clinic was open once a week between 4 and 8 PM and consisted of a reception area and 2 rooms for simultaneous testing and counseling of 2 users. HIV testing was performed using Determine TM HIV 1/2 antibody test.20 Test results were given 20 minutes after sampling. Patients with reactive tests had extended posttest counseling and were referred for confirmatory testing (Western blot) via the infectious disease department of their choice. Rapid testing for syphilis (Determine TM Syphilis TP) and free hepatitis B vaccination were introduced after the first year of the project. A mobile test and counseling unit, using the same staff and equipment, were used to perform on-site syphilis and HIV testing at Copenhagen sex venues such as saunas and during community events such as large sex parties or the annual Pride Parade.
Patient records at the 2 Copenhagen HIV care centers were systematically examined to identify patients who were referred from Checkpoint. The number of identified patients per year was compared with the anonymous yearly reports of Checkpoint to determine percentage lost to follow-up. Subsequently, clinical data were extracted from patient records and the Danish HIV Cohort Study,21 which includes all HIV-infected patients 16 years or older at diagnosis who have been treated at a Danish HIV center since January 1, 1995. As of December 31, 2012, the cohort included 6543 patients, 4338 of which received care in 1 of 2 infectious disease departments in the Copenhagen region. Patients are consecutively enrolled, and multiple registrations are avoided through the use of a unique 10-digit civil registration number assigned to all individuals in Denmark at birth or upon immigration. Data are updated yearly and include demographics, date of HIV diagnosis, AIDS-defining events, date and cause of death, antiretroviral therapy, CD4 cell counts, and viral load measurements. The Danish HIV Cohort Study is approved by the Danish Data Protection Agency (record number 2008-41-1781). All Checkpoint data were anonymous, through the use of aliases. Data on activities in Checkpoint included number of HIV tests, counseling sessions, syphilis tests, and hepatitis B vaccinations. In 2011 and 2012, a questionnaire addressing self-identified sexuality and reasons for getting tested was handed out to all Checkpoint users.
We used χ2 test for dichotomous variables, trend test for ordered groups, and the nonparametric Mann-Whitney test for continuous variables to compare characteristics of MSM diagnosed as having HIV in health care facilities versus Checkpoint and those who tested HIV positive in Checkpoint versus those who tested HIV negative. Age followed normal distribution and was therefore analyzed using the 2-sample t test. Time from diagnosis to viral suppression was estimated using Kaplan-Meier methods. Observation time was calculated from date of HIV diagnosis to date of first viral load less than 50 copies/mL or December 31, 2012, whichever occurred first. Based on the number of HIV tests performed in 2011 to 2012 and data from the questionnaire substudy, we estimated the number of individuals tested in Checkpoint during the period 2008 to 2012. Furthermore, we estimated the number of individuals tested in Checkpoint in 2008 to 2012, who had not been tested for HIV within 12 months. SPSS version 19.0 (SPSS Inc, Chicago, IL) and Stata, Version 8.0 (Stata Corporation, College Station, TX) were used for data analyses. The Centers for Disease Control and Prevention (CDC) method “cost per HIV infection averted” was used as cost-effectiveness analysis.
From 2008 to 2012, a total of 3012 HIV tests with concomitant STI counseling were performed in Checkpoint. The median age of users was 33 years (range, 16–73 years), and 18% were non-Danish citizens. During the study period, 38 tests were positive; however, one was found to be false positive by confirmatory testing. The remaining 37 tests were true positive, accounting for 1% of all performed tests and 11% of all new HIV cases among MSM in Copenhagen in the period covered. In 2011 and 2012, the proportion of new users (the number tested for the first time in Checkpoint) were 39% (245/636) and 36% (233/640), respectively. Thus, for the 2 years combined, 63% of 1510 tests performed were retests. We assumed that this proportion was lower in the early years of the project giving an overall estimate of 60% retesting, corresponding to 1200 individuals, although the exact number could not be determined because of the anonymous structure of the project. In 2011 and 2012, there were 15 positive tests among 559 individuals, corresponding to an HIV-positive rate of 3%. When calculating the positivity rate per individual during the whole study period, using the 60% retest estimate, the positivity rate was similar (37/1200).
Thirty-six (97%) of the 37 HIV-positive MSM were successfully linked to outpatient follow-up at an HIV care center. Although all 36 patients were reported to the national HIV surveillance system by an infectious disease specialist, only 26 (72%) were reported as being diagnosed in Checkpoint. The proportion of cases reported as coming from Checkpoint increased from 50% in 2008 to 2009 to 93% in 2011 to 2012.
All test sessions included pretest and posttest counseling. Users identified during counseling as having a very high-risk behavior were offered extended psychosocial counseling. Fifty-seven MSM accepted this offer. Patients who were found HIV positive were given comprehensive posttest counseling. Linkage to care was in each of the 37 cases customized to the patients’ needs and included telephone follow-up by Checkpoint staff. A questionnaire filled out before receiving the HIV test result was used in 2011 and 2012 and was accepted by 87% of users. Results are summarized in Table 1.
Questions on sexual identity and relationship status were answered by 83% and 81% of questionnaire participants, respectively. Seventy-one percent of replies were from self-identified homosexual men, whereas 29% identified as either bisexuals or heterosexuals. Forty-five percent stated that they were in a relationship, although the sex and HIV status of partners were not reported.
When comparing the responses of the 15 patients found HIV positive in the period with the remaining 1294 responses, the 2 groups were quite similar, although there a was a trend toward differences in HIV testing behavior. Although 12% of HIV-negative users reported that this was their first HIV test, the same was true for 21% of users found HIV positive (not significant). For users who had previously been HIV tested, median time since last test was 12 months for HIV-negative users (interquartile range [IQR], 6–24) and 24 months for the HIV-positive users (IQR, 9–48); however, the difference was not statistically significant. There was a trend toward HIV-positive patients being more likely to state HIV symptoms as a reason for getting tested (20% vs. 7%, P = 0.06) and less likely to declare that they were getting tested for routine purposes (13% vs. 32%, P < 0.12).
In the study period from 2008 to 2012, supplementary rapid syphilis testing was accepted in 2272 (75%) of 3012 sessions in the walk-in clinic. Fifty-two tests were syphilis positive (2%), and users were referred for confirmatory testing, as the rapid test could not distinguish between newly and previously acquired syphilis cases. In addition, 264 MSM completed a 3-shot hepatitis B vaccination program.
On-site HIV testing in sex venues was first introduced in 2012, and a total of 46 tests were performed, accounting for less than 2% of all HIV testing activity. No HIV-positive cases were found in this setting. However, on-site testing for syphilis, which started in 2010, found 24 syphilis-positive cases in 268 tests (9%). Testing in bars was generally found to be inappropriate by both Checkpoint staff and users because of privacy concerns and intoxication, whereas sex venues and MSM community events were found to be suitable for both counseling and testing. Great care was taken to build trust with sex venue owners, and 3 of 4 of the major Copenhagen MSM sex venues welcomed the project.
The median time from linkage to care to full viral suppression among MSM diagnosed in Checkpoint was 8 months (IQR, 5–19 months), and the probability of viral suppression 1.5 years after linkage to care was 75% (95% confidence interval, 58–90), similar to that of other MSM in Copenhagen as shown in Figure 1.
To examine whether HIV-positive patients diagnosed in Checkpoint were different from other MSM patients diagnosed in conventional health care settings in the Copenhagen region during the same period, their characteristics were compared (Table 2). HIV-positive MSM diagnosed in Checkpoint were younger than other MSM patients with a median age of 33 (IQR, 28–40) and 37 (IQR, 32–44) years, respectively (P = 0.02). Thus, 19% of the newly diagnosed HIV-positive MSM from Checkpoint were younger than 25 years compared with 6% of all other newly diagnosed MSM in Copenhagen. Checkpoint patients had a median CD4 count at time of diagnosis of 420 (IQR, 260–590), similar to other newly diagnosed MSM in Copenhagen in the same period, who had a median CD4 count of 400 (IQR, 270–575). Median time from HIV diagnosis to HAART initiation was 6 months in both groups.
Checkpoint’s average annual budget was 120,000 US dollars (USD; 2010), making a cost per new HIV diagnosis in the 5 year period of 16,000 USD (2010).
Easily accessible walk-in clinics and targeted testing in high-risk settings such as sex venues are measures designed to reach populations of MSM that would otherwise not seek HIV testing. A recent review found 13 peer-reviewed studies in English on community HIV testing facilities targeted at MSM. With a total of 4429 persons and a median of 341 tested participants per study (range, 21–1201), the median positivity rate was 4% (range, 2%–10%).22
The HIV-positive rate of 1% in our study is lower but should be seen in relation to the inability to accurately assess the proportion of retested users over the 5-year period. The 3012 tests, thus, represent a significantly smaller group of MSM. Both a subgroup calculation for the years 2011 to 2012 and an overall estimation of retested users for the whole study period thus set the positivity rate at 3%. The inability to assess retests was brought on by the anonymous structure of the project, but improvements in anonymous coding and registration have since solved this issue.
Checkpoint found 37 new cases of HIV, accounting for 11% of all newly diagnosed MSM in Copenhagen diagnosed in 2008 to 2012. At what HIV stage these patients would have been diagnosed in the established health care system, had the clinic not existed, remains unknown. Checkpoint was seemingly better at reaching young HIV-positive MSM compared with conventional health care testing sites in Copenhagen. All of the 36 MSM who were linked to care subsequently received HAART and achieved viral suppression. Thus, 1.5 years after linkage to care, 27 (75%) of 36 had full viral suppression, suggesting a genuine impact on community HIV transmission in a Danish setting where at least 40% of HIV-positive MSM continue to practice unprotected anal intercourse with HIV-negative sex partners.23
A questionnaire handed out in 2011 to 2012 showed that patients chose Checkpoint primarily because test results were quick and there was easy access to the walk-in clinic. Eleven of the 15 HIV-positive MSM were in relationships. Exploring how safer sex is negotiated in this setting might prove an area of interest for future MSM HIV interventions in Denmark. A substantial share of the HIV-positive users had not had any previous HIV testing performed, and the ones who did reported longer time intervals since the last HIV test than their HIV negative peers. One could speculate that users who were found HIV positive were less likely to seek HIV testing in general and that Checkpoint was a convenient choice due to features that distinguishes it from conventional health care testing services, such as quick test results, accessibility, and anonymity. Checkpoint might also be an ideal choice for men less likely to label themselves as gay, as 29% of MSM self-identified as bisexual or heterosexual, compared with 12% in national MSM surveys.1
In the present study, 97% of the MSM who tested HIV positive were linked to care. Reports on linkage to care from community testing projects are few. In US studies, the main factor associated with no or delayed linkage is having no medical insurance,24 whereas less is known about the barriers in a system with universal health care free of charge. A project from New York bathhouses reported that 15 (75%) of 20 new HIV cases were successfully linked to a care provider,25 whereas an Australian and a British MSM study both reported a 100% linkage to care but were limited to a combined total of 11 patients with HIV.26,27 A sister project to Checkpoint called Barcelona Checkpoint reported that 448 (91%) of 495 HIV-positive MSM were successfully linked to care.28 As HIV testing expands outside the established health care system, it is increasingly important that fruitful partnerships are build to maintain high linkage to care and proper disease surveillance. By reporting to the national HIV surveillance system, in what setting their patient was first diagnosed, HIV care physicians can contribute to effective monitoring of non–health care testing. That the proportion notified to the national HIV surveillance system as diagnosed in Checkpoint increased during the study period (from 50% to 93%) is therefore encouraging.
Measuring the cost-effectiveness of community HIV testing for MSM is inherently difficult and rarely reported.9 The lifetime treatment cost of an HIV-infected individual can be used as a measure of how much is saved by averting one HIV infection and is currently estimated at 675,000 USD (2010) in a Danish setting and at 379,668 USD (2010) in the United States, as estimated by the CDC.29 When using CDC’s conservative estimate and disregarding any other potential savings or costs of early diagnosis, Checkpoint could be deemed cost-effective if just 2 new cases of HIV have been averted in the project lifespan. According to the CDC, testing in non–health care settings such as community-based organizations and outreach venues in the United States typically costs between 10,334 and 20,413 USD (2010) per new HIV diagnosis,29,30 which places Checkpoint well within this range with a cost of 16,000 USD (2010).
The limitations of the study were the inability to accurately assess how many users were retesters and that questionnaire data were only available for 2 of the 5 years studied. The main strengths of the study include being the first testing initiative outside the established health care system in Denmark and, through a unique access to comprehensive national longitudinal data, demonstrating that community testing is noninferior, when it comes to time to HAART and subsequent viral suppression. To our knowledge, this has not previously been shown in a comprehensive fashion.
Although the annual number of MSM newly diagnosed as having HIV in Denmark has been stable for more than a decade,2 37% of MSM remain late presenters, which leaves considerable room for improvement. The experiences of the recent 5 years will shape the future of community testing in Denmark. The Checkpoint project has now been expanded to 2 other major cities in Denmark, and based on the high syphilis positivity rate found in sex venues (9%), HIV rapid testing in this setting is being scaled up. Lessons learned in the first 5 years include providing users with more flexible opening hours, performing better registration of users allowing for both anonymity and retest registration, improving rapid testing with instant HIV tests that gives results in seconds instead of after 20 minutes, introducing oral HIV testing, and supplementary rapid testing for hepatitis C, all of which have recently been initiated.
Checkpoint has highlighted that easy access in a non–health care setting is convenient for MSM who wish to get tested for HIV, without posing a barrier to linkage to care. Although the major success of the project was finding 37 HIV-positive cases, reducing community viral load and reaching younger MSM, the project has also proven an ideal platform for trying out new interventions and test forms, which conventional health care providers have not yet embraced. Such highly cost-effective measures are essential for expanding HIV and STI testing among MSM less likely to seek out the established health care system.
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