New approaches for increasing HIV testing among men who have sex with men in the United States Public

Abstract

Men who have sex with men (MSM) remain disproportionately affected by HIV in the United States. Testing is the cornerstone of comprehensive prevention efforts and the gateway to treatment. However, many MSM do not test annually, and a high proportion are unaware they are infected. This dissertation comprises three studies focusing on the acceptability and evaluation of new strategies to promote frequent HIV testing. In the first study, we determined collective attitudes towards using six testing options among 973 MSM recruited online in 2012: Testing at a physician's office; Individual voluntary counseling and testing; Couples' HIV counseling and testing; Expedited/express testing; Rapid home self-testing using an oral fluid test; Home dried blood spot (DBS) self-collection for laboratory testing. Most participants indicated being likely to use all modalities except DBS self-collection. Rapid home self-testing and testing at a physician's office were consistently top ranked. In the second study, we surveyed 840 internet-using MSM in 2014 regarding past experiences with HIV self-testing, and future intentions of distributing free rapid home test kits and testing with their social or sexual network associates. Although 80% were aware, only 9% reported using home tests before. MSM self-identifying as bisexual had reduced odds of potentially distributing kits. Unprotected anal intercourse with one man in the past year, previous HIV testing, and willingness to distribute kits were associated with higher odds of potentially testing with others. In the third study, we simulated several randomized trials evaluating a new HIV prevention strategy, formulated three analytical outcomes (screening a certain number of times during the entire trial; screening at least once within a clinically meaningful interval; instantaneous rate of screening), and compared them with regard to interpreting results and estimating power. Methods utilizing detailed prospective data, while also accounting for within-participant correlations, were less likely to miss the actual underlying intervention benefit compared to those relying on dichotomous measures derived from aggregating events. Our findings demonstrate the potential for combining multiple testing options as part of packages to increase HIV testing among MSM. Rapid home tests hold immense promise and research assessing their public health impact should be prioritized.

Table of Contents

CHAPTER 1: Background and significance 1

SECTION 1.1: MSM and HIV in the United States 1

SECTION 1.2: Role of HIV testing in prevention efforts 2

SECTION 1.3: Inadequate HIV testing among MSM 3

SECTION 1.4: Menu of available HIV testing options 4

SECTION 1.5: Internet-based HIV prevention strategies 14

SECTION 1.6: Motivation for dissertation studies 15

SECTION 1.7: Specific objectives for dissertation studies 17

SECTION 1.8: Structure of this dissertation 19

CHAPTER 2: Acceptability and intended usage preferences for six HIV testing options among internet-using men who have sex with men 20

SECTION 2.1: Abstract 22

SECTION 2.2: Introduction 24

SECTION 2.3: Methods 28

SECTION 2.4: Results 31

SECTION 2.5: Discussion 34

CHAPTER 3: Willingness to potentially self-test, distribute and test with social or sexual network associates using rapid home HIV test kits and associated factors among men who have sex with men 46

SECTION 3.1: Abstract 48

SECTION 3.2: Introduction 50

SECTION 3.3: Methods 55

SECTION 3.4: Results 60

SECTION 3.5: Discussion 65

CHAPTER 4: Evaluating interventions to promote routine preventive screenings: A comparison of analytical outcomes 92

SECTION 4.1: Abstract 94

SECTION 4.2: Introduction 96

SECTION 4.3: Methods 99

SECTION 4.4: Results 103

SECTION 4.5: Discussion 105

SECTION 4.6: Supplementary content 116

CHAPTER 5: Relevance and Contributions 144

SECTION 5.1: Review of major findings 144

SECTION 5.2: Current relevance of dissertation studies 147

SECTION 5.3: Public health contributions of this dissertation 150

SECTION 5.4: Future directions emerging from this dissertation 153

REFERENCES 155

APPENDICES 181

A1: Survey questions on the acceptability and ranking of six HIV testing options 181

A2: Press copy of Chapter 2 (SpringerPlus 2014, 3:109) 184

A3: KnowAtHome.org landing page 194

A4: Survey questions on the awareness and previous use of home HIV tests, and willingness to potentially self-test, distribute and test with friends or sex partners using rapid home test kits 195

A5: SAS code for simulations and subsequent analyses 204

A6: Press copy of Chapter 4 (Contemporary Clinical Trials 2015, 41:152-159) 321

About this Dissertation

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School	Laney Graduate School
Department	Epidemiology
Degree	PhD
Submission	Dissertation
Language	English
Research Field	Biology, Biostatistics Psychology, Behavioral Health Sciences, Epidemiology
Mot-clé	Online HIV prevention research Rapid home HIV self-testing Randomized trials with recurrent events Combination prevention approaches Analytical outcome choices HIV testing preferences
Committee Chair / Thesis Advisor	Sullivan, Patrick S, Emory University
Committee Members	McNaghten, AD , Emory University Johnson, Brent, Emory University Stephenson, Robert, Emory University

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