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

Sharma, Akshay (2015)

Permanent URL: https://etd.library.emory.edu/concern/etds/pc289j62m?locale=zh
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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 LIST OF TABLES TABLE 2.1: Demographic and behavioral characteristics of 973 HIV-negative or unknown status MSM respondents to a national online health survey, United States, 2012 … 41 TABLE 2.2: HIV testing characteristics of 795 HIV-negative or unknown status MSM respondents to a national online health survey who had previously tested, United States, 2012 … 43 TABLE 2.3: Stated likelihood of using different HIV testing options if offered free of charge by selected demographic and behavioral characteristics of 973 HIV-negative or unknown status MSM respondents to a national online health survey, United States, 2012 … 44 TABLE 3.1: Demographic and behavioral characteristics of 840 HIV-negative or unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 73 TABLE 3.2: Baseline testing characteristics of 840 HIV-negative or unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 76 TABLE 3.3: Reasons and main reason for never being tested for HIV cited by 153 HIV unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 78 TABLE 3.4: Reasons and main reason for not previously using home HIV tests cited by 596 HIV-negative and unknown status MSM participants who had heard about such tests before in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 79 TABLE 3.5: Associations between demographic and behavioral characteristics and the stated likelihood of potentially distributing free oral fluid rapid home tests among 840 HIV-negative or unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 80 TABLE 3.6: Associations between demographic and behavioral characteristics and the stated likelihood of potentially distributing free finger-stick blood rapid home tests among 840 HIV- negative or unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 82 TABLE 3.7: Associations between demographic and behavioral characteristics and the stated likelihood of potentially testing with friends or sex partners using free rapid home tests among 840 HIV-negative or unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 84 TABLE 3.8: Reasons and main reason for being unlikely to self-test using free rapid home tests cited by 79 HIV-negative or unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 86 TABLE 3.9: Reasons and main reason for being unlikely to potentially distribute free rapid home tests cited by 179 HIV-negative or unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 87 TABLE 3.10: Reasons and main reason for being unlikely to potentially test with friends or sex partners using free rapid home tests cited by 232 HIV-negative or unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 88 TABLE 3.S1: Derivation of the analytic sample comprising 840 HIV-negative and unknown status MSM participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 89 TABLE 3.S2: Comparison of 840 HIV-negative and unknown status MSM participants included in the final analytic sample with 152 excluded participants in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 91 TABLE 4.1: Illustrative demographic characteristics of 1,200 simulated participants from a single replication of a randomized trial … 113 TABLE 4.2: Screening characteristics from a single replication of a randomized trial with 1,200 simulated participants assuming the first parameter specification under Scenario A … 114 TABLE 4.3: Point estimates from different analytical approaches on 10 replications of a randomized trial each with 1,200 simulated participants assuming the first parameter specification under Scenario A … 115 TABLE 4.S1: Data layout example for the first analytical outcome definition … 122 TABLE 4.S2: Data layout example for the second analytical outcome definition … 124 TABLE 4.S3: Data layout example for the third analytical outcome definition … 130 LIST OF FIGURES FIGURE 2.1: Stated likelihood of using different currently available HIV testing options if offered free of charge to 973 HIV-negative or unknown status men who have sex with men in a national online health survey, United States, 2012 … 39 FIGURE 2.2: Modified Borda Count ranking of different currently available HIV testing options if offered free of charge to 973 HIV-negative or unknown status men who have sex with men in a national online health survey, United States, 2012 … 40 FIGURE 3.1: Stated likelihood of potentially self-testing, distributing and testing with friends or sex partners using free rapid home test kits among 840 HIV-negative or unknown status men who have sex with men participating in a national online research study on rapid HIV self-testing (KnowAtHome), United States, 2014 … 72 FIGURE 4.1: Power curves from 1,000 trial replications assuming the first and second parameter specifications under Scenario A … 110 FIGURE 4.2: Power curves from 1,000 trial replications assuming the first and second parameter specifications under Scenario B … 111 FIGURE 4.3: Power curves from 1,000 trial replications assuming the first and second parameter specifications under Scenario C … 112 FIGURE 4.S1: Screening patterns and inter-test intervals for 20 simulated participants by study arm from a single trial replication assuming the first parameter specification under Scenario A … 132 FIGURE 4.S2: Screening patterns and inter-test intervals for 20 simulated participants by study arm from a single trial replication assuming the first parameter specification under Scenario B … 133 FIGURE 4.S3: Screening patterns and inter-test intervals for 20 simulated participants by study arm from a single trial replication assuming the first parameter specification under Scenario C … 134 FIGURE 4.S4: Retention at 3, 6, 9 and 12 months for 1,200 simulated participants by study arm from a single trial replication under three censoring scenarios … 135 FIGURE 4.S5: Frequency distribution of point estimates generated from SLR and GEE for correlated data on 1,000 trial replications each with 1,200 simulated participants assuming the first parameter specification under Scenario A … 136 FIGURE 4.S6: Frequency distribution of point estimates generated from the total follow-up time and gap time models for stratified Cox PH regression on 1,000 trial replications each with 1,200 simulated participants assuming the first parameter specification under Scenario A … 137 FIGURE 4.S7: Power curves from 1,000 trial replications assuming the third and fourth parameter specifications under Scenario A … 138 FIGURE 4.S8: Power curves from 1,000 trial replications assuming the third and fourth parameter specifications under Scenario B … 139 FIGURE 4.S9: Power curves from 1,000 trial replications assuming the third and fourth parameter specifications under Scenario C … 140 FIGURE 4.S10: Power curves from 1,000 trial replications assuming the fifth and sixth parameter specifications under Scenario A … 141 FIGURE 4.S11: Power curves from 1,000 trial replications assuming the fifth and sixth parameter specifications under Scenario B … 142 FIGURE 4.S12: Power curves from 1,000 trial replications assuming the fifth and sixth parameter specifications under Scenario C … 143

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