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

Sharma, Akshay (2015)
Dissertation (340 pages)
Committee Chair / Thesis Adviser: Sullivan, Patrick S
Committee Members: Johnson, Brent ; McNaghten, AD ; Stephenson, Robert
Research Fields: Health Sciences, Epidemiology; Psychology, Behavioral; Biology, Biostatistics
Keywords: HIV testing preferences; Rapid home HIV self-testing; Online HIV prevention research; Combination prevention approaches; Randomized trials with recurrent events; Analytical outcome choices
Program: Laney Graduate School, Epidemiology
Permanent url: http://pid.emory.edu/ark:/25593/pgnd8

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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 1 -- SECTION 1.1: MSM and HIV in the United States ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 1 -- SECTION 1.2: Role of HIV testing in prevention efforts ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 2 -- SECTION 1.3: Inadequate HIV testing among MSM ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 3 -- SECTION 1.4: Menu of available HIV testing options ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 4 -- SECTION 1.5: Internet-based HIV prevention strategies ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 14 -- SECTION 1.6: Motivation for dissertation studies ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 15 -- SECTION 1.7: Specific objectives for dissertation studies ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 17 -- SECTION 1.8: Structure of this dissertation ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 19 -- CHAPTER 2: Acceptability and intended usage preferences for six HIV testing options among internet-using men who have sex with men ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 20 -- SECTION 2.1: Abstract ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 22 -- SECTION 2.2: Introduction ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 24 -- SECTION 2.3: Methods ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 28 -- SECTION 2.4: Results ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 31 -- SECTION 2.5: Discussion ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 46 -- SECTION 3.1: Abstract ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 48 -- SECTION 3.2: Introduction ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 50 -- SECTION 3.3: Methods ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 55 -- SECTION 3.4: Results ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 60 -- SECTION 3.5: Discussion ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 65 -- CHAPTER 4: Evaluating interventions to promote routine preventive screenings: A comparison of analytical outcomes ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 92 -- SECTION 4.1: Abstract ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 94 -- SECTION 4.2: Introduction ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 96 -- SECTION 4.3: Methods ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 99 -- SECTION 4.4: Results ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 103 -- SECTION 4.5: Discussion ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 105 -- SECTION 4.6: Supplementary content ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 116 -- CHAPTER 5: Relevance and Contributions ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 144 -- SECTION 5.1: Review of major findings ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 144 -- SECTION 5.2: Current relevance of dissertation studies ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 147 -- SECTION 5.3: Public health contributions of this dissertation ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 150 -- SECTION 5.4: Future directions emerging from this dissertation ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 153 -- REFERENCES ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 155 -- APPENDICES ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 181 -- A1: Survey questions on the acceptability and ranking of six HIV testing options ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 181 -- A2: Press copy of Chapter 2 (SpringerPlus 2014, 3:109) ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 184 -- A3: KnowAtHome.org landing page ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 195 -- A5: SAS code for simulations and subsequent analyses ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 204 -- A6: Press copy of Chapter 4 (Contemporary Clinical Trials 2015, 41:152-159) ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 91 -- TABLE 4.1: Illustrative demographic characteristics of 1,200 simulated participants from a single replication of a randomized trial ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 115 -- TABLE 4.S1: Data layout example for the first analytical outcome definition ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 122 -- TABLE 4.S2: Data layout example for the second analytical outcome definition ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 124 -- TABLE 4.S3: Data layout example for the third analytical outcome definition ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 72 -- FIGURE 4.1: Power curves from 1,000 trial replications assuming the first and second parameter specifications under Scenario A ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 110 -- FIGURE 4.2: Power curves from 1,000 trial replications assuming the first and second parameter specifications under Scenario B ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 111 -- FIGURE 4.3: Power curves from 1,000 trial replications assuming the first and second parameter specifications under Scenario C ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 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 ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 137 -- FIGURE 4.S7: Power curves from 1,000 trial replications assuming the third and fourth parameter specifications under Scenario A ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 138 -- FIGURE 4.S8: Power curves from 1,000 trial replications assuming the third and fourth parameter specifications under Scenario B ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 139 -- FIGURE 4.S9: Power curves from 1,000 trial replications assuming the third and fourth parameter specifications under Scenario C ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 140 -- FIGURE 4.S10: Power curves from 1,000 trial replications assuming the fifth and sixth parameter specifications under Scenario A ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 141 -- FIGURE 4.S11: Power curves from 1,000 trial replications assuming the fifth and sixth parameter specifications under Scenario B ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 142 -- FIGURE 4.S12: Power curves from 1,000 trial replications assuming the fifth and sixth parameter specifications under Scenario C ΓƒΒ’Γ’β€šΒ¬Γ‚Β¦ 143

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