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      Preferences for HIV testing services among men who have sex with men in the UK: A discrete choice experiment

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          Abstract

          Background

          In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare.

          Methods and findings

          Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world.

          Conclusions

          Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free.

          Abstract

          In a discrete choice experiment, Carrie Llewellyn and co-workers investigate the preferences of men who have sex with men for provision of HIV testing.

          Author summary

          Why was this study done?
          • HIV testing remains low in high-risk populations, such as men who have sex with men (MSM).

          • HIV tests can be performed by healthcare professionals (HCPs) or remotely, using self-testing and self-sampling kits.

          • However, the relative importance of the test characteristics most likely to optimise their use—such as the time it takes to receive a result and the cost of the tests—is not fully understood.

          What did the authors do and find?
          • We assessed the strength of preference for different HIV test characteristics by asking men in the UK who expressed an interest in online material used by MSM to complete an online questionnaire.

          • Participants were recruited using social media.

          • Most respondents preferred to be tested by HCPs rather than to test remotely.

          • The most important barrier to remote testing was its cost.

          What do these findings mean?
          • In this study, HIV testing carried out by HCPs was found to be particularly valued by respondents.

          • There was some evidence that remote testing might increase testing rates, albeit for a minority of respondents.

          • Remote HIV testing should generally be viewed as supplementary to HCP-delivered services.

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          Most cited references34

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          A New Approach to Consumer Theory

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            Examining the effects of HIV self-testing compared to standard HIV testing services: a systematic review and meta-analysis

            Abstract Introduction: HIV self-testing (HIVST) is a discreet and convenient way to reach people with HIV who do not know their status, including many who may not otherwise test. To inform World Health Organization (WHO) guidance, we assessed the effect of HIVST on uptake and frequency of testing, as well as identification of HIV-positive persons, linkage to care, social harm, and risk behaviour. Methods: We systematically searched for studies comparing HIVST to standard HIV testing until 1 June 2016. Meta-analyses of studies reporting comparable outcomes were conducted using a random-effects model for relative risks (RR) and 95% confidence intervals. The quality of evidence was evaluated using GRADE. Results: After screening 638 citations, we identified five randomized controlled trials (RCTs) comparing HIVST to standard HIV testing services among 4,145 total participants from four countries. All offered free oral-fluid rapid tests for HIVST and were among men. Meta-analysis of three RCTs showed HIVST doubled uptake of testing among men (RR = 2.12; 95% CI: 1.51, 2.98). Meta-analysis of two RCTs among men who have sex with men showed frequency of testing nearly doubled (Rate ratio = 1.88; 95% CI: 1.17; 3.01), resulting in two more tests in a 12–15-month period (Mean difference = 2.13; 95% CI: 1.59, 2.66). Meta-analysis of two RCTs showed HIVST also doubled the likelihood of an HIV-positive diagnosis (RR = 2.02; 95% CI: 0.37, 10.76, 5.32). Across all RCTs, there was no indication of harm attributable to HIVST and potential increases in risk-taking behaviour appeared to be minimal. Conclusions: HIVST is associated with increased uptake and frequency of testing in RCTs. Such increases, particularly among those at risk who may not otherwise test, will likely identify more HIV-positive individuals as compared to standard testing services alone. However, further research on how to support linkage to confirmatory testing, prevention, treatment and care services is needed. WHO now recommends HIVST as an additional HIV testing approach.
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              Attitudes and Acceptability on HIV Self-testing Among Key Populations: A Literature Review

              HIV self-testing (HIVST) is a potential strategy to overcome disparities in access to and uptake of HIV testing, particularly among key populations (KP). A literature review was conducted on the acceptability, values and preferences among KP. Data was analyzed by country income World Bank classification, type of specimen collection, level of support offered and other qualitative aspects. Most studies identified were from high-income countries and among men who have sex with men (MSM) who found HIVST to be acceptable. In general, MSM were interested in HIVST because of its convenient and private nature. However, they had concerns about the lack of counseling, possible user error and accuracy. Data on the values and preferences of other KP groups regarding HIVST is limited. This should be a research priority, as HIVST is likely to become more widely available, including in resource-limited settings. Electronic supplementary material The online version of this article (doi:10.1007/s10461-015-1097-8) contains supplementary material, which is available to authorized users.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                11 April 2019
                April 2019
                : 16
                : 4
                : e1002779
                Affiliations
                [1 ] Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
                [2 ] Department of Psychology, University of Southampton, Southampton, United Kingdom
                [3 ] Royal South Hants Hospital, Solent NHS Trust, Southampton, United Kingdom
                [4 ] Institute for Global Health, University College London, London, United Kingdom
                [5 ] Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, United Kingdom
                University of California, San Francisco, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-7010-5308
                http://orcid.org/0000-0003-2384-4807
                http://orcid.org/0000-0002-9107-8473
                Article
                PMEDICINE-D-18-01809
                10.1371/journal.pmed.1002779
                6459507
                30973868
                f5901a41-6b29-4ec7-a311-4e21481abdab
                © 2019 Miners et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 24 May 2018
                : 12 March 2019
                Page count
                Figures: 1, Tables: 3, Pages: 15
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Biology and Life Sciences
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                Medical Microbiology
                Microbial Pathogens
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                Pathogens
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                Custom metadata
                The full dataset used for the conditional logit and latent class analyses have been de-identified and uploaded to the Sussex Research Data Repository (SURE). The data files and analysis syntax can be downloaded from https://figshare.com/articles/Preferences_for_HIV_testing_services_among_men_who_have_sex_with_men_in_the_UK_a_discrete_choice_experiment/7791455.

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