HIV Self-Sampling: Establishing a sustainable service Dr Anthony Nardone Centre for Infectious Disease Surveillance and Control

Outline Background: Results form national services Proposed next steps HIV epidemiology What is HIV self-sampling PHE support Results form national services Volumes of requests Dependence on health promotion work Profile of users Linkage into care Satisfaction of service Proposed next steps

Background An estimated 1 in 5 people living with HIV are undiagnosed (22,000) An estimated 6,500 (29%) of undiagnosed in London HIV epidemiology in 2012 : 47% of new HIV diagnosed with CD4 count <350 ~½ of MSM diagnosed at first HIV test Two populations most at-risk of HIV Men who have sex with men (MSM) Black-Africans Need to increase HIV testing and frequency of testing, especially among MSM

Background (2) HIV Self Sampling: person takes a sample (saliva or blood from a finger prick), and sends it to a laboratory for testing. Results are then given by the service, advising you what to do next HIV Self Testing: Person performs an HIV test on themselves, in a non-medical setting (e.g. home), and sees a result immediately 6th April: Repeal of the HIV testing and Services Regulations hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317141025695

HIV Self-Sampling Services HIV tests ordered on-line 4th generation dried blood spot 3rd generation oral swab Samples posted to laboratory Individual informed of result Negatives by text Positives by phone and letter Referral to HIV service recommended The service offered dried blood-spot kits to communities with the highest prevalence of undiagnosed HIV infection in England: Men who have sex with men (MSM) Black African heterosexuals

Results from 2nd phase support PHE has supported two services for 5 months of operation (Nov 13 – March 14) which has delivered: 12,485 test requests 6,593 returned (53%) 92 new diagnoses (1.4% positivity) Major issues highlighted from pilot phases High volumes that can be managed through the internet Different to clinic populations (younger and more rural) Used by those at high risk due to testing and sexual behaviour Linked to care User satisfaction

Self sampling kits delivered in West Midlands In 5 months (Nov 13 – Mar 14), 2 national services have delivered: 12791 kits delivered, 1089 to the West Midlands

Relationship to marketing (Phase 2) National HIV testing week Brady M et al BHIVA/BASHH conference 2014

Geo-demography of users (MSM)

Self-reported HIV testing history 33% 41% 25% MSM Black African Heterosexuals

Sexual partners in last year and testing history, MSM MSM reporting more sexual partners tested more recently (χ2=123.80, p< 0.001). This self-sampling service facilitates access to testing for a population of MSM who are already testing. As it is recommended that these individuals test up to quarterly intervals, this method of providing HIV testing will alleviate burden on GUM clinics whilst allowing men who need to test frequently to do so conveniently. (n=1088) (n=1350) (n=832)

Confirmed attendance at HIV service (%) Access to care (Phase 1) Brady M et al BHIVA/BASHH conference 2014 Outcome Number Confirmed attendance at HIV service (%) Accepted referral to HIV service 38 32 (84.2) Self referral to HIV service 46 33 (71.7) Already known to be positive and accessing care 11 11 (100) Declined further contact/failed to respond to messages 8 1 Living abroad (Spain/Zambia) 2 N/A Total 105 77 (74.7)

User Satisfaction with the National HIV Self-Sampling Services HPE/THT (N=861) Dean Street (N=229) Would you recommend the service to a friend expected to test negative 97% 96% Would you recommend the service to a friend expected to test positive 65% 58% I would use the service again - “I was really grateful that this existed as I don't think I would have gone to a clinic. I would have taken a lot of courage. an anonymous postal service made it so much easier. I would be really happy if this existed for other sexual health screening.” McOwan et al BASHH/BHIVA conference 2014

Conclusion Successful self-sampling pilots: Large volumes with high return and positivity rates ~¾ users had either never tested before or insufficiently Closely linked to health promotion activity Accessing Black African populations remains a challenge Costs much lower than clinic or outreach based services Major contribution to plans to increase HIV testing Adjunct to HIV testing in clinical services Platform to which other STI tests could in future included

Acknowledgments: Michael Brady and colleagues at Terrence Higgins Trusts /HIV Prevention England Alan McOwan and colleagues at Dean Street Clinic/Chelsea & Westminster Hospital NHS Foundation Trust