1. Case-finding and Treatment: What’s New and What’s Next?
Patrick Sullivan
Emory University, Atlanta Georgia

2. Undiagnosed HIV Infection
HIV Prevalence and Proportion with Undiagnosed HIV Infection in MSM in 21 Cities – NHBS, 2010
Characteristic
Total Tested
HIV Prevalence
N (%)
Undiagnosed HIV Infection
N (%)
Total
8,153
1,562
(19)
680
(44)
Age
18-19
20-24
25-29
30-39
40-49
≥ 50
423
1,466
1,529
2,231
1,712
792 28
170
223
470
474
197
(7)
(12)
(15)
(21)
(28)
(25) 21
115
128
214
164 38
(75)
(65)
(57)
(46)
(35)
(10)
Race
White
Black
Hispanic
API
NA/AN
Multiracial/Other
3,580
1,895
2,045
230 62
336
560
539
358 22 11 72
(16)
(18) 23
139 2
<10 13
(67)
(48)
(29)
(100)
(52)

3. Other ways of gauging our success
Inter-test interval?
Goal: days?
PHSKC: 215 days
GCHP: 257 days
And these are places that can measure!
Coverage of treatment among positives
Katz et al, STI 2013

4. Goals of an optimized HIV testing program for MSM
Increase HIV testing frequency to 3-4 times/year by providing acceptable options
Test groups of men who are at high risk, but currently not testing or not testing often enough
Use new testing options to leverage network
Use internet-based technologies to reach men who are in rural areas, or who don’t want to use gay-serving community organizations
Build on ACA and recent changes in USPSTF recommendations for testing in medical care

5. Why haven’t MSM tested for HIV recently?

6. New approaches to HIV testing
Couples HIV counseling and testing
At-home specimen collection kit distribution
Internet-administered social networks strategy
Finding the role for at-home self HIV testing
Improving linkage to care strategies based on the testing approach

7. Couples HIV Counseling and Testing for Male Couples

8. CVCT Developed in Rwanda in the 1980s Zambia in the 1990s
Supported by PEPFAR
Demonstrated to reduce HIV transmission in discordant couples
Not historically offered in the US
Couples do pretest, testing, return of results, and post-test planning together
Being rolled out by CDC in the US
Preliminary data from an RCT in Atlanta and from a 5-city scaleup

9. Willingnes to Use CVCT
Wagenaar et al, PLoS ONE 2012

10. Seropositivity in men tested in couples
Analysis Group
(N of clients)
HIV Negative (%)
HIV Positive (%)
All Eligible (212)
187 (88)
25 (12)
All Randomized
(156)
137 (89)
19 (12)
All Excluded for Coercion or IPV
(56)
50 (89)
6 (11)
Sullivan et al, Archives Sex Behav, in press

11. Distribution of couple serostatus
Atlanta RCT (N=78)
Expanded Evaluation (N=272)

13. Qualitative results -- CVCT
“I knew I was HIV positive and I didn’t know how to tell him, we hadn’t had sex yet, we were just flirting around with each other. But he was so damn persistent about being tested, but for whatever reason back then I just couldn’t say it, so I said let’s just go get tested”
Those who self-identified as HIV+ noted that CVCT would provide a forum for them to share their sero-status with their new partner in a more supportive environment
Many participants also reported that the opportunity that CVCT afforded for them to provide and receive emotional support from a partner was a major factor in the decision to adopt CVCT
“I think it would’ve been a lot better, during that time all I wanted to do was to hold someone’s hand, I just knew it was really emotional for him, and I knew it would be a lot better for him if I were in the room and able to calm him down”

14. Lessons
Testing couples together may bring in men who have higher seropositivity rates than men tested alone
Couples testing offers a chance to test the partners of those who know that they have HIV
Couples want to test together to support one another. This can be used to support next steps for linkage and treatment.

15. At-home specimen collection
Commercially available
Some men prefer having a lab do the testing
Allows confirmation of positive results
Acceptable to men

17. Willingness to Take a Free Home HIV Test among 6163 HIV-Negative or -Unknown MSM, 2009
Sharma et al, JIAPAC 2011

19. Implementation of at-home specimen collection: research
896 MSM recruited online in 2011 agreed to receive an at-home specimen collection kit
Mailed DBS specimen and received test result by automated voice response system
Linkage to care was by Home Access or Emory staff

20. Demographics of at-home testing MSM

21. Return of acceptable specimens
Return was more common among men who were white, younger, and more educated.

22. Other results 3.4% of men had a positive HIV test result
vs 3.6% among MSM in CDC-supported settings*
96% of positive men collected their HIV result through the phone system
80% of HIV+ men were confirmed to have linked to HIV care
*Centers for Disease Control and Prevention. HIV Counseling and Testing at CDC-Funded Sites, United States, Puerto Rico, and the U.S. Virgin Islands, Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; November 2011:1-44.

23. Next steps: at-home collection
8,000 kits to be distributed through CDC’s MSM Testing Initiative
Internet-based recruitment
Gift card distributed through venue-based testers
Referrals from successful testers
Distribution planned to start in June 2013

24. Main messages
The testing needs of MSM are different than for other populations. Most MSM need to be tested for HIV more often than we are at present.
Testing needs, as for other prevention needs, change over the lives of MSM.
A menu-driven approach might support developing and implementation of a tailored testing plan for MSM.
Linkage to appropriate services – whether behavioral or treatment – need to be built into testing approaches.

25. Thanks Funders: Emory University NIMH NIAID NICHD MAC AIDS Fund
Emory CFAR
Emory University
Rob Stephenson
Travis Sanchez
Mondie Tharp
Alexandra Ricca
Christine Khosropour
Brent Johnson
Other Collaborators
Abt Associaties
Kristina Grabbe