1. MSM Attending STD Clinics HIV Testing More Frequently: Implications for HIV Prevention and Surveillance D Helms1, H Weinstock1, K Mahle1, A Shahkolahi1,2, J Klausner3, K Rietmeijer4, M Golden5 1Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA 2Whitman Walker Clinic, Washington DC 3San Francisco Dept. of Public Health, San Francisco, CA 4Denver Public Health, Denver, CO 5Public Health, Seattle and King County, Seattle, WA

2. HIV among Men Who Have Sex with Men
Throughout the US, MSM remain the group most affected by HIV
HIV testing remains the cornerstone of prevention
MSM preferentially have sex with men of the same HIV status
MSM who learn they are HIV infected alter their sexual behavior to diminish transmission
A central goal of prevention efforts is to assure that HIV-infected persons know about their infection as soon as possible following HIV acquisition

3. Current HIV Testing Recommendations
CDC recommends:
“Persons at high-risk for HIV, including MSM, be tested at least annually”
Some local health departments have issued recommendations advocating testing every 3-6 months in higher risk MSM
The frequency of HIV testing or the period between HIV tests has not been monitored as an index of prevention program success

4. Objectives
1) To determine the proportion of MSM previously tested for HIV
2) To estimate the time between HIV tests (i.e. inter-test interval) among MSM
3) To identify predictors of longer inter-test intervals
4) To assess whether there is a trend toward shorter inter-test intervals

5. Methods
Data from a sentinel surveillance project (MSM Prevalence Monitoring Project);
57,131 visits from MSM aged years
4 STD clinics in Denver, CO, the District of Columbia, San Francisco, CA, and Seattle, WA
Clinic visit was the unit of analysis throughout the study

6. Analysis
Evaluated visits from MSM who denied previously testing positive for HIV
Among MSM tested at current visit with a history of prior HIV testing:
calculated the inter-test interval among the overall population and the newly diagnosed
Inter-test interval is defined as the number of days between the reported previous HIV test and the HIV test from the current visit

7. Multivariate Analysis
Used generalized estimating equations (GEE)
Included in the model:
Age
Race/ethnicity
City in which patients were tested
Concurrent diagnosis with a bacterial STI
Year of HIV testing

8. Results 57,131 separate visits by MSM
49,617 not known to be previously HIV positive
27,887 HIV tested at current visit
1,060 (3.8%) tested positive for HIV
23,600 previously tested for HIV

9. Demographics Characteristics % (N) Race/Ethnicity Cities Age (years)
(8464)
(18431)
(15360)
(5776)
> (1905)
Race/Ethnicity
White (31685)
Black (4537)
Hispanic (8237)
Asian (3783)
Other (1058)
Cities
Denver (6092)
District of Columbia (8140)
San Francisco (25566)
Seattle (9819)

10. Percent of MSM who Never Previously Tested for HIV, 2002-2006

11. Factors Associated with Never Previously Testing for HIV
Risk Factors AOR % C.I.
Age (years) ( )
Year of visit ( )
Race/ethnicity
White
Black ( )
Hispanic ( )
Asian ( )
Other ( )
Site
San Francisco
DC ( )
Denver ( )
Seattle ( )
Diagnosed w/ STI ( )

12. HIV Inter-test Interval for All MSM Tested
Characteristic Estimate p-value
Age (years) <0.0001
Year of visit
Race/ethnicity
White
Black
Hispanic
Asian
Other
Site
Seattle
DC <0.0001
Denver
San Francisco <0.0001
Site*Year of visit DC
Denver
San Francisco
Using age as an example, for each one year increase in age of MSM, there was a two percent increase in the inter-test interval.
We observed a significant interaction between year of clinic visit and testing in Denver.
p < 0.03

13. Percent of MSM who Never Previously Tested for HIV among New HIV Positives, 2002-2006

14. Factors Associated with New HIV
Risk Factors AOR 95% C.I.
Age (years) ( )
Year of visit ( )
Race/ethnicity
White
Black ( )
Hispanic ( )
Asian ( )
Other ( )
Site
Seattle
DC ( )
Denver ( )
San Francisco ( )
Diagnosed w/ STI ( )
Time between testing
<1 year
1-2 years ( )
>2 years ( )
We observed a dose-response relationship for time between HIV testing.

15. HIV Inter-test Interval for New HIV Positives
Characteristic
Estimate
p-value
Age
1.02
<0.0001
Year of visit
0.95
GEE for New Positives
For each one year increase in age of MSM, there was a two percent increase in the inter-test interval.
For each one year increase in year of HIV test, there was a five percent decrease in the inter-test interval.
p =

16. Limitations
Results reflect MSM in STD clinics/Gay Men’s Health Clinics
Evaluated MSM visits, not individual MSM
Did not include anonymous testers and investigators indicated that they believed that the proportion of tests performed anonymously was decreasing in their areas
Behavioral variables were not available to evaluate in the model

17. Conclusions
The percentage of MSM that reported never testing and the time period between HIV tests decreased
This change was notable in men newly testing HIV positive
Could affect on the performance of currently used HIV tests
More patients will test in the “window” period
Programs should consider incorporating the use of more sensitive tests (e.g. pooled RNA testing)

18. Next Steps
Prevention efforts should attempt to further decrease the inter-test interval
Public health authorities should monitor the proportion of MSM previously tested and the inter-test interval as prevention indices

19. Acknowledgements Colorado (Denver): Kees Rietmeijer Doug Richardson
Mark Foster
DC:
Philippe Chiliade
Bruce Furness
Gonzalo Saenz
Mike Smoot
San Francisco:
Charlotte Kent
Bob Kohn
Washington (Seattle):
Matthew Golden
James Hughes
Fred Koch
CDC (Atlanta, GA):
Jim Braxton
Kristen Mahle
Maya Sternberg
Hillard Weinstock
The findings and conclusions in this presentation are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention

20. Additional Slides

21. MSM Prevalence Monitoring Project
Objectives: To collect national STD and HIV data among MSM and assess prevalence of and trends in STDs, HIV, and HIV risk behaviors among MSM
Inform national and local screening and prevention policy (e.g., syphilis elimination campaigns)

22. Pooled HIV Test Combine standard ELISA tests with viral load tests.
If a pooled sample tests positive, the laboratory technicians test individual samples in the pool until they find the sample that is positive.
This method allows the benefit of both standard antibody tests and viral load tests to more accurately determine whether someone is HIV infected.

23. Risk Factors of Never Previously Testing for HIV
Never Previously Tested Never Tested
Risk Factors AOR 95% C.I AOR 95% C.I.
Age (years) ( ) ( )
Year of visit ( ) ( )
Race/ethnicity
White
Black ( ) ( )
Hispanic ( ) ( )
Asian ( ) ( )
Other ( ) ( )
Site
Seattle
DC ( ) ( )
Denver ( ) ( )
San Francisco ( ) ( )
Diagnosed w/ STI ( ) ( )