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Voluntary HIV testing and counselling is a key element in HIV prevention. In Australia, 85% of HIV infections occur among gay and other homosexually active men . Encouraging regular HIV testing among homosexual men remains an important, explicit part of HIV prevention policy , and HIV testing plays a central role in gay men's strategies to reduce harm to themselves and their partners.
HIV testing rates among homosexual men in Australia are high compared with other major industrialized countries. In a 1996 national survey, 77% of 3039 homosexually active men reported ever being tested , and testing rates of close to 90% have been described in the gay communities of Melbourne and Sydney . Reported ever testing rates were 60% in a national survey of homosexual men in the United States of America , 63% in a Canadian survey , 63% in London  and 50% in Scotland .
Increasing HIV risk behaviour among homosexual men, and some evidence of an association between HIV treatment optimism and reporting unprotected anal intercourse has been described since the mid-1990s [4, 9]. Recently, a slight decrease over time both in the percentage of men ever HIV tested and in the frequency of testing in Sydney has been reported . This study further examines trends in recent HIV testing in homosexual men in Australia and explores possible reasons for these trends.
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This study confirms a decline in recent HIV testing among homosexual men participating in behavioural surveillance in Australia between 1996 and 2001, from 62.8% to 54.7%, but it suggests that the reasons for this decline have been complex, and may be related to changes in the sample over time, or to broader changes in the gay community. In the sample, there was a change over time towards factors which predicted less recent testing such as less gay community attachment, older age, having no sexual partners, being monogamous, the mix of cities, and having a relationship of more than 2 years duration. Only a few factors predictive of more recent HIV testing increased, including UAI in the last 6 months. After adjusting for all of these factors, time trends in HIV testing were no longer significant.
Apart from the time trend, we found a variety of strong predictors of HIV testing. These related to perceptions of heightened HIV risk (UAI in the last 6 months, more sexual partners in last 6 months, having an HIV-positive partner) and attachment to the gay community (proportion of friends who are gay). In addition, demographic factors such as younger age and residence in Sydney were associated with a higher likelihood of being tested. This paints a picture of informed and reasoned choice about the need for HIV testing, particularly in gay community-attached men.
This study highlights some of the limitations of a longitudinal analysis of repeated cross-sectional surveys for behavioural surveillance. There are difficulties in interpreting time trends because of differences in sampling over time, but the collection of contextual data, allowing a multivariate analysis, at least partially defrays this criticism. The Gay Community Periodic Surveys covered the large capital cities of Australia, which account for more than half of the population of this country. These samples were designed to recruit large and heterogeneous samples of gay and homosexually active men recruited from gay communities. However, the sample is likely to over-represent those in the population who are socially attached to the gay community, because only those who were present at gay venues could be included. A possible statistical limitation of this analysis is that, in different survey rounds, some respondents will have participated several times. In this analysis, each returned questionnaire was treated as a discrete individual response.
Levels of HIV testing in this study were similar to those found in other Australian samples of gay community-attached men. In a 1996 national phone-in survey of homosexually active men, 83.0% of gay community-attached men and 58.4% of non-gay community-attached men had been tested, and in a survey included in sex video catalogues in 2000, these figures were 84.6% and 66.1%, respectively .
Most of the predictors for HIV testing in this analysis appear to be related to a reasoned decision making regarding HIV risk, and attachment to gay community. In the multivariate analysis, Sydney men remained more likely to be tested. Similar geographical differences in testing behaviour have been described in Canada . Such variations may reflect basic differences in the individuals who choose to live in a given location or, on the other hand, they may also reflect the differences in gay community cultures in different areas, or perception of HIV risk. It may also reflect the higher visibility of gay community and gay community organizations in Sydney. An association between more frequent HIV testing and young age has been previously reported in Australian gay men . It has also previously been described that young men are more likely to be in short-term relationships, and more likely to be in regular relationships of undetermined sercoconcordance . It is reassuring to see that young gay men, who were not exposed to the prevention campaigns of the 1980s, are still seeking HIV testing at high levels. Our finding of an association between gay community attachment and testing is also consistent with other research results [6,13,14]. Men who knew their regular sexual partner's HIV serostatus were more likely to be recently tested, and others have also reported that testing for HIV is associated with inquiring about the HIV serostatus of, and having unprotected with, sexual partners [15,16].
This study clearly indicates that Australian gay men are using informed strategies in their testing behaviour. Those who are at highest risk are most likely to be tested. Perhaps the most concerning aspect of this analysis is that testing occurs less frequently among non-gay community attached men. Innovative strategies may be necessary to ensure that those men are well informed with respect to risk practice and HIV testing.