Early detection of HIV is an important prevention strategy, enabling timely interventions that facilitate behaviour modification and access to treatment.1–3 Encouraging testing among populations that are at high risk of acquiring or transmitting HIV, e.g. men who have sex with men (MSM) is a key strategy and studies suggest that options for non-invasive and convenient testing will encourage greater uptake.4–6
We would like to report on a study that sought to provide confidential, accessible HIV testing to MSM across the rural areas of south west Queensland, Australia by utilizing a postal kit for non invasive oral fluid collection incorporating the OraSure oral fluid collection swab (OraSure Technologies, Beaverton, Oregon USA). Though HIV notification rates among rural MSM have not been reported as higher than their urban counterparts in Queensland, less geographic proximity to HIV testing, health promotion resources, and gay social networks, small communities and perceptions of greater marginalisation for those disclosing MSM behaviour, may contribute to a greater reluctance or inability to test by rural MSM.7–9 We undertook this study to assess the usefulness of a postal HIV testing service within this context.
Attempts to recruit participants were made through:
- key informants within the gay community engaged as peer recruiters outreaching through selected venues
- key informants invited to transmit messages by sms, twitter or email to their network of sexual contacts, inviting their participation in the study
- web sites utilised by men in the local area for establishing sexual contacts
- gay and local newspaper advertising and posters displayed in community venues and places where public sexual contact may occur (beats).
An outreach worker employed by a gay men's peer organisation, Queensland Association for Healthy Communities (QAHC,) was enlisted to conduct on-line, venue and beat outreach.
Persons contacted were offered the opportunity for HIV testing in their homes or discrete community settings. Collection kits were arranged to be mailed or personally delivered by a health worker. Samples were mailed back to the Chief Investigator who forwarded the oral samples to the National Reference Laboratory in Melbourne for testing and Western Blot confirmatory testing if required. All results were reported back to the Sexual Health Clinic based in the largest regional centre of Toowoomba. Particpants were then contacted to convey results and undertake counselling, referral and follow-up clinic appointments as required.
Recruitment was conducted over an eight month period in 2012, resulting in a very low number of participants (n=17). Despite this low response, it was noted that where postal kits were obtained through direct contact with health or outreach workers, return rates were 100% (n=8). Enabling telephone contact with the project officer when persons had received the test kit in the mail and immediately prior to conducting the test also resulted in high compliance, i.e. eight of the nine persons receiving test kits in the mail telephoned the project officer and all returned specimens.
Unfortunately, although most advertising strategies did attract an initial enquiry and request for a test kit, no one strategy produced a sustained response. Signs posted in public toilets were the most commonly cited promotion that elicited interest in testing.
A number of factors could explain the poor participation rate in this trial to provide confidential, accessible HIV testing in rural Queensland. Unfortunately, just as the project commenced, the State Government decided to cease Health Department funding to QAHC, the organisation that was intended as a key partner in promoting this project. Consequently, many of the promotional strategies planned online and as part of venue/beat outreach could not be completed or even started. Further, there was anecdotal evidence that the decision to defund QAHC was perceived by some gay-identified men as a change in social culture that would no longer be supportive of them and therefore efforts to engage men who may be secretive about their sexuality in small communities were met with fear, disinterest or hostility. Certainly a number of gay key informants who were initially considered supportive to the project were reluctant to assist for fear of compromising their public profile.
The lack of paid incentives for persons to recruit other men in their social networks may have been a factor, particularly in lieu of other recent, more successful research studies in the area that had relied on ‘snowballing’ techniques and reimbursed participants for recruiting peers.
While this system of postal HIV kits could be presumed to increase accessibility to testing, it should not be considered a timely strategy for rapidly identifying people in the early acute stage of infection. Generally, several weeks would elapse between persons receiving a kit and receiving a result.
An observation from our study was the importance of personal contact through the telephone. This optimised our ability to explain the test in more detail, respond to any queries, reassure them of confidentiality and reinforce education regarding safer sexual behaviours and the importance of regular testing following possible exposure. This has implications for any future remote testing service utilising either the post or internet. Regardless of the technology, a brief intervention delivered personally (via the phone) can serve as an effective adjuvant for encouraging test uptake and follow-up.