CATIE News

24 August 2020 

U.S. study finds frequent HIV testing among young gay and bisexual men is cost effective

  • Half of young gay and bisexual men with HIV in the United States are undiagnosed
  • Researchers modelled the clinical impact and cost of more frequent HIV testing
  • The study found that testing once every three months offered the best value for money

In the United States, research suggests that young men who have sex with men (YMSM; aged 13 to 24) account for 20% of new HIV diagnoses. Furthermore, research has found that more than 50% of YMSM with HIV are not aware of their infection status. Finding ways to increase awareness of HIV status is an important step toward better individual and societal health.

Researchers at Harvard University and elsewhere in the U.S. cooperated in conducting a computer simulation to explore the impact of different rates of HIV testing among YMSM. The researchers used a well-validated computer simulation. They were interested in assessing the effects of different rates of testing on the spread of HIV and assessing the impact of a positive diagnosis on entry to and engagement with care and treatment over the long term. The research team used data from previous studies to input for HIV sexual risk, estimated engagement in healthcare and so on.

The CDC recommends HIV testing at least once a year for people who are at high risk for HIV. However, research suggests that HIV testing among YMSM at high risk for HIV happens less often.

The researchers explored different rates of HIV testing, as follows:

  • less than once every 12 months
  • once every 12 months
  • once every six months
  • every three months

Results

Compared to the current standard of HIV testing, more frequent rates of testing revealed more cases of new HIV infections earlier. This was shown by higher projected CD4+ cell counts at the time of diagnosis. Furthermore, as earlier HIV diagnosis is associated with less immunological injury, the computer simulation suggested that earlier treatment was linked to greater life expectancy.

Costs

All increased rates of HIV testing were associated with increased costs. However, the researchers stated that HIV testing every three months “offered the best value for money…accounting for the life expectancy gained and costs averted due to reduced onward transmission.”

Other issues

The researchers stated that their analysis underscored “opportunities for improved implementation of the current annual HIV screening recommendations.” By this they meant that if the current guidance from the Centers for Disease Control and Prevention (CDC) was more fully implemented, and more YMSM received the offer of HIV testing, then more infections would be diagnosed.

The researchers also stated that the implementation of HIV screening “relies on healthcare providers’ accurate assessment of sexual histories and patients’ disclosure. This may be difficult in practice: Among CDC-funded programs serving youth in 2015, YMSM received only 28% of HIV tests despite comprising 83% of new HIV diagnoses in the U.S.”

Nevertheless, the researchers stated that their findings should be used “to inform new CDC recommendations for more frequent screening in self-identified high-risk YMSM.”

It is noteworthy that three other computer simulations modelling data captured from studies of adult MSM at high risk for HIV have also found that HIV screening every three months would be cost effective in this population.

Youth-focused solutions

Professor Bruce Schackman, PhD, Cornell University, reviewed the findings from the computer simulation in a commentary in the journal Clinical Infectious Diseases. He noted the absence of HIV screening guidelines for YMSM. He also stated that HIV screening strategies for this population “need to take into account not only the benefits for YMSM, but also potentially different costs of reaching them.” He made the following points:

YMSM are less likely to have a regular source of healthcare compared to older MSM.

Only 28% of HIV-negative urban YMSM report participating in an individual or group-level HIV prevention program.

Existing HIV prevention programs may not effectively engage YMSM because they do not address their unique needs, including interventions that address the developmental context of emerging adulthood.

For the future

Much work lies ahead in developing and testing interventions around the offer of frequent HIV screening for YMSM. What’s more, HIV prevention programs for YMSM need to explore offers of and engagement with pre-exposure prophylaxis (PrEP).

–Sean R. Hosein

Resources

The HIV testing process – CATIE fact sheet

HIV testing technologies – CATIE fact sheet

Seven Ways to Prevent HIV – CATIE

8 Questions about PrEP for Guys – CATIE

REFERENCES:

  1. Neilan AM, Bulteel AJB, Hosek SG, et al. Cost-effectiveness of frequent HIV screening among high-risk young men who have sex with men in the United States. Clinical Infectious Diseases. 2020; in press.
  2. Schackman BR. The value and challenge of frequent HIV testing among young men who have sex with men in the United States. Clinical Infectious Diseases. 2020; in press.
  3. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recommendations and Reports. 2006;55(RR-14):1-CE4. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
  4. Nosyk B, Krebs E, Zang X, et al. ‘Ending the Epidemic’ will not happen without addressing racial/ethnic disparities in the US HIV epidemic. Clinical Infectious Diseases. 2020; in press.
  5. Marano M, Stein R, Song W, et al. HIV testing, linkage to HIV medical care, and interviews for partner services among black men who have sex with men – non-health care facilities, 20 Southern U.S. Jurisdictions, 2016. MMWR Morbidity and Mortality Weekly Report. 2018;67(28):778-781.