Challenges in rolling out rapid HIV testing in Australia

Abstract

In a recent issue of Sexual Health, Chen and Estcourt suggest that rapid HIV testing should be encouraged in Australia, referring to the positive experiences of rapid testing in the USA and UK. In the USA, where there have been low levels of HIV testing among at-risk populations, the introduction of rapid HIV testing has had undeniably impressive effects in increasing testing rates. Consumer experiences of rapid testing also tend to be very positive. However, the attractiveness and benefits of rapid HIV testing may vary depending on the context in which it is implemented. The Australian Federation of AIDS Organisations is currently undertaking a review of rapid HIV testing, drawing on the experience of clinicians, researchers, and community organisations. The review process has identified particular challenges that will need to be addressed if rapid testing is to become more available in Australia. In Australia, there are already high levels of HIV testing among the group most at risk of HIV infection – gay and other homosexually-active men. Surveys of gay men across Australia show that over 80% have ever been tested for HIV, between 40% and 55% have been recently tested (within the past 6 months), and that these levels of testing are relatively stable over time. Given that HIV testing appears to be well established among Australian gay men, it is unlikely (in our opinion) that rapid testing would generate a significant increase in testing rates among this group. Rapid testing might however be useful in: a) maintaining high testing rates; b) encouraging testing uptake among untested men; and c) increasing the frequency of testing among those men most at risk of HIV infection e.g. men who engage in unprotected anal intercourse with casual partners, sexually adventurous men and HIV-negative men with HIVpositive partners. The appeal of rapid testing (quick results, less invasive collection methods, alternative testing locations) may help sustain high testing rates and overcome barriers to firsttime testing or more regular testing. There are, however, some serious challenges in making rapid HIV testing more available in Australia. Currently, there are no rapid HIV tests approved for routine screening in Australia. A few rapid tests are approved for limited use, for example, in emergency situations or assessing occupational exposures. For a rapid test to be approved for routine screening in Australia, it is expected that the test’s performance should be of an equivalent or improved level to that of existing assays. The quality of HIV tests currently used for routine screening in Australia is extremely high. ‘Fourth generation’ combined antigen/antibody assays introduced in 2002 have reduced the window period for detecting early infections and have demonstrated the ability to identify acute infections that would have been missed by previous generations of tests. Rapid assays currently used overseas cannot match these performance levels, so for rapid tests to be approved for wider use in Australia different benefits would have to be suggested or proven e.g. the engagement of previously untested consumers or significant improvements in the consumer experience of testing. There are also challenges in adapting preand post-test discussions to handle the rapid testing process and in deciding how to describe reactive rapid test results to consumers. The advantage of standard testing (in which consumers typically wait for up to a week for their results) is that a confirmatory Western blot can be conducted for reactive results before the consumers return to the test site. While rapid testing would undeniably be attractive to the majority of Australian consumers who would return HIV-negative results, for the minority who would receive reactive results there is likely to be a period of limbo in which they have a ‘preliminary positive’ status requiring confirmation. Overall, while we agree with Chen and Estcourt that rapid HIV testing can generate useful benefits, we believe that its introduction in Australia is not necessarily straightforward. It may be more prudent to run a trial of rapid HIV testing in order to identify the most effective ways to implement this testing technology in Australia, to gauge the responses of consumers and to provide evidence of rapid HIV testing’s public health impact for assessment by regulatory authorities.