“There is such a thing as asking for trouble”: taking rapid HIV testing to gay venues is fraught with challenges

Abstract

Objectives

To explore the feasibility and acceptability of offering rapid HIV testing to men who have sex with men in gay social venues.

Methods

Qualitative study with in‐depth interviews and focus group discussions. Interview transcripts were analysed for recurrent themes. 24 respondents participated in the study. Six gay venue owners, four gay service users and one service provider took part in in‐depth interviews. Focus groups were conducted with eight members of a rapid HIV testing clinic staff and five positive gay men.

Results

Respondents had strong concerns about confidentiality and privacy, and many felt that HIV testing was “too serious” an event to be undertaken in social venues. Many also voiced concerns about issues relating to post‐test support and behaviour, and clinical standards. Venue owners also discussed the potential negative impact of HIV testing on social venues.

Conclusion

There are currently substantial barriers to offering rapid HIV tests to men who have sex with men in social venues. Further work to enhance acceptability must consider ways of increasing the confidentiality and professionalism of testing services, designing appropriate pre‐discussion and post‐discussion protocols, evaluating different models of service delivery, and considering their cost‐effectiveness in relation to existing services.

Men who have sex with men (MSM) are the group at greatest risk of acquiring HIV infection in the UK. Despite sustained increases in the uptake of HIV voluntary counselling and testing (VCT) in genitourinary medicine (GUM) clinics, in 2005, 43% of HIV‐infected MSM left services unaware of their status.¹ New rapid HIV antibody tests may help to increase VCT uptake by allowing providers to offer testing in a wider range of settings, including primary care and community venues.² For example, novel interventions might offer rapid HIV antibody tests to MSM in venues such as shops, pubs and saunas. Such interventions could increase the uptake of VCT and reduce the proportion of undiagnosed HIV infection.

Would such interventions be appropriate to MSM and to service providers? In the US, rapid HIV testing services have been offered to MSM in universities, gay community health centres and commercial venues (www.homohealth.org/mens_program/testing.htm).³,⁴,⁵,⁶,⁷,⁸ Their acceptability has been demonstrated in sexually transmitted infection clinic‐based studies as well as in bathhouse‐based interventions.⁷,⁸ In the UK, rapid HIV tests are currently used in some GUM clinics to establish patients' serostatus before HIV post‐exposure prophylaxis, in National Health Service (NHS) walk‐in centres, and in community‐based testing services (http:info.tht.org.uk/fastet).⁹ Rapid, point of care HIV tests are highly suited for work in community settings—they minimise the need for laboratory infrastructure, decrease waiting times and limit patient loss to follow‐up. Although standard HIV tests using enzyme immunoassays require venous blood sampling and transport to a laboratory, rapid HIV tests detect antibodies against HIV 1 and 2 antigens in whole blood, plasma or oral fluid without the need for specialised equipment. Many rapid HIV tests also show sensitivities and specificities comparable to those of enzyme immunoassays, although they may be less sensitive in detecting early infection.¹⁰ Little is known, however, about the feasibility and acceptability of offering such tests to UK MSM in non‐clinical settings. This qualitative study set out to explore perceptions of rapid HIV testing for MSM in social venues in order to inform service provision and intervention development.

Methods

Participants and recruitment

Six gay venue owners (VOs), four gay service users (GMs) and one service provider (SP) agreed to take part in interviews. In addition, three focus groups were formed: two with eight members of staff from an NHS walk‐in centre offering rapid HIV tests to MSM (C1 and C2), and a third with five gay men living with HIV (MLH) recruited from a patient group at a London GUM clinic. All respondents were approached by MC and written consent was obtained before the interview. The Riverside Ethics Committee (London) gave ethical approval for the study.

The sample was purposefully chosen to encompass a range of stakeholders including service providers, potential users, venue owners and people living with HIV. Qualitative methods were appropriate as the study was exploratory in nature, focusing on complex and sensitive issues related to sexual lifestyles and HIV testing, and sought explanatory data regarding the feasibility and acceptability of rapid HIV testing in social venues.

Interviews and analysis

All interviews were conducted by MC between November 2005 and March 2006. Service users and staff were interviewed in a clinic setting. VOs were interviewed in their own premises. Interviews lasted between 40 and 90 min. They were recorded and transcribed verbatim. We used a semi‐structured interview guide to explore perceptions of the benefits and disadvantages of rapid HIV testing in non‐clinical settings. Rapid HIV testing was described as an HIV antibody test used with a blood sample and giving results in 20 minutes. The interviewer explained that the aim of the study was to explore the acceptability of offering rapid HIV tests to gay men in non‐clinical settings, and gave the example of testing in private spaces within gay venues such as saunas, clubs and bars. Participants were not given any information about whether pre‐test or post‐test counselling would be available as part of such a service. The topic guide covered: (1) the acceptability of rapid HIV testing in gay social venues; (2) differences between testing for HIV in non‐clinical settings compared with clinical settings; (3) possible locations for the service; and (4) best ways to deliver and promote the service. Transcripts were read repeatedly and independently by MC, AP and JI. They were then coded and analysed by MC and AP using a framework approach: after familiarising ourselves with the data, we identified a thematic framework focusing on acceptability barriers, enhancers and feasibility issues.¹¹ MC and AP then indexed, charted and mapped the data independently to identify recurrent themes.

Results

Four themes had implications for the development of interventions offering rapid HIV testing to gay men in non‐clinical settings: (1) concerns about confidentiality and privacy; (2) the idea that HIV tests are “too serious” to be undertaken in social venues; (3) issues relating to post‐test support and clinical standards; and (4) the impact of HIV testing on gay venues.

Confidentiality and privacy

Retaining confidentiality when undertaking HIV testing in social venues was regarded as essential. The stigmatising impact of HIV persisted and informed men's concerns that being seen to access rapid tests in social venues could constitute an automatic assumption of risky sexual behaviour. Achieving such confidentiality was regarded as problematic because venues were not designed to provide required levels of seclusion and, if a positive HIV test result arose, there would be no privacy for men leaving the venue in a distressed state.

Box 1: Concerns about lack of confidentiality and privacy

The need for privacy

“You need a quiet corner or an area. I think there's an issue about confidentiality as well. Because if it's actually right in the centre of the bar it's not actually private. You're not actually getting confidential, it's not actually ethical […] I would want to be somewhere where there was privacy, so that while I was having the test or discussing it or whatever, it would be private, no one else could crash it…” (GM2)

Lack of confidentiality when receiving a positive HIV diagnosis

“I might like to do it, I might agree and get a positive result, and in the end I might walk out in tears. Now if other people know there's a testing facility in there, people may think, oh look he's just been diagnosed positive…the one that's crying and leaving the pub.” (SP)

Stigma around being seen taking an HIV test in a social venue

“If people see me taking a test, that means that they will, by implication, think that I'm risky, uh, you know, that I have risky sex or things like that.” (GM4)

HIV testing “too serious” for pubs and clubs

Clubs and pubs were regarded as inappropriate venues to deal with an event as serious as an HIV test. Men viewed clubs and bars as places associated with fun and pleasure, and therefore saw them as incompatible with thinking about serious health issues. Respondents repeatedly asserted that men testing in social venues would not be in the right frame of mind to think about the potential consequences of a test. In addition, many participants felt that men would not be able to give informed consent for testing when under the influence of alcohol or drugs, let alone deal with a positive test result. Some of the NHS staff taking part in focus groups explained that men generally found interventions like syphilis testing and hepatitis B vaccination in social venues acceptable, but that HIV testing was different and more serious.

Box 2: Social venues as inappropriate environments for HIV testing

Dissociating fun and health

“You've psyched yourself up to go out or go to a venue where you're going to have potential sexual interaction with somebody, then it's sort of like… your mindset isn't in your HIV thing, is it?” (MLH, R4)

“A nightclub is probably not the most auspicious environment for that […] people don't go to the nightclub, you know, because they want to be reflective about their sex life.” (GM2)

The impact of alcohol and drugs

“When you've got someone in an altered state already, putting them and giving them a diagnosis such as that would, when they're already on whatever combination of drugs or alcohol, it may be… it's not the right way to receive an HIV diagnosis.” (MLH, R1)

Inappropriate environments to receive a positive HIV diagnosis

“At the end of the day, you don't want sort of Kylie blaring out like that and hearing loads of people laughing and cheering and then saying “oh, I'm terribly sorry, it's positive.” […] It's just, I think it's a bit insensitive.” (VO5)

“If the risk of this person having a positive result was really high then maybe it is a better idea to get them to a clinic and do it sort of somewhere a bit more controlled […] I just think there is such a thing as asking for trouble…” (VO4)

Post‐test follow‐up and service standards

Concerns about the feasibility of providing adequate post‐test support in the context of a busy social venue were paramount in men's accounts. Such concerns were driven by fears that men would not be supported after receiving a positive result, and that service providers' ability to contain strong post‐test reactions such as suicidal ideation would be undermined in non‐clinical settings. Because of concerns related to post‐test support, respondents thought that men would be more likely to use a rapid HIV testing service in a social venue if they expected the result to be negative.

Respondents also discussed issues related to post‐test behaviour—for example, the possibility that negative testers might use their results as a serosorting strategy to engage in unprotected anal intercourse, or that positive testers might have unprotected sex as a destructive reaction after their diagnosis.

Finally, respondents felt that providing good clinical standards in commercial or community venues would be highly challenging. VOs, for example, felt that hygiene and safety standards would be difficult to maintain in clubs and saunas. Respondents also talked about social venues being dirty because of sexual activity, and felt that having HIV testing in venues where sex occurred was potentially unsafe.

Box 3: Post‐test support, post‐test behaviour and service standards

Potential lack of post‐test support in non‐clinical settings

“In a [GUM] clinic, all that [support] mechanism can be offered to the person on the day of the test, whereas in a commercial venue, it's not inconceivable that the person may just disappear off and never be seen or heard of again... until their body's found on Brighton beach.” (MLH, R2)

Attracting low‐risk testers

“If I thought I was negative, I would definitely use that [service].” (GM3)

“There are guys who come into the clinic for… for them it is just a run‐of‐the‐mill thing and they show up because, there it is, 3 months ago, and it's about time to do it, in which case you know, 20‐min rapid test in a bar is probably… it'd suit them right down to the ground” (VO4)

Post‐test behaviour

“In venues where men pick up other men, there will be a risk that if you met somebody, that you might, sort of, have a test and then think, ah we're both clear, we can both therefore have unsafe sex …” (VO1)

“I think the knee‐jerk reaction of getting a positive result in a bar is to get pissed, the knee‐jerk reaction in a sauna would be to go and have sex.” (VO4)

Safety issues

“If you're gonna prick someone's hand and draw blood and they're gonna go to places where there is sexual activity going on, you know… you're creating a wound. That can't be good for you.” (VO1)

Box 4: Impact on venues

Positive association for venue owners—being seen as pro‐active for the gay community

“I think it [rapid HIV testing] would be a good thing if anything because it seems that I'm prepared to do something for the gay community other than fleece them off their money.” (VO2)

Negative impact on the venue

“In terms of the venue owners, I guess some of them might be a bit cautious about erm killing the atmosphere with people sobbing in a corner…” (VO4)

Negative association of venue with HIV test results

“There could obviously be the possibility that if somebody has a test and it comes up as positive, em… Then they're forever gonna remember that place, the place that, you know, they found out some quite dreadful news, and that's possibly not the most beneficial thing that you want your store to be remembered for…” (VO5)

Alternative service delivery models: an appointment system or a general health service for MSM

R1: An acceptable routine and one that I think would actually work…would be an educational and information intervention along with an appointment system here on a Saturday night

MC: But not doing the test?

R1: But not doing the test and that but doing the testing on a Sunday […] in the venue, but open up the venue specifically for it.

“Having a range of diagnostic tests doesn't blow your confidentiality or blow you out of the water, if you're coming out of the room because you could have had one of many tests […] and that could be general health stuff.” (SP)

Impact on venues

Although venue owners were generally supportive of rapid HIV testing, they also felt that having tests available in bars or shops might repel customers. Alternative service models suggested by VOs included offering HIV testing as part of a more general sexual health service based in a quiet venue or a “health bus”. Owners also discussed the possibility of developing a community‐led education service to publicise testing in gay venues. In this model, peer educators or health advisers would offer men appointments for HIV testing within social venues, but the testing itself would be carried out in a community location converted into a clinic.

Discussion

Offering rapid HIV testing in non‐clinical settings is a possible intervention to tackle persistent high levels of undiagnosed HIV infection among MSM in the UK. However, the factors that influence the acceptability and feasibility of rapid HIV testing for MSM in social venues have not been thoroughly investigated.

This study has identified several substantial barriers to establishing rapid HIV testing services in venues such as bars, clubs and saunas. Firstly, social venues are settings where the confidentiality and privacy required for HIV testing are difficult to achieve. Secondly, men articulate a preference for maintaining clear boundaries between clinical, health‐related spaces and social venues: although GUM clinics were associated with taking responsibility and health, the majority of respondents in this study felt that bars and saunas should remain areas where men can socialise and have fun without being pressurised into taking part in health promotion interventions. Thirdly, commercial venues pose specific challenges to the provision of high‐standard pre‐test and post‐test support. In particular, post‐test counselling and effective referral to HIV care are likely to be problematic in busy social settings. Fourthly, the potential for unintended behavioural outcomes and increased sexual risk taking remains unknown.

In addition to the concerns raised by respondents in this study, two other issues must be considered here. Firstly, little is known about the sensitivity and specificity of rapid HIV tests in UK community settings. A recent evaluation of a community‐based rapid HIV testing service in three UK cities found one false positive in 1721 antibody tests (0.006%) and an HIV prevalence of 3% (n = 1453), suggesting that rapid HIV tests are relatively safe to use in a community context.¹² Further epidemiological evidence is however needed to confirm these findings. Secondly, concerns about the availability of adequate support in case of a positive result may make HIV rapid testing in venues particularly attractive to low‐risk “worried‐well” testers. In order to attract high‐risk gay men, it will be essential to publicise how quality, confidentiality and support will be ensured in non‐clinical settings. Considerable community mobilisation must be undertaken to enlist the participation of venue owners and reassure men that testing services are of a high professional standard. The acceptability of syphilis testing for at‐risk MSM in social venues offers an encouraging precedent, as do the positive results of US acceptability studies of bathhouse‐based VCT.¹²,¹³

Further work to enhance the acceptability of rapid HIV testing in gay social venues should explore four main areas.

(1) Formative research must be conducted to define the best ways of ensuring privacy, confidentiality, hygiene and professionalism in venues used for rapid HIV testing.

(2) Appropriate pre‐test and post‐test counselling protocols need to be designed in order to ensure that men are able to consent and test in a supportive environment.

(3) Staff offering rapid HIV testing in social venues should be trained to foresee potentially hazardous post‐test behaviours and make appropriate referrals to GUM services.

(4) Research must investigate alternatives to testing in pubs/clubs, where alcohol and drug use is pervasive, and in saunas, where men are less likely to be open to engaging in health‐seeking behaviour.

More acceptable models of service delivery might include embedding rapid HIV testing in broader sexual health testing services (eg, offering Chlamydia urine tests as part of a “health bus” service), or delivering services in more private and quiet venues such as gay retail shops or gyms. Finally, future research will need to assess the cost‐effectiveness of such testing strategies in relation to existing services in GUM clinics and primary care.

Key messages

• There are substantial barriers to offering rapid HIV tests in commercial and community venues.

• MSMs are concerned about the lack of confidentiality and privacy for HIV testing in social venues, and about the potential lack of post‐test support for those who test positive.

• Extensive formative work and community mobilisation should be undertaken before offering rapid HIV testing to MSM in social venues.

Would offering rapid HIV testing to MSM in social venues help decrease the proportion of undiagnosed HIV infection in this group? A recent pilot study of a community‐based rapid HIV testing service in three UK cities found that one in four (26%) MSM accessing the service had not previously tested, despite many reporting high levels of HIV risk.¹⁴ In addition, a recent US pilot study of bathhouse‐based VCT proved that testing in this setting was acceptable to men at risk, and effective in changing some specific HIV‐related risk behaviours.¹³ These findings suggest that expanding access to HIV testing in non‐clinical venues is likely to increase the uptake of VCT among MSM and to contribute to reducing the proportion of undiagnosed HIV infections in this group. Future pilot studies of rapid HIV testing for MSM in social venues should build on qualitative research findings to develop appropriate service delivery models.

Abbreviations

GM - gay service user

GUM - genitourinary medicine

MSM - men who have sex with men

NHS - National Health Service

SP - service provider

VCT - voluntary counselling and testing

VO - venue owner