1. HIV Prevention Objectives among MSM in England: Data from the Gay Men’s Sex Surveys 2010 and 2014 Ford Hickson, David Reid, Peter Weatherburn Sigma Research, London School of Hygiene & Tropical Medicine

2. HIV Testing is now central to HIV Prevention for MSM Annual testing is recommended by PHE Testing for HIV is a central call to action of It Starts with Me Testing for HIV is the main message of National HIV Testing Week Indicators are needed for the chain of events from interventions to public health outcomes.

3. The chain of events from interventions to public health outcomes in HIV testing as prevention HPE activity encounters most-at-risk populations, which… Reduces HIV testing needs (opportunities, motivations, capabilities), which… Increases HIV testing behaviours, which… Reduces time spent with undiagnosed HIV, which… Reduces time spent with untreated infection, which… Reduces community viral load, which… Reduces HIV incidence, which… Reduces human misery. Reduces future health care costs.

4. The chain of events from interventions to public health outcomes in HIV testing as prevention HPE activity encounters most-at-risk populations, which… Reduces HIV testing needs (opportunities, motivations, capabilities), which… Increases HIV testing behaviours, which… Reduces time spent with undiagnosed HIV, which… Reduces time spent with untreated infection, which… Reduces community viral load, which… Reduces HIV incidence, which… Reduces human misery. Reduces future health care costs.

6. 2014 survey recruited 15,704 men

8. Was HPE activity encountered? Recognition of It Starts with Me campaign material Heard of National HIV Testing Week

11. Was HPE activity encountered? Recognition of It Starts with Me campaign material – 43% recognised it and 20% had read it Heard of National HIV Testing Week – 27% had heard of it

12. Did HIV testing needs change? Did HIV testing behaviour change? Did HIV testing service quality change? Did the time spent with undiagnosed HIV reduce?

13. In 2010 the UK took part in EMIS, a pan-European internet survey for MSM. Survey was developed collaboratively within a network of 77 partners. Respondents had a choice of 25 survey languages. The challenge of comparable samples

14. In the UK we recruited over 18,000 men to EMIS. Most were recruited on 3 gay dating websites. Number of respondents 2010 Dating site 16878 Dating site 22692 Dating site 31949 Total11519

15. 2014 survey was commissioned as part of HIV Prevention England. Used the core of the 2010 EMIS survey with additional questions developed within HPE. Available in English language only.

16. We recruited on the same 3 gay dating websites – but far fewer men, and they were older than those in 2010. Changes in advertising products. The arrival of the smart phone app. Number of respondents 20102014 Dating site 168783247 Dating site 22692991 Dating site 31949193 Total115194431

17. In 2014 we also recruited on a major GS-app. Men living in England who are sexually attracted to other men. Recruited on internet hook-up products. Who completed the survey in English. Number of respondents 20102014 Dating site 168783247 Dating site 22692991 Dating site 31949193 Geo-spatial app--2353 Total115196784

18. 20102014 Sample size115196784 Born outside England (%) (n.s.)23.524.3 Out to all or almost all, % (n.s.)47.546.9 Current steady relationship with a man, % (n.s.) 33.733.8 Female sex partner in last year, % (n.s.)10.810.1 Household, % (n.s.) Alone35.033.7 With male partner22.822.5 Others (not male partner) 42.343.8

19. 20102014 Sample size115196784 Age mean (sd), years (p<.05)38.3 (12.4)39.9 (13.8) Median age (range), years38 (16-88)39 (16-84) Public Health England region of residence, % (p<.05) North22.423.6 Midlands & East20.423.5 London 33.928.2 South23.324.7 Education, % (p<.05) Low (to GCSE)21.218.7 Medium31.530.4 High (Degree+)47.250.9 Employed full time, % (p<.05)40.942.8 Gay identified, % (p<.05)82.178.7

20. Did HIV testing needs change? Confidence in accessing a test Knowledge about HIV and testing Doubt about HIV status Autonomy to test

21. How confident are you that you could get a test for HIV if you wanted one? (n.s.) Never testedLast test negative 2010 N=3176 2014 N=1531 2010 N=7078 2014 N=4505 Very confident59.559.089.488.1 Quite confident24.7 8.18.9 A little confident7.6 1.8 Not at all confident4.85.10.40.7 I don’t know3.43.70.30.4

22. % did not already know the statement is true 20102014 AIDS is caused by a virus called HIV.1.2 You cannot be confident about whether someone has HIV or not from their appearance. 2.62.5 There is a medical test that can show whether or not you have HIV. 1.0 If someone becomes infected with HIV it may take several weeks before it can be detected in a test. 9.910.7 There is currently no cure for HIV infection.3.65.2 HIV infection can be controlled with medicines so that its impact on health is much less. 4.64.1 Effective treatment of HIV infection reduces the risk of HIV being transmitted. 41.828.1

23. What do you think your current HIV status is? Never testedLast test negative 2010 N=3189 2014 N=1532 2010 N=7101 2014 N=4505 Definitely negative (I don’t have HIV) 52.754.263.557.4 Probably negative38.737.632.338.6 Not sure or I don’t know 8.07.53.6 Probably positive0.50.40.50.3 Definitely positive (I do have HIV) 0.10.3>0.10.2

24. “Have you ever been forced or tricked into taking an HIV test when you did not want one?” 5.0% said yes in 2010 3.1% said yes in 2014

25. Did HIV testing needs change? Confidence in accessing a test – no change Knowledge about HIV and testing – more knowledge of preventative impact of treatment Doubt about HIV status – more uncertainty about being negative among those last tested negative Autonomy to test – no increase in non-consensual testing

26. Did testing behaviour change? Ever tested Most recent negative test Testing in the last 12 months

27. “Have you ever received an HIV test result?” 72.1% said yes in 2010 77.2% said yes in 2014 (AOR 1.35, 95%CI 1.25-1.46)

29. HIV test in the last 12 months (excluding men diagnosed with HIV over 12 months ago) 42.9% had in 2010 56.3% had in 2014 (AOR 1.83, 95%CI 1.70-1.96).

30. Did testing behaviour change? Ever tested – more men had ever tested Most recent negative test – those who had tested had done so more recently Testing in the last 12 months – men had almost twice the odds of having tested in the last year (AOR 1.83)

31. Did HIV testing service quality change? Satisfaction with confidentiality Satisfaction with respect treated with Satisfaction with HIV test counselling

32. Men who tested for HIV in the past 12 months The last time you tested for HIV, how satisfied were you with… Last tested negative Tested positive 20102014 20102014 …the way the testing service kept your confidentiality Very satisfied (%) 74.379.558.884.5 Satisfied (%)23.418.935.113.8 Dissatisfied (%)1.41.14.40.0 Very dissatisfied (%)0.80.51.81.7 N3664331111458

33. Men who tested for HIV in the past 12 months The last time you tested for HIV, how satisfied were you with… Last tested negative Tested positive 20102014 20102014 …the respect you were treated with Very satisfied (%) 73.379.8 67.281.7 Satisfied (%)23.117.725.013.3 Dissatisfied (%)2.72.04.33.3 Very dissatisfied (%)0.80.53.41.7 N3708330611660

34. Men who tested for HIV in the past 12 months Last tested negative Tested positive 20102014 20102014 Did you receive counselling Yes (%) 53.143.4 80.575.4 N3543316811357 The last time you tested for HIV, how satisfied were you with the counselling you received Very satisfied (%)53.956.138.558.1 Satisfied (%)39.538.345.134.9 Dissatisfied (%)4.64.311.04.7 Very dissatisfied (%)2.11.45.52.3 N188113759143

35. Did HIV testing service quality change? Satisfaction with confidentiality - improved Satisfaction with respect treated with – improved among last test negatives Satisfaction with HIV test counselling – no change, although fewer men testing negative received it

36. (Was more HIV diagnosed?) Proportion testing positive among those testing in the last year 3.0% (117/3882) in 2010 1.7% (60/3453) in 2014 Annual incidence of HIV diagnosis 1.3% (117/3882) in 2010 1.0% (60/3453) in 2014 (AOR 0.833, 95%CI 0.60-1.16)

37. Did the time spent with undiagnosed HIV reduce? CD4 count at diagnosis

38. “An estimated 43,500 MSM were living with HIV in 2013, of whom 16% (7,200) were unaware of their infection. This compares to 41,000 in 2012, with 17% (6,900) undiagnosed.” (p.8 of the same report)

39. % of men diagnosed with HIV in the 4 calendar years preceding the survey (n.s.) “When you were first diagnosed with HIV, what was your CD4 count?” 2010 (N=424) 2014 (N=225) Less than 200 cells / µl15.618.2 200-349 cells / µl17.915.6 350-500 cells / µl27.122.7 More than 500 cells / µl31.433.8 I don’t remember / don’t know8.09.8

40. Did the time spent with undiagnosed HIV reduce? CD4 count at diagnosis – no evidence of change

41. HOMOSEX

42. Safer sex needs HIV transmission knowledge Access to condoms

43. % who did not already know the statement is true 20102014 HIV cannot be passed during kissing, including deep kissing, because saliva does not transmit HIV. 18.921.1 People can pick up HIV through their penis while being 'active' in unprotected intercourse (fucking) with an infected partner, even if they don’t ejaculate. 10.414.6 People can pick up HIV through their rectum while being 'passive' in unprotected intercourse (being fucked) with an infected partner. 2.02.8 Even without ejaculation, oral sex (sucking and being sucked) carries a risk of infection with syphilis or gonorrhoea. 15.113.1 When HIV infected and uninfected people have sex together, the chances of HIV being passed on are greater if either partner has another sexually transmitted infection. 39.141.8 Most sexually transmitted infections can be passed on more easily than HIV. 27.628.3

44. When was the last time you wanted a condom but did not have one? (Men who had sex with a man in the last 12 months) (p<.05) Within the last… (Cumulative proportion) 2010 Cumulative % N=10777 2014 Cumulative % N=6220 24 hours0.60.9 7 days2.83.6 4 weeks6.57.7 6 months13.114.6 12 months18.719.8 5 years26.726.4 Ever31.8

45. When was the last time you had unprotected intercourse sorely because you did not have a condom? (Men who had sex with a man in the last 12 months) (p<.05) Within the last… (Cumulative proportion) 2010 Cumulative % N=10887 2014 Cumulative % N=6201 24 hours0.7 7 days1.92.4 4 weeks3.85.2 6 months8.010.0 12 months11.113.5 5 years17.218.7 Ever22.823.9

46. Safer sex needs HIV transmission knowledge - declined Access to condoms - declined

47. Sexual risk behaviour Recency of intercourse Condom use at last intercourse Recency of condom-less intercourse

48. When did you last have intercourse with a man (either with or without a condom)? (Men who had experienced sex with a man) (p<.05) Within the last… (Cumulative proportion) 2010 Cumulative % N=11171 2014 Cumulative % N=6449 24 hours10.58.5 7 days35.930.9 4 weeks58.150.5 6 months75.569.2 12 months82.676.9 5 years89.985.4 Ever93.790.1

51. Sexual risk behaviour Recency of intercourse – less recent Condom use at last intercourse – less condom use Recency of condom-less intercourse – less recent Intercourse without a condom was slightly less recent in 2014 than in 2010 not because condoms were used more (they were used less) but because intercourse was less frequent.

52. SUMMARY We found evidence that HPE activity was encountered by a large proportion of MSM. We found evidence that compared with 2010, in 2014: More HIV testing needs were met (more knowledge, more doubt about status); More men had tested and those who had had done so more recently; Collective HIV testing service quality was maintained or improved. But…

53. SUMMARY But… No evidence in infections being diagnosed swifter. Data suggest that increased testing has been disproportionately among those without HIV infection. Safer sex needs have got worse. Time between sex events has increased. Time between intercourse events has increased. Condom use has decreased. Time between condom-less intercourse has increased slightly.

54. Take home message HIV testing has improved among MSM in England. Safer sex has declined among MSM in England. Are we putting all our prevention eggs in one testing basket?

55. Thanks to… The funder (DoH via THT) All our health promotion collaborators All the men who take part in GMSS