The MSM Testing Initiative (MTI): Innovative approaches for HIV testing and linkage to medical care

Abstract

Issue: CDC estimates that in 2011 more than half of the number of diagnosed HIV infections in the United States were attributed to male-to-male sexual contact, indicating that gay, bisexual and other men who have sex with men (MSM) continue to be most impacted by HIV. The high prevalence of unrecognized HIV infection among MSM highlights an urgent need to expand HIV testing efforts and identify best practices for identifying the previously undiagnosed.
Setting: In 2011, CDC funded the MSM Testing Initiative (MTI). The purpose of this testing program was to identify HIV diagnoses among MSM who are unaware of their infection status, with particular focus on African American and Hispanic/Latino MSM, ensure that they are linked to HIV medical care, and document best practices in a report.
Project: MTI was a contract awarded to Abt Associates, Inc. Activities began in May 2012 and continued through May 2015. Goals of the project were to test approximately 60,000 men who reported sex with one or more men ever in their lifetime, identify 3,000 MSM with undiagnosed infection, and link at least 2550 (85%) to medical care within 90 days of their diagnosis. Five HIV testing strategies were implemented: venue-based testing, couples-based voluntary counseling and testing, large-scale episodic events, social network strategy, and home-based testing. Over the course of the project, 37 partners from across the U.S. were subcontracted to perform these strategies.
Results: As of February 2015, 64,912 eligible men were tested for HIV, 1,954 (3%) previously undiagnosed men received an HIV diagnosis, and 1,328 (68%) men were linked to care within 90 days. A vast majority of the HIV tests (94%) and new diagnoses (94%) were obtained in a venue-based setting. Age and race/ethnicity characteristics were available on a subset of 1,127 MSM who were tested and identified as newly HIV-positive prior to June 2014. Of these, 33% were Hispanic/Latino, 46% black, and 21% were some other race. Most newly diagnosed HIV-positive men were aged 13-29 years old (60%). Social network strategies had a high yield of identifying new HIV diagnoses (12 new HIV-diagnosed MSM for 174 tests, or 6.9%), but was a resource-heavy strategy for partners to implement.
Lessons Learned: The MTI project demonstrated that a large-scale HIV testing contract can be used to engage multiple partners across the country and successfully test large numbers of MSM – in particular, black and Hispanic MSM – and link those who are diagnosed with HIV infection to medical care. Venue-based HIV testing can yield a high proportion of newly diagnosed HIV cases but challenges remain, such as identifying suitable and productive venues. In addition, linking MSM to HIV medical care immediately following diagnosis, particularly in non-clinical settings, is challenging and requires additional staff and support. Finally, in cities where both MTI and other CDC-funded testing programs were operating, local organizations experienced considerable overlap. A more coordinated effort should be implemented for the success of future HIV testing campaigns.

Full text

The MSM Testing Initiative (MTI): Innovative
approaches for HIV testing and linkage to medical care
National HIV Prevention Conference
December 9, 2015
Elizabeth DiNenno1, Luke Shouse1, Tricia Martin1, Muazzam Nasrullah1,
Chanza Baytop2, Alex Orr2, Liza Solomon2
1DHAP/NCHHSTP, Centers for Disease Control and Prevention
2Abt Associates

Goals of Presentation
•Describe goals of MTI
•Outcomes of the initiative
•Key Findings
•Lessons learned
–Recruitment and testing
–Linkage to care

Background of HIV Infection among Men who have Sex
with Men (MSM)
•Estimated 667,000 males age 13+ living with HIV infection
attributed to male-male sexual contact in the U.S. in 20121
•Approximately 14.8%, or 98,700, of these are estimated to
be undiagnosed 1
•Among MSM tested and interviewed in 2011 as part of
national study and who tested HIV-positive, 33% were
unaware of their HIV-positive status 2
•Black/African American and Hispanic MSM, and young
MSM, are less likely to know their HIV status
1 Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States
and 6 dependent areas—2013. HIV Surveillance Supplemental Report 2015;20(No. 2).
2 HIV Infection and Awareness among Men Who Have Sex with Men–20 Cities, United States, 2008 and 2011. PLoS One. 2013; 8(10): e76878

Background of HIV Infection among MSM (cont.)
•The National HIV/AIDS Strategy updated to 2020 calls
for 85% of persons diagnosed with HIV be linked to
care
•In 2011 only 79% of MSM diagnosed with HIV
infection* were estimated to be linked to care 1
•Younger and Black MSM are less likely to be linked to
care
* Includes only MSM living in 19 surveillance areas in the US in 2011
1Centers for Disease Control and Prevention. Vital Signs: HIV Diagnosis, Care, and Treatment Among Persons Living with HIV —United
States, 2011. MMWR Weekly November 28, 2014 / 63(47);1113-1117

Objectives of the MSM and Transgender Testing
Initiative (MTI)
1. Identify 3,000 previously undiagnosed HIV-infected
MSM or TG (at least 50% minority MSM), by testing
approximately 60,000 persons (estimated 5% HIV
positivity rate).
2. Link 2,550 (85%) of newly-diagnosed HIV-positive MSM
and TG into HIV medical care within 90 days of
diagnosis.
3. Report and document best strategies or methods to
identify undiagnosed MSM and TG and link them to
care.

MTI Overview
•Contract awarded to Abt Associates, September
2011
•Subcontracts were structured to incentivize MTI
goals
•Testing and linkage activities implemented
March 2011 –September 2015

MTI Eligibility
•Male sex at birth (transgender women were
eligible)
•HIV status unknown, previously tested negative,
or indeterminate
•History of sex (oral or anal intercourse) with
another man at any time during lifetime

Overview of MTI Testing Components
•Venue-Based Testing (VBT): Recruiting and testing MSM and TG in
locations frequented by target population
•Couples Voluntary Counseling and Testing (CVCT): Men and TG in
sexual relationships are encouraged to test and receive their results
together
•Social Network Strategy (SNS): Men and TG utilized their social
networks to engage other MSM for testing
•At-Home Internet Testing (iTestatHome): Test kits sent to eligible
men and TG who conducted their own dried blood spot (DBS) tests
and sent these in for testing; results given via phone
•Testing Events Across America (TEAA): Large-scale, one time testing
events by agencies without an ongoing contract with Abt Associates

The MSM Testing Initiative:
35 Partner sites, 25 cities
Atlanta
Miami
San Juan
New Orleans
Dallas
Houston
Los Angeles
Chicago
Detroit New York City
Philadelphia
Baltimore
Washington
DC
San Francisco
Oakland
Birmingham
Lexington
Orlando
Palm Springs
St. Louis
Tallahassee
Charlotte
Las Vegas
Pensacola
Midwest City

Primary MTI Outcomes
Total Tested
71,322
New
Diagnoses
2,241
(3.1%)
Negative or
Unconfirmed
69,081
(96.8%)
Linked to Care
1,546 (68.9%)
Not Linked or No
Linkage Data
695 (31.0%)

Recruitment and Testing
Outcomes

Overview of Tests and HIV Status
•Of the 71,321 tests conducted:
–Over half were among Blacks (27.1%) and Hispanics (29.6%)
–Most (65.4%) were under 33 years old (mean age 32)
•Of the 2,241 MSM and TG newly diagnosed with HIV
infection:
–Close to half were Black (42.8%); a third (32.9%) were Hispanic
–Most (69.9%) were under 33 years old (mean age 31)
•Men and TG who had never been previously tested
comprised 8% of the total tests and 9.6% of the total
testing HIV-positive
•A total of 2,170 transgender women (3.7%) were tested in
MTI; of these, 3.8% were newly diagnosed with HIV
infection

Tests and HIV Status by Participant
Characteristics
Variable Tests HIV Positive
N= 71,321 N= 2,240 3.1%
Race/Ethnicity*
Black/AA 19,323 959 5.0%
White 24,749 397 1.6%
Hispanic 21,124 739 3.5%
Other 4,904 113 2.3%
Age
≤24 20,386 731 3.6%
25 –32 26,242 834 3.2%
33 –54 21,371 616 2.9%
55 and older 2,893 46 1.6%
*missing not reported

Tests and HIV Status by MTI Testing Component
Components Tests HIV Positive
N= 71,321 N= 2,240 3.1%
Social Network
Strategy 175 12 6.9%
Venue Based Tests 67,517 2,124 3.1%
Testing Events
Across America 1,946 61 3.1%
Couple-Based
Voluntary C&T 992 28 2.8%
iTestatHome 691 15 2.2%

Venue Type and MTI Outcomes
•Per contract, less than 20% of testing was offered
in clinical settings
–13.6% were in clinical settings
•Most testing (86.4%) done in non-clinical sites
–62.5% conducted in bars/clubs or public areas
–22.1% were done in HIV testing sites

Tests and participants newly diagnosed with
HIV infection by Venue Type (Venue-Based Tests)
Variable Total Test s Newly diagnosed HIV
infection
N= 67,517 N= 2,124 3.1%
Clinical Testing Sites 9,229 435 4.7%
Non-Clinical Sites (reference) 58,288 1,689 2.9%
HIV Testing Site 12,782 619 4.8%
Community Settings 2,702 107 4.0%
MSM Episodic Events 6,506 205 3.2%
Public Areas 17,639 388 2.2%
Bars/Clubs/Adult
Entertainment (reference) 18,569 370 2.0%
p<0.001

Linkage to Care
Outcomes

Overview of Linkage to Care
•Overall linkage to care rate was 68.9%
•Most (70.7%) linked were under 33 years old
•Linkage to care rate varied by component and
where test took place
•10% with CD4 test results had a count ≤200/mL

Linkage by Participant Characteristics
Variable
HIV
Positive Successful Linkage
N = 2,240 N = 1,545 68.9%
Race/Ethnicity*
Black/AA 959 644 67.2%
White 397 281 70.8%
Hispanic 739 514 69.6%
Other 113 84 74.3%
Age
≤24 731 496 67.9%
25 –32 834 597 71.6%
33 –54 616 412 66.9%
55 and older 46 34 73.9%
*missing not reported

Linkage by MTI Component
Components HIV Positive Successful Linkage
N= 2,240 N= 1,545 68.9%
Couple-Based
Voluntary C&T 28 23 82.1%
Testing Events
Across America 61 50 81.9%
Social Network
Strategy 12 975.0%
Venue Based Tests 2,124 1,456 68.5%
iTestatHome 15 746.7%

Linkage to Medical Care by Venue Type
Variable HIV Positive Successful Linkage
N= 2124 N= 1456 68.5%
Clinical Testing Sites 435 401 92.2%
Non-Clinical Sites (reference) 1689 1055 62.5%
Community Settings 107 86 80.3%
HIV Testing Site 619 455 73.5%
Bars/Clubs/Adult
Entertainment
(reference)
370 218 58.9%
Public Areas 388 197 50.8%
MSM Episodic Events 205 99 48.3%
p<0.001

Key Findings
Large scale HIV testing contract yielded large numbers of
MSM and TG with newly diagnosed HIV infection
•Of 40,447 Black and Hispanic participants tested, 4.2% were
HIV-positive
•Approximately 2,200 TG were tested; 3.8% were HIV-positive
Yield of new diagnoses, and linkage to care rates, were lower
than anticipated
•Goal: 5% (new) HIV positivity rate; Result: 3.1% HIV positivity
rate
•Goal: 85% linked to medical care in 90 days; Result: 68.9%

Key Findings (2)
HIV testing and linkage to care differ according to the testing
components and where testing is conducted
•HIV positivity and linkage is high in clinical settings, lower in bars
and clubs
•Social network strategies had a high yield of persons with newly
diagnosed HIV, but were difficult to implement
•Linkage to care for those tested in bars and clubs, or public
areas, is very challenging

Lessons Learned
Identifying remaining persons with undiagnosed HIV
infection is challenging; creative approaches needed
Organizations should consider multiple strategies to best
target HIV testing and linkage to reach high risk MSM and TG
Use of social networks (formal and informal) may improve
the ability of organizations to identify persons with newly
diagnosed HIV infection
Testing organizations should establish relationships with
clinical testing sites to secure dedicated medical
appointment slots, especially when testing at bars or clubs

For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position
of the Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division Name in this space
Contact: Elizabeth DiNenno, PhD
Edinenno@cdc.gov
404-639-8482