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    Photo Credit: SFAF

Where To Go, What To Get: A Primer On HIV Testing For Gay Men

By Steve Gibson

Editor’s note: This piece appears as part of an ongoing partnership between RealJock and the San Francisco AIDS Foundation. The San Francisco AIDS Foundation provides leadership to prevent new HIV infections. Linking community experience with science, the Foundation develops ground-breaking prevention programs and bold policy initiatives to promote health and create sustainable progress against HIV. Established in 1982, the Foundation refuses to accept that HIV transmission is inevitable. Visit them at www.sfaf.org.

Gay men know that part of a good sex life is knowing their HIV status. But getting tested is a little more complicated than it sounds. Where should you go? What kind of test should you have? There are a number of options, and the key is finding the one that fits your concerns and resources. To help you figure out where to start, here's a brief primer on HIV testing for gay men.

Community Organizations, Doctor's Offices and other Medical Settings, Home-Based
HIV testing is widely available throughout the country. Depending on the type of test you prefer and the availability of these testing options, you may be wondering where you should get tested. In the end, the answer is pretty straight-forward--wherever you feel comfortable.

The obvious place to start is with your regular doctor. Lots of primary care docs—even straight ones—are knowledgeable about HIV testing. But that relationship depends on your comfort level in discussing sexual health concerns with your doctor, and vice-versa, and whether or not you have health insurance in the first place. If that's not you, don't despair; you have other options.

For example, for some guys a community health center that focuses on gay men's health might be the best resource. If you live in the San Francisco Bay Area, you probably know about Magnet, the San Francisco AIDS Foundation's gay men's community health center in the heart of the Castro. Magnet was founded in 2003 by a group of men and women who thought the gay community needed culturally appropriate healthcare on its doorstep. In the past 12 months, Magnet has nearly doubled the number of people it sees for HIV testing as well as STD screening and treatment for gonorrhea, syphilis, Chlamydia and Hepatitis A and B vaccinations. In addition to health services, Magnet hosts a variety of community events such as art openings and open mic nights. If you're in the Bay Area, we encourage you to drop by their storefront on 18th between Castro and Collingwood to see what Magnet is all about.

If you want to get tested without having to talk to anyone, there is an at-home option. The Food and Drug Administration (FDA) has approved one home-based testing kit, Home Access. Users of this kit do their own fingerstick and send a blood sample to a laboratory for processing. Results are available in seven business days and are provided by phone. The retail cost for the kit is around $44.00. An Express kit is available that provides next-day results at a cost of roughly $60.

Finally, it is important to know that in some states, hospitals and other clinical settings can now test patients using an opt-out system. In opt-out testing, patients are informed that an HIV antibody test is going to be conducted as part of routine testing. Patients not wanting an HIV test must opt-out: that is, they must specifically tell their provider that they do not wish to have an HIV test performed.

Anonymous vs. Confidential
There are two kinds of privacy categories with regard to test results: anonymous and confidential. Most states provide the option of either anonymous or confidential testing. (Some states that do not offer anonymous testing). For states that have both, it is up to each state to determine the percentage of confidential over anonymous testing sites. The distinction is fairly simple: Anonymous means no name is attached to the test. Confidential means that there is a name attached to it. Some testing sites check for ID, some don't. Back in the day, anonymous testing was pretty much the way to go with HIV testing, and in some places, that still may be the case.

When California switched over to names-based reporting, most of the resistance came from providers rather than consumers. Providers, therefore, have to be careful with that information. At Magnet in San Francisco, for example, one key to making names-based reporting successful was informing clients about what gets reported to whom and why. The names of people testing antibody-positive at confidential sites in the city are reported to the local Department of Public Health which in turn reports names to the State Office of AIDS. Any data reported at the Federal level have identifying information removed and only aggregate data are reported. Names are not reported to third parties such as insurance providers or immigration services. And, even people who test HIV-positive at anonymous sites will, as soon as they seek HIV care and treatment, either at their doctor's office or in a public clinic, have their names then entered into the system and reported in much the same way as sites doing confidential HIV antibody testing.

Once you've decided to have the test, you have a number of different types of tests that may be used. Here's a run-down of the options, which differ primarily with regard to how long they take to produce results, how those results are communicated, and how early they can detect the virus.

Rapid vs. Standard
The Oraquick(c) rapid HIV antibody test was approved by the FDA in November 2002. Rapid testing can use either oral fluid or blood. (More on that below.) Rapid testing can provide antibody results within 20 to 40 minutes. That's a far cry from the days when you had to wait up to two weeks for results! Back then, the CDC estimated that up to 25 percent of people who tested HIV-positive never came back for their results. Rapid testing gives results the same day. Check with your provider as to how they manage providing results.

Standard testing is still done, of course. It also involves using either oral fluid or blood samples. With standard testing, samples are sent to a lab where the specimen is tested and results are sent back to the testing site. Clients return either one or two weeks later for results.

How the results will be delivered is a key aspect to determining whether rapid or standard testing is the way to go for you. All tests (either rapid or standard) require confirmation of an HIV-positive result. With standard testing, all positives have been confirmed by the time the client returns for his or her appointment. But with rapid testing, HIV-positive results may be provided on site, depending on the sites' capacity. In that case, it's possible that the client will be given a "preliminary positive" result pending the confirmation of the test. When that happens, clients are counseled to assume that they are HIV-positive pending their confirmation results. If that idea is really worrying to you, you may want to do your waiting up front, with a standard test.

One note: As mentioned earlier, either rapid or standard testing can use blood or oral fluid specimens to test for HIV antibodies. Both provide highly sensitive and accurate results and it is up to the site to determine which form of specimen collection they prefer. In both cases, the tests are looking for the presence of HIV antibodies, our body's immune response to the presence of HIV, rather than the actual virus.

Antibody vs. RNA/NAAT Testing
Even with rapid testing, the test still detects the presence of antibodies to HIV and not the actual virus. That means that the window period from exposure to the point at which antibodies begin to develop still exists. Current technologies in antibody testing are narrowing this window from the previous two weeks to six months, but the test still relies on an immune response to the presence of HIV.

Ideally, you'd be able to test right soon after a potential exposure. A few sites have started piloting a version of testing known as RNA or NAAT testing. HIV RNA (Ribonucleic Acid) or NAAT (Nucleic Acid Amplification testing) detects the presence of HIV in the blood. RNA testing allows for the detection of HIV in the body prior to the standard antibody testing, which requires an immune response. RNA testing can detect the presence of HIV within 10 days of exposure. This type of testing can diagnose people with acute or recent infection and help them get into treatment sooner and reduce the likelihood of transmitting HIV to their partners.

Unfortunately, RNA testing is not yet widely available. The test is not yet approved by the FDA to diagnose people with HIV. It is used to measure the amount of virus (viral load) in individuals known to be infected with HIV. But it points the way toward auspicious developments in testing for the future.

False Positives
Any kind of disease screening carries the risk of false positives. A false positive result is when the antibody test indicates the presence of what are perceived to be—but in fact are not—HIV antibodies. False positive tests are exceedingly rare but have become a topic of interest with the advent of rapid testing. With standard testing, false positives are detected in the laboratory during confirmation testing. With rapid testing, false positives are now being detected in the clinical setting.

We know that false positives can be expected in four out of 1,000 tests using oral fluid. Using blood samples, that number decreases to two out of 1,000. It's for this reason that negative tests don't need to be confirmed, positive tests do. Though the rate of false positives is low, it is again something to be aware of if you choose the rapid testing option.

Anything else?
Everyone wants to know how often they should get tested, but no single answer applies to everyone. The CDC recommends that gay guys get tested for HIV every six months. But a sexually active gay man should evaluate his risk and proceed with testing accordingly. Understanding your options should help make you more informed about what you can do to take care of yourself and your partners, and improving the health of our community.

About Steve Gibson: Steve Gibson is the Director of Magnet, the gay men's health outreach center in San Francisco's Castro neighborhood, providing testing for HIV and STDs in addition to community outreach and support services. Visit them at www.magnetsf.org.