BMJ Open. Determinants for never having tested for HIV among MSM in the Netherlands

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1 Determinants for never having tested for HIV among MSM in the Netherlands Journal: BMJ Open Manuscript ID: bmjopen Article Type: Research Date Submitted by the Author: -Jul-0 Complete List of Authors: den Daas, Chantal; National Institute for Public Health and the Environment, Center for Infectious Disease Control Doppen, Martine; National Institute for Public Health and the Environment, Center for Infectious Disease Control Schmidt, Axel; London School of Hygiene and Tropical Medicine, Sigma Research, Department of Social & Environmental Health Research Op de Coul, Eline; National Institute of Public Health and the Environment, Centre for Infectious Disease Control <b>primary Subject Heading</b>: HIV/AIDS Secondary Subject Heading: Public health Keywords: HIV & AIDS < INFECTIOUS DISEASES, PUBLIC HEALTH, EPIDEMIOLOGY BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

2 Page of BMJ Open Running head: Determinants of never having tested for HIV among MSM in the Netherlands Chantal den Daas, Martine Doppen, Axel J. Schmidt, Eline Op de Coul, Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands Sigma Research, Department of Social & Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK Author Note: Correspondence concerning this paper should be addressed to Chantal den Daas, Centre for Infectious Disease Control, National Institute for Public Health and the Environment, P.O. Box, 0 BA, Bilthoven, The Netherlands. Telephone number: + (0) chantal.den.daas@rivm.nl Keywords: HIV-testing, men who have sex with men, sexual behavior, the Netherlands Word count (excluding title page, abstract, references, figures and tables):, abstract BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

3 Page of ABSTRACT Objectives: Men who have sex with men (MSM) who are unaware of their HIV infection are more likely to infect others, and unable to receive treatment. Therefore, we aimed to identified characteristics of Dutch MSM who never tested for HIV. Methods: We analysed data from Dutch participants from the European MSM Internet Survey (EMIS, N NL =,). The outcome we investigated was having never been tested for HIV. Results: A total of MSM (0.%) had never been tested for HIV. Not being from Amsterdam, with low education and knowledge on HIV-testing were associated with never having tested. Lower sexual risk (including having fewer sexual partners, and no anal intercourse), and less social engagement (including being less out) were also associated with having never been tested. Additionally,.% of MSM who never tested for HIV reported sexual behavior that may have put them at HIV risk. Conclusion: MSM make their own risk assessments that inform their choices about HIVtesting. Nevertheless, MSM who were never tested may have been at risk for HIV, and remain important to target for HIV interventions. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

4 Page of BMJ Open ARTICLE SUMMARY Strengths and limitations of this study The aim of the current study was to get insight into MSM never tested for HIV, as mobilizing them could potentially reduce the number of people unaware of their HIV status. A strength of this study was the topic, as recent estimation studies show that there are still many MSM unaware of the HIV infection in the Netherlands. A limitation of this study was possible effects of self-selection and social desirability biases, for example the number of MSM never tested for HIV might be higher in the general population do to interest in the study topic. Our findings showed that more MSM with lower sexual risks were never tested for HIV, suggesting that MSM made risk assessments that informed their choices about testing for HIV Promoting HIV testing is important, as MSM who never tested for HIV showed sexual behavior that may put them at risk for HIV BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

5 Page of INTRODUCTION The goal of UNAIDS states that 0 percent of all people living with human immunodeficiency virus (HIV) should be aware of their status, 0 percent of all HIV infected people should receive antiretroviral therapy, and of that group 0 percent should achieve viral suppression by 00.[] To reach this goal in the Netherlands, we specifically have to increase the number of people aware of their HIV status. Recent studies found that approximately -% of people in the Netherlands are unaware of their HIV status, which is still far from the percent goal.[, ] People who have never tested for HIV can be seen as the ultimate unaware group, assuming that at least some of them have been at risk for HIV. Therefore, mobilizing this group to test for HIV could potentially reduce the number of people unaware of their HIV status. Whereas much research focusses on the risk factors associated with contracting HIV and sexually transmitted infections (STIs), much less research investigates risk factors associated with never testing for HIV (see [-] for some notable exceptions). In 0, data from the European MSM Internet Survey (EMIS) first became available with data on demographics, sexual behavior, and psychosocial factors related to sexual health among men who have sex with men (MSM).[] As 0 percent of all new HIV cases in the Netherlands were diagnosed among MSM, they are considered important to target for prevention efforts.[, ] In the current study, we investigated risk factors associated with never being tested for HIV among EMIS participants residing in the Netherlands. METHODS The European MSM Internet Survey (EMIS) is a -language, cross-sectional, online study that covered MSM in countries. In the Netherlands,, men completed the EMIS questionnaire between June and August 0. After data-cleaning (excluding respondents with for example discrepant answers), the NL sample consisted of, MSM. Participants BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

6 Page of BMJ Open residing in the Netherlands were recruited predominantly via instant messages on internet sites visited by MSM, such as PlanetRomeo (.0%), Gaydar (.%), and s to Schorer Monitor participants (a Dutch internet survey;.%)[], as well as via banners on websites that are frequently visited by MSM, through gay community organizations, and by using printed materials at locations frequented by MSM (.%). An extensive description of the survey methods can be found elsewhere.[, ] EMIS was approved by the Research Ethics Committee of the University of Portsmouth, United Kingdom (REC application number 0/0:). Participants had to confirm that they had read and understood the introductory text, had reached the age of consent ( years in the Netherlands), and consented to participate in the study before proceeding to the questions. We analyzed the variables age, residence, country of birth, educational level, sexual identity, being out about their sexual attraction to men among family, friends, and colleagues (outness or being out of the closet ), the proportion of gay friends among all friends, number of non-steady sexual partners in the last months, anal intercourse ever, unprotected anal intercourse (UAI) with any male partner of unknown or discordant HIV serostatus in the last months, ever visiting social venues, ever visiting sex venues, ever having had sex abroad, ever and recent use of sex and party drugs (i.e., ecstasy, amphetamine, crystal meth, mephedrone, GHB/GBL, ketamine, cocaine), and self-reported STI diagnoses in the last months. We also calculated an approximation of the number of sexually active years, by subtracting age at first anal intercourse from current age. However, if MSM filled out the categories younger than or older than 0 years of age at first anal intercourse, we qualified this as and years old at first anal intercourse. In addition, we analyzed two variables of knowledge. First, HIV test-related knowledge was measured with items ( AIDS is caused by a virus called HIV, There is a medical test that can show whether or not you have HIV, If someone becomes infected with HIV it may BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

7 Page of take several weeks before it can be detected in a test, There is currently no cure for HIV infection, HIV infection can be controlled with medicines so that its impact on health is much less ). Men who answered I knew this already to at least items were classified as high in knowledge on HIV-testing. Second, HIV transmission-related knowledge was also measured with items ( You cannot be confident about whether someone has HIV or not from their appearance, Effective treatment of HIV infection reduces the risk of HIV being transmitted, HIV cannot be passed during kissing, including deep kissing, because saliva does not transmit HIV, You can pick up HIV through your penis while being active in unprotected anal or vaginal sex (fucking) with an infected partner, even if you don t ejaculate, You can pick up HIV through your rectum while being passive in unprotected anal sex (being fucked) with an infected partner ). Uni- and multivariable logistic regression analyses were conducted to investigate associations between the outcome, demographic, psychosocial, and behavioral factors. Variables showing an association of p < 0.0 (Wald test, univariable analysis) were included in the multivariable analyses. Backward stepwise logistic regression analyses were performed, including variables with p < 0.0 for the likelihood ratio test. Associations were examined using adjusted odds ratios (aor) and % confidence intervals (% CI). In addition, we checked the variables in the multivariate model for collinearity, and did not find any, as indicated by tolerance coefficients between. and. (below. indicates collinearity), and variance inflation factors between.0 and.00 (above indicates collinearity). RESULTS Respondents residing in the Netherlands were mostly older than 0 years (.%) compared to.% younger than years, and.%, between and years, of Dutch origin (.%), from Amsterdam (.%), and highly educated (.% with tertiary education). The proportion of MSM who reported to never have tested for HIV during their BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

8 Page of BMJ Open lifetime was 0.% (N = ). The median age of MSM who were never tested was years (range -). Of all MSM who were never tested for HIV,.% had sex with more than one casual partner in the last months and.% had unprotected anal intercourse. Among those who were tested for HIV,.% were tested HIV positive and.% were diagnosed HIV negative at their last test. Among HIV negative MSM who were ever tested,.% were tested longer than months ago. Demographics associated with never being tested for HIV in univariable analysis were age group and residence. Being untested was particularly likely among MSM younger than years (.%), and MSM living outside of Amsterdam (Table ). Higher odds to never be tested for HIV were also found among MSM who had low to moderate educational levels, who had low to moderate knowledge about HIV-testing and transmission. In the univariable analysis, MSM with a country of birth other than the Netherlands were less likely to be never tested for HIV. This was mainly explained by lower odds of never been tested for MSM from Europe (OR 0., % CI 0.-0.), and from North America, Canada and Australia (OR 0., CI 0.-0.). BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

9 Page of Table. Characteristics of MSM (N =,) who ever and who never tested for HIV in the Netherlands. Ever tested Never tested N (%) N (%) OR [% CI] aor [% CI] Age (years) >0 (.) (.) ns - 0 (0.) (.). [0.-.] < (.) (.). [.0-.] Residence Amsterdam (.) (.0) Other (.) (.0).0 [.-.]. [.-.0] Country of birth Netherlands (.) (.) ns Other (.) (.) 0. [0.-0.] Education level High* (.) (.) Low / Medium 0 (.) 0 (.).0 [.-.]. [.0-.] Knowledge on HIV-testing High** (.) 0 (0.) Low / Moderate (.) 0 (.). [.-.]. [.-.] Knowledge on HIV-transmission High (.) (0.) ns Low / Moderate (.) (.).0 [.-.] Sexual identity Gay/homosexual (.) (.) ns Bisexual /other 0 (.) (.). [.-.] Sexual active > years (0.) (.) < years (.) (.). [.0-.].0 [.-.] Outness to nearly everybody Out (.0) 00 (.) Not out (.0) (.). [.0-.0]. [.-.0] on October 0 by guest. Protected by copyright. BMJ Open: first published as./bmjopen on January 0. Downloaded from

10 Page of BMJ Open Proportion of gay friends Most (.) (.) Some (.) 0 (.0). [.-.]. [0.-.] Few (.) (.).0 [.-.]. [.-.] Sexual partners in last months > (.0) (.) - (.) (.). [.0-.]. [.0-.00] - (.) 0 (.). [.-.00].0 [.-.] (.) (.). [.-.].0 [.-.] 0 (.) (.). [.-.]. [.-.0] AI ever Yes (.) (.0) No (.) (.).0 [.-.].00 [.0-.] UAI*** Yes (.) (.) No 0 (.) (0.) 0. [0.-0.] 0. [0.-0.] No sex with men (.) (.). [.-.] 0.0 [0.-.0] Visit to social venues Ever (.) (.) Never (.) (.). [.-.]. [.-.] Visit to sex venues Ever (.) (.0) ns Never 0 (.) (.0).0 [.-.] Sex abroad in the last months Yes 0 (.) (.) No (.) (.). [.-.]. [.-.] Sex/ party drugs**** Yes < months (.0) (.) Yes ever (.) (.). [.0-.]. [0.-.0] No (.) (.0).00 [.-.0].0 [.-.] on October 0 by guest. Protected by copyright. BMJ Open: first published as./bmjopen on January 0. Downloaded from

11 Page of STI diagnosis in the last months Yes (.) (.) No (.) (.). [.-.]. [.-.] Bold printed statistics differ significantly (p-value <.0). AI indicates anal intercourse; aor, adjusted odds ratio; CI, confidence interval; ns, not significant; OR, odds ratio; STI, sexually transmitted infection; UAI, unprotected anal intercourse. * High education = tertiary education (ISCED- levels and ) ** High knowledge = Men stating to have already known at least of true statements on HIV-testing, or respectively, HIV-transmission *** UAI with any male partners of unknown or discordant HIV serostatus in the last months **** Use of sex and party drugs (i.e., ecstasy, amphetamine, crystal meth, mephedrone, GHB/GBL, ketamine, cocaine). on October 0 by guest. Protected by copyright. BMJ Open: first published as./bmjopen on January 0. Downloaded from

12 Page of BMJ Open In addition, some social factors played an important role in never being tested. Notably, MSM who were sexually active for less than years, those were not out to nearly everybody, and those with a lower proportion of gay friends had higher odds to never be tested for HIV. Finally, related to sexual behavior, MSM who had fewer non-steady sexual partners, who never had anal intercourse, who had no recent UAI with any male partner of unknown or discordant HIV serostatus, who had no sex abroad, who did not visit social venues, who did not visit sex venues, who reported to have never used sex- or party drugs, and who reported no STI diagnoses in the last months had higher odds to have never tested for HIV in the univariable analyses. In multivariable analysis, there was still an association between never being tested and living in Amsterdam, lower education, lower knowledge on HIV-testing, fewer than years of sexual activity, low outness (or being closeted ), not visiting social venues, having fewer gay friends, having fewer non-steady sexual partners, no anal intercourse ever, no sex abroad, and no self-reported STI diagnoses. DISCUSSION Our findings show that perceived higher sexual risks in the recent past decreased the odds to never be tested for HIV. It makes sense that MSM who behave in less risky ways, for example who have not had UAI, had fewer non-steady sexual partners, or have not had sex abroad, also perceived their risk for contracting HIV as lower, and therefore did not feel the need to test for HIV. Importantly, however,.% of untested men reported UAI with a male partner of unknown or discordant HIV serostatus in the last months, underlining that the untested group is an important target for HIV-testing campaigns. Additionally, educational level, knowledge about HIV-testing were also related to testing. Knowledge about HIV-testing seemed to be especially important in decreasing odds to never be tested. Notably, HIV-testing in the Netherlands is predominantly organized in BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

13 Page of specialized centers (not hospitals or clinics), and differs in this regard from other Western European countries. MSM who are more assimilated into the gay community seemed less likely to never be tested for HIV, as exemplified by having a higher proportion of gay friends, visit social venues, and being out to nearly everybody. These MSM possibly havd more positive examples or role models and social support. Analysis of EMIS data of Portuguese MSM showed that higher educational level, gay or homosexual sexual identity, and number of sexual partners in the last months were associated with HIV-testing.[] These factors were also associated with HIV-testing among Dutch MSM, however, gay or homosexual sexual identity did not reach significance in our multivariable model. An Australian study found that HIV-testing was associated with sexual practices as well, and that many of the untested men reported multiple sex partners and unprotected anal intercourse.[] A limitation to our study is that the data used has been collected in 0, whereas there has been an increased focus on testing for HIV in the Netherlands since then. It would be very insightful to go through with the intended repetition of the EMIS, in order to be able to see whether the proportion of MSM never tested for HIV has already decreased in the Netherlands and other European countries. However, as seen in recent estimations of the number of MSM who are unaware of their HIV status should still be reduced,[, ] suggesting that insights into the risk factors associated with never having tested for HIV remain important. In addition, the findings are all based on self-reports. These reports could be biased due to social desirability concerns. However, we think this effect is limited as EMIS guaranteed anonymity of the results. Moreover, some of more risky behaviors are still frequently reported. Finally, we do not expect social desirability to influence MSM who never tested differently than MSM who did test for HIV previously. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

14 Page of BMJ Open CONCLUSION MSM with lower sexual risks were more likely to be never tested for HIV, suggesting that MSM made risk assessments that informed their choices about whether to test for HIV or not. However, we also showed that MSM who never tested for HIV showed sexual behavior that may put them at risk for HIV, and are therefore an important group for targeted HIV interventions. Interventions should encourage regular HIV-testing for sexually active MSM. With the evolving of mobile meeting applications that could replace gay venues, it seems important that especially young MSM do develop strong social ties, to have role models and social support to inspire testing for HIV. Otherwise, mobile apps could be used for intervention (i.e., to increase knowledge or encourage testing) in the increasingly individualistic social contexts and among MSM lacking strong social connections in the gay community. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

15 Page of ACKNOWLEDGEMENTS The EMIS project was funded by: Executive Agency for Health and Consumers, EU Health Programme 00 0 (funding period: ); CEEISCat - Centre d Estudis Epidemiològics sobre les ITS/HIV/SIDA de Catalunya; Terrence Higgins Trust (CHAPS) for Department of Health for England; Maastricht University; Regione del Veneto; Robert Koch Institute. Scientific co-ordination: Robert Koch Institute (Germany); Administrative co-ordination: GIZ Gesellschaft für Internationale Zusammenarbeit (Germany); Technical Implementation: Sigma Research, London School of Hygiene & Tropical Medicine (UK); Questionnaire drafting: University College, Maastricht (The Netherlands). In the Netherlands EMIS was supported by the Schorer Stichting. CONTRIBUTOR STATEMENT All authors contributed to the design of the study. CdD led on the data analysis and drafting of the manuscript supported by EOdC, MD and AJS. All authors commented on drafts of the manuscript and approved the final version. DATA SHARING STATEMENT No additional data available. COMPETING INTEREST AND FUNDING None declared. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

16 Page of BMJ Open REFERENCES. UNAIDS : An ambitious treatment target to help end the Aids epidemic. 0.. Stichting HIV Monitoring. Monitoringrapport 0. HIV infectie in Nederland 0.. Op de Coul ELM, Schreuder I, Conti S, et al. Changing Patterns of Undiagnosed HIV Infection in the Netherlands: Who Benefits Most From Intensified HIV Test and Treat Policies? PLoS ONE. 0; (): e0.. Carvalho C, Fuertes R, Lucas R, Martins A, Campos M, Mendão L, et al. HIV testing among Portuguese men who have sex with men results from the European MSM Internet Survey (EMIS). HIV medicine. 0;(S):-.. Margolis AD, Joseph H, Belcher L, et al. Never testing for HIV among men who have sex with men recruited from a sexual networking website, United States. AIDS and Behavior. 0;():-.. Zablotska I, Holt M, De Wit J, et al. Gay men who are not getting tested for HIV. AIDS and Behavior. 0;():-.. The EMIS network. EMIS 0: The European Men-Who_Have_Sex-With-Men Internet Survey. Findings from countries. Stockholm: European Centre for Disease Prevention and Control: 0.. van Oeffelen AAM, Van Aar F, Van den Broek IV, et al. Sexually transmitted infections including HIV, in the Netherlands in 0. Bilthoven: Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), 0.. van Empelen P, Van Berkel M, Roos E, et al. Schorer Monitor 0: Schorer; 0.. Weatherburn P, Schmidt AJ, Hickson F, et al. The European Men-who-have-sex-withmen internet survey (EMIS): design and methods. Sexuality Research and Social Policy. 0;():-. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

17 Page of LICENCE FOR PUBLICATION The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non-exclusive for government employees) on a worldwide basis to the BMJ and co-owners or contracting owning societies (where published by the BMJ on their behalf), and its Licensees to permit this article (if accepted) to be published in Sexually Transmitted Infections and any other BMJ products and to exploit all subsidiary rights, as set out in our licence. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

18 Determinants of never having tested for HIV among MSM in the Netherlands Journal: BMJ Open Manuscript ID bmjopen r Article Type: Research Date Submitted by the Author: -Sep-0 Complete List of Authors: den Daas, Chantal; National Institute for Public Health and the Environment, Center for Infectious Disease Control Doppen, Martine; National Institute for Public Health and the Environment, Center for Infectious Disease Control Schmidt, Axel; London School of Hygiene and Tropical Medicine, Sigma Research, Department of Social & Environmental Health Research Op de Coul, Eline; National Institute of Public Health and the Environment, Centre for Infectious Disease Control <b>primary Subject Heading</b>: HIV/AIDS Secondary Subject Heading: Public health Keywords: HIV & AIDS < INFECTIOUS DISEASES, PUBLIC HEALTH, EPIDEMIOLOGY BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

19 Page of 0 BMJ Open Running head: Determinants of never having tested for HIV among MSM in the Netherlands Chantal den Daas, Martine Doppen, Axel J. Schmidt, Eline Op de Coul, Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, The Netherlands Sigma Research, Department of Social & Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK Author Note: Correspondence concerning this paper should be addressed to Chantal den Daas, Centre for Infectious Disease Control, National Institute for Public Health and the Environment, P.O. Box, 0 BA, Bilthoven, The Netherlands. Telephone number: + (0) chantal.den.daas@rivm.nl Keywords: HIV-testing, men who have sex with men, sexual behavior, the Netherlands Word count (excluding title page, abstract, references, figures and tables):, abstract BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

20 Page of ABSTRACT Objectives: Men who have sex with men (MSM) who are unaware of their HIV infection are more likely to infect others, and unable to receive treatment. Therefore, we aimed to identify the proportion and characteristics of Dutch MSM who never tested for HIV. Methods: In 0, the European MSM Internet Survey (EMIS) recruited,0 men from countries through an anonymous online questionnaire in languages. We analysed data from Dutch participants (N=,). The outcome we investigated was having never (lifetime) been tested for HIV. Results: A total of MSM (0.%) had never been tested for HIV. In multivariate regression analyses, not being from Amsterdam (aor., CI.-.0), with low education (aor., CI.0-.) and knowledge on HIV-testing (aor., CI.-.) were significantly associated with never having tested. Lower sexual risk (including having fewer sexual partners (aor., CI.-.0), and no anal intercourse (aor., CI.0-.)), and less social engagement (including being less out (aor., CI.-.0)) were also associated with having never been tested. Additionally,.% of MSM who never tested for HIV reported sexual behavior that may have put them at HIV risk. Conclusion: MSM make their own risk assessments that inform their choices about HIVtesting. Nevertheless, MSM who were never tested may have been at risk for HIV, and remain important to target for HIV interventions. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

21 Page of 0 BMJ Open ARTICLE SUMMARY Strengths and limitations of this study The aim of the current study was to get insight into MSM never tested for HIV, as mobilizing them could potentially reduce the number of people unaware of their HIV status. A strength of this study was the topic, as recent estimation studies show that there are still many MSM unaware of the HIV infection in the Netherlands. A limitation of this study was possible effects of self-selection and social desirability biases, for example the number of MSM never tested for HIV might be higher in the general population do to interest in the study topic. Our findings showed that more MSM with lower sexual risks were never tested for HIV, suggesting that MSM made risk assessments that informed their choices about testing for HIV Promoting HIV testing is important, as MSM who never tested for HIV showed sexual behavior that may put them at risk for HIV BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

22 Page of INTRODUCTION The goal of United Nations Programme on Acquired Immune Deficiency Syndrome (UNAIDS) states that 0 percent of all people living with human immunodeficiency virus (HIV) should be aware of their status, 0 percent of all HIV infected people should receive antiretroviral therapy, and of that group 0 percent should achieve viral suppression by 00.[] To reach this goal in the Netherlands, we specifically have to increase the number of people aware of their HIV status. Recent studies found that approximately -% of people in the Netherlands are unaware of their HIV status, which is still far from the percent goal.[, ] However, this is an improvement compared to 00 when this percentage was estimated to be 0%. [] One estimation indeed showed that % of people infected with HIV were in care (.0 of.000), of those % were on cart (.0 of.0), and of those % had reached viral suppression (.0 of.0). [] Even though there is much to gain in the other steps of the treatment cascade, the percentage of people unaware of HIV infection is a priority. One thing that could possibly explain the decrease in people unaware is the opt-out HIV screening that has been implemented in STI clinics since 0, meaning that HIV routinely takes place unless someone refuses. [-] Also, men who have sex with men (MSM) are encouraged to be tested repeatedly, once every six months. [] However, these interventions mainly reach MSM who have already found their way to the STI clinic and might miss a population of men who have never tested. As there were new HIV infections in STI-clinic in 0 among MSM in the Netherlands, which is a % decline compared to 0 [], new perspectives should be added to keep up this trend. As such, people in the most at risk populations (such as MSM), who have never tested for HIV can be seen as the ultimate unaware group, assuming that at least some of them have been at risk for HIV. People who are unaware of their HIV infection have been estimated to BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

23 Page of 0 BMJ Open contribute up to 0% of new HIV infections. [] Therefore, mobilizing the group never tested to test for HIV could potentially reduce the number of people unaware of their HIV status and onward transmission. Whereas much research focusses on the risk factors associated with contracting HIV and sexually transmitted infections (STIs), less research investigates risk factors associated with never testing for HIV. [-]In addition, although the number of HIV infections among MSM has decreased between 0 and 0, this is probably not explained by a reduction in sexual risk behavior, as other sexually transmitted infections do keep increasing in this group. [] In 0, data from the European MSM Internet Survey (EMIS) first became available with data on demographics, sexual behavior, and psychosocial factors related to sexual health among MSM.[] As in 0 0 percent of all new HIV cases in the Netherlands were diagnosed among MSM, they are considered important to target for prevention efforts.[, ] In the current study, we investigated risk factors associated with never being tested for HIV among EMIS participants residing in the Netherlands. METHODS The European MSM Internet Survey (EMIS) is an anonymous, self-administered, cross-sectional, online study in languages that covered MSM in countries. In the Netherlands,, men completed the EMIS questionnaire between June and August 0. After data-cleaning (excluding respondents with for example discrepant answers), the Dutch sample consisted of, MSM. Participants residing in the Netherlands were recruited predominantly via instant messages on internet sites visited by MSM, such as PlanetRomeo (.0%), Gaydar (.%), and s to Schorer Monitor participants (a Dutch internet survey;.%)[], as well as via banners on websites that are frequently visited by MSM, through gay community organizations, and by using printed materials at locations frequented by MSM (.%). An extensive description of the survey methods can be found elsewhere.[, ] BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

24 Page of EMIS was approved by the Research Ethics Committee of the University of Portsmouth, United Kingdom (REC application number 0/0:). Participants had to confirm that they had read and understood the introductory text, had reached the age of consent ( years in the Netherlands), and consented to participate in the study before proceeding to the questions. We analyzed the association between never been tested and the variables age, residence, country of birth, educational level, sexual identity, being out about their sexual attraction to men among family, friends, and colleagues (outness or being out of the closet ), the proportion of gay friends among all friends, number of non-steady sexual partners in the last months, anal intercourse ever, unprotected anal intercourse (UAI) with any male partner of unknown or discordant HIV serostatus in the last months, ever visiting gay social venues, ever visiting sex venues, ever having had sex abroad, ever and recent (in the last months) use of sex and party drugs (i.e., ecstasy, amphetamine, crystal meth, mephedrone, GHB/GBL, ketamine, cocaine), and self-reported STI diagnoses in the last months. We also calculated an approximation of the number of sexually active years, by subtracting age at first anal intercourse from current age. However, if MSM filled out the categories younger than or older than 0 years of age at first anal intercourse, we qualified this as and years old at first anal intercourse. In addition, we analyzed two variables of knowledge. First, HIV test-related knowledge was measured with five items ( AIDS is caused by a virus called HIV, There is a medical test that can show whether or not you have HIV, If someone becomes infected with HIV it may take several weeks before it can be detected in a test, There is currently no cure for HIV infection, HIV infection can be controlled with medicines so that its impact on health is much less ). Men who answered I knew this already to at least four items were classified as high in knowledge on HIV-testing. Second, HIV transmission-related knowledge was also measured with five items ( You cannot be confident about whether someone has HIV or not BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

25 Page of 0 BMJ Open from their appearance, Effective treatment of HIV infection reduces the risk of HIV being transmitted, HIV cannot be passed during kissing, including deep kissing, because saliva does not transmit HIV, You can pick up HIV through your penis while being active in unprotected anal or vaginal sex (fucking) with an infected partner, even if you don t ejaculate, You can pick up HIV through your rectum while being passive in unprotected anal sex (being fucked) with an infected partner ). Uni- and multivariable logistic regression analyses were conducted to investigate associations between the outcome, demographic, psychosocial, and behavioral factors. Variables showing an association of p < 0.0 (Wald test, univariable analysis) were included in the multivariable analyses. Backward stepwise logistic regression analyses were performed, including variables with p < 0.0 for the likelihood ratio test. Associations were examined using adjusted odds ratios (aor) and % confidence intervals (% CI). In addition, we checked the variables in the multivariate model for collinearity, and did not find any, as indicated by tolerance coefficients between. and. (below. indicates collinearity), and variance inflation factors between.0 and.00 (above indicates collinearity). All statistical analyses were performed using IBM SPSS for Windows. RESULTS Respondents residing in the Netherlands were mostly older than 0 years (.%) compared to.% younger than years, and.0%, between and years, of Dutch origin (.%), from Amsterdam (.%), and highly educated (.% with tertiary education). The proportion of MSM who reported to never have tested for HIV during their lifetime was 0.% (N = 0). The median age of MSM who were never tested was years (range -). Of all MSM who were never tested for HIV,.% had sex with one or more casual partners in the last months and.% had unprotected anal intercourse. Among those who were tested for HIV,.% were tested HIV positive and 0.% were diagnosed BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

26 Page of HIV negative at their last test. Among HIV negative MSM who had tested negative at their last test,.% were tested longer than six months ago. Demographics associated with never being tested for HIV in univariable analysis were age group and residence. Untested MSM were particularly likely to be younger than years (.%), and MSM living outside of Amsterdam (Table ). Higher odds to never be tested for HIV were also found among MSM who had low to moderate educational levels, who had low to moderate knowledge about HIV-testing and transmission. In the univariable analysis, MSM with a country of birth other than the Netherlands were less likely to be never tested for HIV. This was mainly explained by lower odds of never been tested for MSM from Europe (OR 0., % CI 0.-0.), and from North America, Canada and Australia (OR 0., CI ). BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

27 Page of 0 BMJ Open Table. Characteristics of MSM (N =,) who ever and who never tested for HIV in the Netherlands. Total Ever tested Never tested N (%) N (%) N (%) OR [% CI] aor [% CI] Age (years) >0 (.) (.) (.) Ns - (.0) 0 (0.) (.). [0.-.] < (.) (.) (.). [.-.] Residence Amsterdam (.) (.) (.0) Other (.) (.) (.0). [.-.]. [.-.0] Country of birth Netherlands (.) (.) (.) Ns Other (.) (.) (.) 0. [0.-0.] Education level High* (.) 0 (.) (.) Low / Medium (.) (.) (.).0 [.-.]. [.0-.] Knowledge HIV-testing High** (.) (.) 0 (.) Low / Moderate (.) (.) (.). [.-.]. [.-.] Knowledge HIV-transmission High (.) (.) (.0) Ns Low / Moderate (.) (.) (.0). [.-.] Sexual identity Gay/homosexual (.) (.) (.) Ns Bisexual /other (.) 0 (.) (.). [.-.] Sexual active years (.) (0.) (.) < years (.) (.) (.). [.-.].0 [.-.] Outness to nearly everybody Out (0.) (.0) (.) Not out (.) (.0) (.). [.-.]. [.-.0] on October 0 by guest. Protected by copyright. BMJ Open: first published as./bmjopen on January 0. Downloaded from

28 Page of Proportion of gay friends Most (0.) (.) (.) Some 0 (.) (.) (.0). [.-.0]. [0.-.] Few (0.) (.) -0 (.). [.-.]. [.-.] Sexual partners in last months > (.0) (.0) (.) - (.) (.) (.). [.0-.]. [.0-.00] - (.) (.) 0 (.). [.-.0].0 [.-.] (.) (.) (.). [.-.].0 [.-.] 0 (0.) (.) (.). [.-.]. [.-.0] AI ever Yes (.) (.) (.) No (.) (.) (.). [.-.0]. [.0-.] UAI*** Yes 0 (.) (.) (.) No (.) 0 (.) (0.) 0. [0.-0.] 0. [0.-0.] No sex with men (.) (.) (.). [.-.] 0.0 [0.-.0] Visit to social venues Ever 0 (.) (.) (.) Never 0 (.) (.) (.).0 [.-.]. [.-.] Visit to sex venues Ever 00 (.) (.) (.) ns Never (.) 0 (.) 0 (.). [.-.] Sex abroad in the last months Yes (.) 0 (.) (.0) No (.) (.) (.0).0 [.0-.]. [.-.0] Sex/ party drugs**** Yes < months 0 (.) (.0) (.) Yes ever 0 (.) (.) (.). [.0-.]. [0.-.0] No 0 (.) (.) (.). [.-.0].0 [.-.] on October 0 by guest. Protected by copyright. BMJ Open: first published as./bmjopen on January 0. Downloaded from

29 Page of 0 BMJ Open STI diagnosis in the last months Yes 0 (.) (.) (.) No (.) (.) (.). [.-.]. [.-.] Bold printed statistics differ significantly (p-value <.0). AI indicates anal intercourse; aor, adjusted odds ratio; CI, confidence interval; ns, not significant; OR, odds ratio; STI, sexually transmitted infection; UAI, unprotected anal intercourse. * High education = tertiary education (ISCED- levels and ) ** High knowledge = Men stating to have already known at least of true statements on HIV-testing, or respectively, HIV-transmission *** UAI with any male partners of unknown or discordant HIV serostatus in the last months **** Use of sex and party drugs (i.e., ecstasy, amphetamine, crystal meth, mephedrone, GHB/GBL, ketamine, cocaine). on October 0 by guest. Protected by copyright. BMJ Open: first published as./bmjopen on January 0. Downloaded from

30 Page of In addition, some social factors played an important role in never being tested. Notably, MSM who were sexually active for less than five years, those were not out to nearly everybody, and those with a lower proportion of gay friends had higher odds to never be tested for HIV. Finally, related to sexual behavior, MSM who had fewer non-steady sexual partners, who never had anal intercourse, who had no recent UAI with any male partner of unknown or discordant HIV serostatus, who had no sex abroad, who did not visit social venues, who did not visit sex venues, who reported to have never used sex- or party drugs, and who reported no STI diagnoses in the last months had higher odds to have never tested for HIV in the univariable analyses. In multivariable analysis, there was still an association between never being tested and living in Amsterdam, lower education, lower knowledge on HIV-testing, less than five years of sexual activity, low outness (or being closeted ), not visiting social venues, having fewer gay friends, having fewer non-steady sexual partners, no anal intercourse ever, no sex abroad, and no self-reported STI diagnoses. DISCUSSION Our findings show that perceived higher sexual risks in the recent past decreased the odds to never be tested for HIV. It makes sense that MSM who behave in less risky ways, for example who have not had UAI with any male partner of unknown or discordant HIV status, had fewer non-steady sexual partners, or have not had sex abroad, also perceived their risk for contracting HIV as lower, and therefore did not feel the need to test for HIV. Importantly, however,.% of untested men reported UAI with a male partner of unknown or discordant HIV serostatus in the last months, underlining that the untested group is an important target for HIV-testing campaigns. Additionally, educational level, knowledge about HIV-testing were also related to testing. Knowledge about HIV-testing seemed to be especially important iin the testing BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

31 Page of 0 BMJ Open decision, people with less knowledge we more likely to never be tested, or in other words people with more knowledge were less likely to never been tested. Notably, HIV-testing in the Netherlands is predominantly organized in specialized centers (not hospitals or clinics), and differs in this regard from other Western European countries. MSM who are more assimilated into the gay community seemed less likely to never be tested for HIV, as exemplified by having a higher proportion of gay friends, visit social venues, and being out to nearly everybody. These MSM possibly had more positive examples or role models and social support. Analysis of EMIS data of Portuguese MSM showed that higher educational level, gay or homosexual sexual identity, and number of sexual partners in the last months were associated with HIV-testing.[] These factors were also associated with HIV-testing among Dutch MSM, however, gay or homosexual sexual identity did not reach significance in our multivariable model. An Australian study found that HIV-testing was associated with sexual practices as well, and that many of the untested men reported multiple sex partners and unprotected anal intercourse.[] Insights into the risk factors associated with never having tested for HIV remain important. Specifically, our findings show that in order to reach the group of MSM who have never tested for HIV assimilation into the gay community is important. In the current climate, in which mobile applications seem to be replacing gay-venues as primary meeting ground [], it could become increasingly difficult for young MSM to build supportive social networks. Health care professionals should be vigilant that the reduction of gay venues (social or sexual) does not lead to more MSM who never test for HIV and try to stay in touch with the population through other means. The current findings correspond with known barriers to test, namely low-risk perception and fear and worries. [] MSM in sample also made risk assessment that BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

32 Page of informed their testing behavior. However, low-risk perception was not always similar to norisk, emphasizing the importance to also reach lower risk MSM. In addition, assimilation in the gay community was important, which could influence the amount of fear and worries MSM experience. Men with more gay friends, who visited more gay social and sex venues, and were out to almost everybody probably have better role models and experience more social support, and possible less stigma than men who are not as assimilated in the gay community. A limitation to our study is that the data used has been collected in 0. We have several reasons for still considering this data as important. First, a recently published paper indicated that in the Netherlands still an unacceptable large group of people are unaware of their diagnosis. [] We believe this might partly be explained by MSM who never tested, who as our paper shows do behave less riskily, but who still are at risk for HIV. Therefore, we think having better insights in risk factors for never being tested still is important. Strength of this study is its completeness regarding testing behavior, sexual behavior, and possible variables influencing this behavior. Secondly, although more frequent testing is encouraged, in the past couple of years there have not been many initiatives focusing on never tested MSM. Therefore, we have no reason to believe that their behavior has changed dramatically. We instead believe that increased use of apps for meeting sexual partners might have made this group more difficult to find, making insight into risk factors even more important. Although EMIS data have been collected years ago, it offers the most comprehensive dataset on this group of men, including most factors that could play a role in not testing for HIV. A repeat EMIS study would allow us to see whether the proportion of MSM never tested for HIV has already decreased in the Netherlands and other European countries. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

33 Page of 0 BMJ Open Another limitation could be recruitment bias, as more than 0% of the men were recruited from PlanetRomeo. Although PlanetRomeo users were rather young, they were less likely to have never tested for HIV (.%), compared to Gaydar (.%), Schorer (.%), and other recruitment methods (.%). This might have caused recruitment bias, we however think that PlanetRomeo users might be more sexually active, therefore at higher risk, which explains the smaller odds to never be tested. Moreover, a recent study found that the proportion of MSM never tested for HIV in the EMIS is comparable to the proportion of another internet survey in that same year (Schorer Monitor), which found a proportion of.0% of MSM never tested for HIV. Another venue-based recruitment method found that a lower percentage of MSM were never tested (.%), however this could be explained by the venue used namely STI-clinics. [] Despite the possible recruitment bias, this way of recruiting MSM probably does give a more realistic picture than venue-based sampling frames and insights into MSM at risk for HIV. Moreover, in the Netherlands over % of the population has access to the internet (at home), therefore we believe that an internet survey does not limit the possible response due to lack of internet access. In this light, we think this way of recruiting MSM could actually be the strength of this study, even though we might reach more sexually active MSM, but in particular this group is interesting when looking at those within this group who have never tested for HIV. We find that they still behave riskily and could contract HIV, thus determinants influencing never testing is particularly interesting. In addition, the findings are all based on self-reports. These reports could be biased due to social desirability concerns. However, we think this effect is limited as EMIS guaranteed anonymity of the results. Moreover, some of more risky behaviors are still frequently reported. Finally, we do not expect social desirability to influence MSM who never tested differently than MSM who did test for HIV previously. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

34 Page of CONCLUSION MSM with lower sexual risks were more likely to be never tested for HIV, suggesting that MSM made risk assessments that informed their choices about whether to test for HIV or not. However, we also showed that MSM who never tested for HIV showed sexual behavior that may put them at risk for HIV, and are therefore an important group for targeted HIV interventions. Interventions should encourage regular HIV-testing for sexually active MSM. With the evolving of mobile meeting applications that could replace gay venues, it seems important that especially young MSM do develop strong social ties, to have role models and social support to inspire testing for HIV. Otherwise, mobile apps could be used for intervention (i.e., to increase knowledge or encourage testing) in the increasingly individualistic social contexts and among MSM lacking strong social connections in the gay community. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

35 Page of 0 BMJ Open ACKNOWLEDGEMENTS The EMIS project was funded by: Executive Agency for Health and Consumers, EU Health Programme 00 0 (funding period: ); CEEISCat - Centre d Estudis Epidemiològics sobre les ITS/HIV/SIDA de Catalunya; Terrence Higgins Trust (CHAPS) for Department of Health for England; Maastricht University; Regione del Veneto; Robert Koch Institute. Scientific co-ordination: Robert Koch Institute (Germany); Administrative co-ordination: GIZ Gesellschaft für Internationale Zusammenarbeit (Germany); Technical Implementation: Sigma Research, London School of Hygiene & Tropical Medicine (UK); Questionnaire drafting: University College, Maastricht (The Netherlands). In the Netherlands EMIS was supported by the Schorer Stichting. CONTRIBUTOR STATEMENT All authors contributed to the design of the study. CdD led on the data analysis and drafting of the manuscript supported by EOdC, MD and AJS. All authors commented on drafts of the manuscript and approved the final version. DATA SHARING STATEMENT No additional data available. COMPETING INTEREST AND FUNDING No, there are no competing interests. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

36 Page of REFERENCES. UNAIDS : An ambitious treatment target to help end the AIDS epidemic. 0.. Stichting HIV Monitoring. Monitoringrapport 0. HIV infectie in Nederland 0.. Op de Coul ELM, Schreuder I, Conti S, et al. Changing Patterns of Undiagnosed HIV Infection in the Netherlands: Who Benefits Most From Intensified HIV Test and Treat Policies? PLoS ONE. 0; (): e0.. van Veen MG, Presanis AM, Conti S, et al. National estimate of HIV prevalence in the Netherlands: comparison and applicability of different estimation tools. AIDS. 0;:-.. van Oeffelen AAM, Van Aar F, Van den Broek IV, et al. Sexually transmitted infections including HIV, in the Netherlands in 0. Bilthoven: Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), 0.. Dukers-Muijrers NH, Niekamp AM, Vergoossen MM, et al. Effectiveness of an opting-out strategy for HIV testing: evaluation of years of standard HIV testing in a STI clinic. STI. 00;:-0.. Heijman RL, Stolte IG, Thiesbrummel HF, et al. Opting out increases HIV testing in a large sexually transmitted infections outpatient clinic. STI. 00;:-.. SOA AIDS Nederland. "Strategie voor de aanpak van soa s en hiv onder MSM in Nederland 0 0" [in Dutch]. Amsterdam, the Netherlands: SOA AIDS Nederland; 0.. Bezemer D, de Wolf F, Boerlijst MC, et al. A resurgent HIV- epidemic among men who have sex with men in the era of potent antiretroviral therapy. AIDS. 00;:-. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

37 Page of 0 BMJ Open Carvalho C, Fuertes R, Lucas R, Martins A, Campos M, Mendão L, et al. HIV testing among Portuguese men who have sex with men results from the European MSM Internet Survey (EMIS). HIV medicine. 0;(S):-.. Margolis AD, Joseph H, Belcher L, et al. Never testing for HIV among men who have sex with men recruited from a sexual networking website, United States. AIDS and Behavior. 0;():-.. Zablotska I, Holt M, De Wit J, et al. Gay men who are not getting tested for HIV. AIDS and Behavior. 0;():-.. The EMIS Network. EMIS 0: The European Men-Who-Have-Sex-With-Men Internet Survey. Findings from countries. Stockholm: European Centre for Disease Prevention and Control, 0. Retrieved from van Empelen P, Van Berkel M, Roos E, et al. Schorer Monitor 0: Schorer; 0.. Weatherburn P, Schmidt AJ, Hickson F, et al. The European Men-who-have-sex-withmen internet survey (EMIS): design and methods. Sexuality Research and Social Policy. 0;():-.. Gilbart VL, Simms I, Jenkins C, et al. Sex, drugs and smart phone applications: findings from semistructured interviews with men who have sex with men diagnosed with Shigella flexneri a in England and Wales. Sex Transm Infect. Published Online First: [April,0] doi:./sextrans Deblonde J, De Koker P, Hamers FF et al. Barriers to HIV testing in Europe: a systematic review. Eur J Pub Health, 0;0():-.. Den Daas C, Goenee M, Bakker BHW, et al. Comparing databases: determinants of sexually transmitted infections, HIV diagnoses, and lack of HIV testing among men who have sex with men. Manuscript under review. BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

38 Page 0 of LICENCE FOR PUBLICATION The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non-exclusive for government employees) on a worldwide basis to the BMJ and co-owners or contracting owning societies (where published by the BMJ on their behalf), and its Licensees to permit this article (if accepted) to be published in Sexually Transmitted Infections and any other BMJ products and to exploit all subsidiary rights, as set out in our licence. 0 BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.

39 Determinants of never having tested for HIV among MSM in the Netherlands Journal: BMJ Open Manuscript ID bmjopen r Article Type: Research Date Submitted by the Author: 0-Nov-0 Complete List of Authors: den Daas, Chantal; National Institute for Public Health and the Environment, Center for Infectious Disease Control Doppen, Martine; National Institute for Public Health and the Environment, Center for Infectious Disease Control Schmidt, Axel; London School of Hygiene and Tropical Medicine, Sigma Research, Department of Social & Environmental Health Research Op de Coul, Eline; National Institute of Public Health and the Environment, Centre for Infectious Disease Control <b>primary Subject Heading</b>: HIV/AIDS Secondary Subject Heading: Public health Keywords: HIV & AIDS < INFECTIOUS DISEASES, PUBLIC HEALTH, EPIDEMIOLOGY BMJ Open: first published as./bmjopen on January 0. Downloaded from on October 0 by guest. Protected by copyright.