Knowing When, and Whom, to Test

CHICAGO -- Health center directors know that young people, particularly men who have sex with men, are at the greatest risk of contracting HIV, and as more of them do so, that risk is only growing. But those same officials also report in a new study that myriad political, practical and professional obstacles are making it difficult to reach those students -- if HIV testing is even considered a priority at all.

And Nilay Patel, a recent graduate of Brown University's medical school, is worried that it's not.

"There's clearly certain subgroups that are starting to represent a larger part of that new HIV infection group, that in a sense might shift the way we think about HIV prevention on a national scale," Patel said Wednesday here at the annual convention of the American College Health Association, where he presented his study. "College students are not in any way missing from the HIV picture on a national scale."

Yet Patel found a "general sentiment of complacency" regarding HIV in health centers at the 31 New England colleges that he surveyed (while the study was limited to the Northeast, feedback at the convention suggested this issue is not unique to New England). Despite many directors saying they wanted to perform more testing, there was no ongoing effort to address HIV campuswide. And despite infection rates remaining fairly constant, the sense of urgency that existed when HIV first emerged has "dropped off fairly dramatically," Patel said.

In 2003, when education programs about safe sex had become common on many campuses, the Centers for Disease Control reported 56 cases of recent HIV infection among college students in North Carolina, in what Patel called a "profound reawakening to a lot of people." Yet, he said, "there has been little public health effort to address recent and acute HIV infection in college students."

More recently, a few cases of acute HIV (the stage two or three weeks after a person is exposed to the virus, when he or she actually starts showing symptoms) popped up at colleges in Rhode Island. After one student came into the health center with flu-like symptoms that suggested that he had HIV when the clinician hadn't even considered it, Patel had a wake-up call of his own.

"In a lot of ways what it meant to us was.... hey, maybe we're not fully thinking through acute HIV as a clinical diagnosis for people who come in," he said. Men who have sex with men compose only 2 percent of the population, but account for 61 percent of new HIV infections and just under half of all people with the virus. Most new infections are popping up in younger people. What's more, the CDC reports that one in five people who are infected don't realize it.

"Is this happening and just not being recognized?" Patel asked. "Is this something that's continuing on college campuses and just being misdiagnosed?"

So Patel decided to examine cases of HIV and syphilis among men who have sex with men at 31 colleges representative of New England institutions: mostly private and suburban with more than 5,000 students. The findings regarding rates of testing and diagnoses were notable: despite only about 3.5 percent of students having been tested for HIV in the past academic year (significantly lower than the national average of 25.7 percent reported in the 2010 ACHA National College Health Assessment), HIV was identified in five of those cases. (In the NCHA, 0.3 percent of students, on par with the national average, reported being treated for or diagnosed with HIV.)

The findings that caused the most contention among the audience didn't have to do with the rates per se, but with the themes that emerged in the qualitative questioning.

The first regarded health providers' willingness and ability to diagnose HIV. One-third of medical directors said their providers weren't comfortable recognizing acute HIV, and many felt that providers needed more training on it.

Second, and of particular concern to Patel's study, was the lack of outreach specifically to LGBTQ students. While 77 percent of directors said they had some targeted outreach at some point, "It seemed like they really were few and far between, especially when it came to targeted outreach to gay and bisexual men" -- even though in 2007, college-aged men were up to 85 times more likely to be diagnosed with HIV than other men. And it almost always took the form of a pamphlet, manual or other literature that will probably wind up in the trash.

But judging by the conversation that transpired during the presentation, health officials are struggling to reconcile those shortcomings. How does one target men who have sex with men effectively without making them feel unfairly attacked or judged? How do you get around that stigma that deters students from all backgrounds from getting tested, let alone those in the LGBT community? And what about the students who can't afford the time or money?

One person in the audience said his university polled students on how they wanted to receive educational resources and they said online, so the health center created a Facebook page. After that, 78 percent of people who got tested said they identified the opportunity through Facebook.

"A lot of students were afraid to come into the health center to discuss these issues," he said. "We were able to hit that a lot harder using social networking."

But a major point of Patel's presentation was that health practitioners should have a potential HIV diagnosis in the back of their minds even when the student in question didn't come in to get tested. And he faced pushback against guidelines suggesting that practitioners test students with unexplainable flu- or mono-like symptoms who also are men who have sex with men, or who have a newly diagnosed STI, or may have been exposed in the last two to six weeks (or myriad other scenarios).

One health professional from George Washington University, which he said has a "huge" gay male population, asked whether it was practical to test all those students. "Their perceptions and what we're trying to do -- often there's a big disconnect," he said. "They're going to feel discriminated on campus, and I think that's liable to hurt some of the efforts that I've been doing with our gay groups to get them to come in."

One way to remedy that might be to "finesse" the conversation, another suggested. Perhaps a student with symptoms could receive a handout distinguishing between symptoms of flu and HIV, and then encouraged that the only way to know for sure is to get tested.

Students face other barriers to testing, too.

"The cost of testing was absolutely, far and away the strongest indicator of whether or not a higher percentage of students at that university had been tested," Patel said. "Which I think is going to continue to be an issue." (The second-best predictor of testing was availability of the saliva rapid test, which only takes about 20 minutes and was offered by 35 percent of the colleges surveyed.)

One college has found huge success with hosting free testing days twice each year, on National HIV Testing Day in June and World AIDS Day in December.

"The students are coming in hundreds, and the GLBTQ students are there," the administrator said. "In fact, they go out and tell other students." (He also made a well-taken point that a fixation on "high-risk sexual behavior," which is generally considered to make HIV contraction more likely, is unwise. No matter how much sex or how many partners a student has, all it takes is one time to get infected -- and he's seen that in his students.)

It could be critical for health officials to partner with gay centers and student groups both to reduce that potential tension and stigma, and to get more students tested, Patel said. As one person put it, "Clearly this is an issue that we're missing, and it's at a time when these students are most infectious and contagious."