Health promotion ‘on steroids’: the value of an experiential approach to promote rapid HIV testing in NSW, Australia March 2015, Volume 25, Issue 2

Background

Human immunodeficiency virus (HIV) remains a public health concern with significant costs to the healthcare system. Men who have sex with men (MSM) are the population group most affected by HIV in Australia, with about two-thirds of new infections occurring in this group.¹ Although HIV remains a chronic, incurable disease, approaches to HIV diagnosis, treatment and prevention have significantly evolved in recent years in response to emerging scientific evidence of the effectiveness of antiretroviral treatment as prevention and new rapid testing technologies.² Regular HIV testing remains critical in preventing HIV transmission through early detection and access to timely treatment and care.³

A new era

New South Wales (NSW) has historically had the highest rate of HIV diagnoses in Australia, from the beginning of the epidemic until 2010.¹ In 2012, following a 10-year period of relative stability, the number of HIV notifications in NSW sharply increased⁴, with 408 new notifications, a 24% increase compared with 2011. MSM accounted for 78% of all notifications.⁴

In addition, NSW released the NSW HIV strategy 2012–2015: a new era⁵ on World AIDS Day 2012. The strategy was more ambitious than previous strategies⁶, having the goals of virtually eliminating HIV transmission by 2020, and reducing new infections by 60% among MSM by 2015, through increasing HIV testing and treatment, and safe sex practices.⁵

Successfully scaling up HIV testing to reduce the pool of individuals with undiagnosed HIV is a key component of HIV prevention and is critical to the successful implementation of the strategy.⁵ Interventions that increase testing, together with combination prevention measures and early treatment, are expected to correspond with net decreases in incident infections.² This includes making testing easier and more accessible, disrupting traditional thinking about appropriate settings for HIV testing and increasing awareness among MSM about testing, particularly for those at high risk.⁵

Two implementation challenges identified by NSW Health included addressing resistance to change and parting with traditional approaches among sector stakeholders, and taking testing messages and services to target populations through unexplored service models that are innovative within Australia.

Testing within the community

HIV testing in NSW is traditionally provided in clinical settings such as general practice and public sexual health clinics. To achieve the new strategy targets, accessible service models, including rapid HIV testing (RHT), were needed to achieve the high coverage and frequency of HIV testing required. The increasing availability of RHT in NSW has provided a quick and convenient model for HIV testing that is proving successful in attracting higher-risk MSM and identifying a significant number of new HIV infections (unpublished evaluation by ACON and Sydney Sexual Health Centre for NSW Ministry of Health). RHT allows clients to receive preliminary results within 30 minutes – more quickly than traditional testing methods.⁷ Although 18 public sexual health clinics incorporated RHT, there was little innovation in exploring new RHT settings for people who did not access traditional models of testing. Community-based RHT is widespread in the US and Europe, and some community (clinic based) and outreach HIV testing has been identified in Australia, but there were no pop-up testing services as of 2013.^8,9 Increasing the convenience of RHT, including in nonclinical settings, is likely to raise awareness of the importance of HIV testing and increase testing within groups at risk.⁷

We describe the activities held during the week before World AIDS Day 2013 − phase one (P1) − and HIV testing week in July 2014 − phase 2 (P2). To encourage services to offer HIV testing in more flexible ways and to raise awareness about rapid testing among MSM, Australia’s first ever pop-up testing site was developed for P1. An alliance of key stakeholders and opinion leaders was formed to enable an integrated approach to the development, acceptability and operational aspects of the service. A NSW Health–branded caravan, staffed by one nurse and two peer educators^9,10 (pop-up site) was installed in east Sydney for five days during P1. This location was chosen because of the concentration of MSM living and socialising in the area. During this period, 503 people engaged with the pop-up site, and 195 people requested a rapid HIV test (none of these people were diagnosed with a new HIV infection). Demand was high, averaging seven tests per hour, compared with four at a local clinic-based RHT service.⁹ Consequently, testing hours were extended. A study concluded that pop-up RHT was feasible and, in this situation, reached high-risk MSM.⁹

The ‘test more’ message was reinforced by a NSW Ministry of Health public relations and social media strategy to generate conversations about RHT in MSM, mainstream and health professional communities.

Keeping testing top of mind

A key process for health promotion practice is the communication of health messages and information. It involves the transfer of messages at both individual and community levels to educate and influence decisions to improve health.¹¹ Strategies include, among others, social marketing (applying commercial marketing techniques to planning, executing and evaluating programs¹²), peer education and public relations.

Experiential techniques, or actively involving people in a message¹³, were used in this initiative to enable the target audience to experience RHT firsthand. Compared with mass media campaigns, experiential events tend to communicate on a more personal level, and may generate a deeper level of emotional engagement through physical immersion in a message or brand. Although experiential learning has been used to train public health practitioners¹⁴, it is of interest that there is little literature relating to experiential approaches to communicating health promotion messages to the public.

The public health strategy used by NSW Health represented a facilitation of ‘concrete experience’¹³, in which the pop-up service was used to both deliver the intervention and promote a public health message.

A welcoming environment was created at the pop-up caravan, and community-based peer workers put people at ease with being tested. The visual impact of the site operated at both the service user and community levels to promote the testing message (Figure 1).

Figure 1.    Pop-up testing caravan in Taylor Square, Sydney (click to enlarge)

To build on the success of this approach, during P2 a similar pop-up testing bus was installed at the same location. The social media campaign used during P1 was amplified to include roving installations or ‘hotspots’ around inner Sydney aimed at encouraging the public to be photographed showing their support for the campaign, and to post their photos via social media using the hashtags #HelpEndHIV and #HIVTestingWeek. Brand ambassadors were used to further enable community ownership during the campaign and participation in the ‘movement’ to end HIV. Local businesses and community organisations also participated in social media activities to provide resonance for the community.

Social media – targeting messages cost-effectively

Social media, including Facebook, YouTube and Twitter, are increasingly being used by the public for health-related issues¹⁵ and have been recognised by the World Health Organization as being particularly useful in public health for facilitating direct communication with the public.¹⁶ Evidence suggests that multimedia campaigns in developed countries can significantly increase HIV testing among MSM, but that further, more rigorous, research is needed.¹⁷

In 2012–13, 81% of households in NSW had internet access¹⁸, suggesting that internet-based applications are essential mechanisms for the promotion of public health messages. Further, internet usage via smart phones grew from 13% of the population in 2010 to 42% in 2013, suggesting that people now have increased opportunity to share public health messages when they experience them.¹⁹

Social media mentions of the hashtags #HelpEndHIV and #HIVTestingWeek were analysed for P2, as well as for the preceding and following week. Peaks in the number of mentions of these hashtags corresponded to activities taking place as part of the social media campaign. During P2, the average number of daily mentions was 56, following a baseline of 6 mentions per day one week earlier.

By analysing the number of people who shared the campaign hashtags, combined with follower numbers, it was possible to estimate the total reach of overall social media dialogue during the three-week period. The estimated total reach was 549 769 people via 459 individual posts (unpublished Buzz Numbers report to NSW Health). However, this is likely to be an underestimate, because of privacy settings on some social media platforms, which occasionally restrict monitoring of reach.

Media engagement

It was essential to engage media (community and mainstream) to facilitate targeted and universal approaches to communicating the health promotion message to test more. Media engagement for the period around P1 and P2 was analysed. During P1, more than 30 mainstream, gay and online media channels published stories about the campaign, including in health and medical publications, with an estimated audience of more than four million people. For P2, there were 53 published stories, with an estimated audience of more than one million people (unpublished report by MediaPortal to NSW Government).

Addressing concerns

The campaign aimed to allay any concerns about the viability, acceptability and rigour of pop-up HIV testing among individuals, clinicians and the broader heath sector. This was addressed by communicating the message across multiple platforms, including traditional and social media as well as industry publications.

Structures and mechanisms set in place by NSW Health to coordinate activities across multiple stakeholders (including the alliance of key stakeholders and opinion leaders) worked to facilitate a common understanding. They also helped to further momentum towards embedding contemporary messaging and service delivery within the health sector.

Conclusion and implications

Recent increases in testing have been evident at the state level. In publicly funded sexual health clinics in NSW, where longer-term trend data are available, there were consistent increases in the number of HIV tests conducted with MSM during the first six months of 2014 (an increase of 29% compared with the average number of tests per quarter in 2013).⁴ Levels of testing vary across NSW, but data suggest that there has been ongoing success in efforts to increase testing, particularly among high-risk groups.⁴ The demonstrated uptake of pop-up testing by people at high risk has since provided momentum for both Northern NSW and Mid North Coast Local Health Districts to establish two pop-up RHT services. This suggests initial engagement of the broader NSW health system with the potential for pop-up RHT.

The use of social media and experiential techniques has extended the reach of the ‘test more’ messages considerably. However, further research is required to determine the level of causality between such techniques and testing rates, particularly in the context of other simultaneous health promotion activities relating to HIV. Further evaluation of the communication of public health messages by NSW Health and the frequency of testing and retesting among groups at high risk is required to ensure ongoing effectiveness.

Leadership from all levels of the NSW Government and support from community groups, peak bodies and other stakeholders provided mobilisation and commitment towards promoting testing in 2014. It is important to use a mix of testing settings (including pop-up RHT) to further increase testing, particularly among MSM, to identify HIV-positive individuals and link them to care, and to reduce the pool of undiagnosed people.

Acknowledgements

This work was completed while NR was a trainee on the NSW Public Health Training Program, funded by the NSW Ministry of Health. He undertook this work while based in the Centre for Population Health, NSW Ministry of Health. The NSW Ministry of Health extends thanks to its partner organisations on this project: ACON, St Vincent’s HIV Reference Laboratory, South Eastern Sydney Local Health District and the Kirkton Road Centre.

Copyright:

© 2015 Roberts et al. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.