Zhang, Ci, et al. "Facilitators and Barriers of HIV Self-Testing Among Chinese Men Who Have Sex With Men: A Qualitative Study." The Journal of the Association of Nurses in AIDS Care: JANAC (2020).
Abstract
HIV self-testing (HIVST) could increase HIV testing. However, HIVST uptake rate among Chinese men who have sex with men (MSM) is low. We conducted qualitative interviews with 23 MSM, 4 workers from community-based organizations, and 7 officials from both provincial Centers for Disease Control and Prevention and affiliated city-level Centers for Disease Control and Preventions to explore facilitators and barriers of HIVST among Chinese MSM. Eight barriers were identified, including fear of being duped by a fake test, concern for cost, fear of disclosing sexual orientation, limited access, lack of consulting services, biosafety concerns, lack of policy support, and concern for lost opportunities to link men to care. Five facilitators were identified, including convenience, confidentiality, easy operation, partner HIV testing, and peers' influence. Officials and scholars should urgently address structural barriers and provide accessible, affordable, and high-quality HIVST services that are accompanied by counseling to develop culturally appropriate HIVST guidelines.
Discussion
Our study is one of very few that have qualitatively explored the facilitators and barriers to use of HIVST among Chinese MSM. Based on the analyses of data from interviews with MSM, CBO workers, and CDC staff, our results provide insight into the factors that influenced our sample’s uptake of HIVST at various levels, including the health care system, interpersonal, and individual levels. Multidimensional understanding of usage experience of HIVST provides evidence to Chinese policy makers to increase HIV testing and achieve the first goal of the “90-90-90” global target.
Our findings expand the common barriers summarized in a systematic review (Bernard et al., 2019) by demonstrating the importance of structural barriers related to limited accessibility of kits and biosafety concerns about HIVST that deter the promotion of HIVST in China. Strategies to increase accessibility of HIVST kits were pilot tested in China, including delivering kits in vending machines (Du, 2018), selling kits in pilot pharmacies (Wu, 2017), and providing kits in gayfriendly CBOs (Zuoan gay-friendly community organization, 2020); however, these approaches have not been scaled up in China. The HIVST kits sold online currently are mainly rapid HIV kits, which are targeted at professionals’ use instead of general people’s use. There was only one type of urine-based HIVST kit approved by the Chinese government in October, 2019 (Ministry of Science and Technology of the People’s Republic of China, 2019). At the same time, the Chinese government issued a step-by-step instruction manual designed for the general population and specific to urine-based HIVST kits (Chinese Center for Disease Control and Prevention and STD/AIDS Prevention and Control Center, 2019); however, this was not user friendly because the popular types of HIVST kits used by MSM are oral-based and blood-based kits. Thus, policy support is urgently needed to issue guidelines on implementing oral-based or blood-based HIVST kits, which should be approved by the China FDA and delivered with rigid market supervision to ensure the quality of HIVST kits.
In addition, our results are consistent with earlier reports on barriers to HIVST, including cost concerns, fear of being duped by a fake test, concerns for accuracy or sensitivity, lack of consulting services, and concern for lost opportunities to link men to care (Bernard et al., 2019; Frye et al., 2015). Income might impact the cost expectation of HIVST kits (Jennings et al., 2017), which should be taken into account for policy makers when promoting HIVST. Information dissemination on the reliability of HIVST might enhance trust on the accuracy and sensitivity of HIVST kits (Rooyen et al., 2015). How to integrate consulting services into HIVST implementation and how to link men who have positive HIVST results to care should be explored in further researches.
Research findings indicate that HIVST has the potential to reduce gay-related and HIV-related stigma and discrimination, which are experienced by many MSM when seeking facility-based HIV testing services (Bernard et al., 2019). However, our study showed that gay-related and HIV-related stigma could also be a barrier for married MSM or those living in dormitories because it was difficult for them to receive the delivered package and perform the test in a private room. The prominent Chinese culture characteristic is “family centered,” and most MSM have to get married to women in their lifetimes. Currently, investigations show that 48.9% of single MSM intend to get married to women because of pressure from family and society (Wu et al., 2019). Most married MSM feared facing a marriage breakdown, verbal insults, and stigma from their spouses and family after disclosing their sexual orientation (Zhang et al., 2008).
In addition to the common facilitators of perceiving the benefit of confidentiality, convenience, and the easy operation of HIVST reported in the literature (Du, 2018; Lila, Abby, Rebecca, & John, 2019; Wu, 2017), partner HIV testing and peers’ recommendations were found to be essential facilitators to HIVST uptake in our study. Another study among Chinese MSM similarly reported finding that peer’s influence could promote HIV testing in facility-based testing services (Liu et al., 2015). Advocating partner HIV testing has the great potential for promoting HIVST globally. Previous literature showed that 79–91% of MSM were willing and found it acceptable to deliver kits to their partners (Sharma et al., 2017). Findings from a previous randomized controlled trial indicated that distribution of HIVST kits from antenatal and postpartum women to their sexual partners was a feasible strategy (Sharma et al., 2017).