Abstract
Background
HIV self-testing (HIVST) offers an opportunity to increase HIV testing among people not reached by facility-based services. However, the promotion of HIVST is limited due to insufficient community engagement. We built a Social Entrepreneurship Model (SET) to promote HIVST linkage to care among Chinese MSM in Guangzhou.
Method
SET model includes a few key steps: Each participant first completed an online survey, and paid a $23 USD (refundable) deposit to get a HIVST kit and a syphilis self-testing (SST) kit. After the testing, the results were sent to the platform by the participants and interpreted by CDC staff. Meanwhile, the deposit was returned to each participant. Finally, the CBO contacted the participants to provide counseling services, confirmation testing and linkage to care.
Result
During April–June of 2015, a total of 198 MSM completed a preliminary survey and purchased self-testing kits. Among them, the majority were aged under 34 (84.4%) and met partners online (93.1%). In addition, 68.9% of participants ever tested for HIV, and 19.5% had ever performed HIVST. Overall, feedback was received from 192 (97.0%) participants. Among these, 14 people did not use kits, and the HIV and syphilis prevalence among these users were of 4.5% (8/178) and 3.7% (6/178), respectively. All of the screened HIV-positive cases sought further confirmation testing and were linked to care.
Conclusion
Using an online SET model to promote HIV and syphilis among Chinese MSM is acceptable and feasible, and this model adds a new testing platform to the current testing service system.
Keywords: Men who have sex with men (MSM), HIV, self-testing, Social-Entrepreneurship
Introduction
As the critical entry point into a cascade of service(1), HIV testing is widely used to monitor and control the epidemic of HIV.(2) However, globally, only 51% of people with HIV know their status.(3) In China, about 50% of men who have sex with men (MSM) have never tested for HIV.(4) This lack of awareness plays a key role in HIV transmission.(5, 6) The main reasons for the levels of sub-optimal HIV testing among MSM include concerns about confidentiality, availability of tests, and the stigma attached to HIV testing. (7–11) As a user-friendly, rapid and accurate approach, HIV self-testing (HIVST) has potential to become an important solution for this dilemma.(12)
HIVST is a process whereby a person who wants to know his/her HIV status collects a specimen (oral swab or blood), performs a test, and interprets the test result in private, which is different from facility-based HIV testing.(13) Facility-based HIV testing was defined as HIV testing conducted in health-care facilities (clinics, hospitals, fixed stand-alone voluntary counselling and testing sites).(14) In China, facility-based HIV testing also include community testing sites that supported by government, as majority of the community testing sites are also voluntary counseling and testing sites of government. This provides an opportunity for people to test themselves discreetly and conveniently.(15) It also extends testing to people who are not currently reachable by existing HIV testing and counseling services, especially MSM who are unwilling to take part in facility-based HIV testing with information about their HIV status. Modeling studies have also shown that HIVST could increase the rate of HIV testing, and thereby the levels of confirmatory testing and linkage to care.(16)
Even as HIVST becomes more and more popular, its implementation is still limited by insufficient community engagement and poor promotion. For example, in China, HIVST kits are mainly distributed through online stores, which are organized entirely by private companies with poor HIVST counseling and insufficient attention to linkage.(17) To address these issues, a government-led model that not only promotes HIVST but also HIVST-associated counseling and linkage care is urgently needed. With these goals, we built a social-entrepreneurship HIVST (SET) model. Social entrepreneurship uses entrepreneurial principles to promote the sustainable and innovative use of human, fiscal, and technological resources for social good.(18) Guangzhou provides a unique opportunity to conduct this study. First, the HIV prevalence among MSM in Guangzhou is very high and still increasing, while HIV testing rate is still low.(19, 20) Second, Guangzhou is one of the very first cities that promote HIVST in China, and several different models has been tried. Third, Guangzhou has one of the largest community based organizations (Guangzhou Tongzhi/Linnan Community service center) in China, and this organization has about 10 years of experience on providing friendly service to MSM in Guangzhou, which can reduce stigma and promote confidentiality.(21)
The objectives of this study were to evaluate the acceptability and feasibility of this model in promotes HIV testing and linkage to care among Chinese MSM.
Methods
SET model development
To promote HIV testing among Chinese MSM, we collaborated with a local CBO (Guangzhou Tongzhi, GZTZ) to build an online platform-SET model (http://lingnan.gztz.org/A). This model included the following key steps: First, participants were recruited to complete an online survey using a banner link on the GZTZ (www.gztz.org) web portal page. They were then directed to eligibility screening and consent. Participants needed to be males 18 years or older residing in Guangzhou, and have engaged in anal sex with a man in their lifetime. They must also have been willing to provide a cell phone number and address for shipping the self-testing kits and to sign the informed consent form. Second, after finishing the survey, eligible participants then paid a $23 USD (refundable) deposit in exchange for a HIVST kit and a syphilis self-testing (SST) kit. In addition, each of them also completed an electronic shipping form, which included name, address and phone number. Third, the self-testing packages, which included an HIVST, a SST, a self-destruct safety blood taking needle, a disinfection package and instructions on how to perform self-testing, were shipped to the address provided by the participants. Fourth, after receiving the testing kits and performing self-testing, the participants took pictures of the kits showing the testing results, and sent it back to us through the GZTZ web portal. Fifth, the staff of the Guangzhou CDC then interpreted the results and gave feedback to the participants. Meanwhile, the participants applied for the return of the deposit, and the deposit was then refunded afterward. Finally, GZTZ contacted individuals testing positive for HIV or syphilis to provide counseling services, confirmation testing and linkage to care. For those participants testing negative, a follow-up message was sent to each of them reminding them to do routine HIV testing (figure 1).
Figure 1.
If participants did not report their results to the group within four weeks after the testing packages were shipped, a follow up call was made to each of them to determine why they had not reported back. If the participants reported that they have not used the kits, the detailed reasons of not use were recorded.
Measures
Socio-demographic information collected included age, marital status, living situation, occupation, education, and income. Participants were asked about their sexual orientation as well as their preferred sexual role during anal sex, number of sexual partners in the last six months, and condomless anal intercourse with regular and casual male partners in the last six months and during the last intercourse. They were also asked about condomless sex with female partners, participation in group sex and commercial sex.
Participants were also asked whether they had ever tested for HIV (yes/no), frequency of HIV testing (every three months, every six months, every year or other) and why they had chosen to undergo HIV testing. If participants reported any HIV testing history, they were further asked about HIVST history (yes/no), source of HIVST kits (online, from friends, pharmacy or others) and reasons for performing HIVST. In addition, we also obtained information regarding where participants would conduct HIVST, who would be present while they tested, whether they would seek confirmation testing, with what frequency they would be willing to complete HIVST, and potential barriers for HIVST.
HIV and syphilis self-testing
Finger prick blood samples were collected by each participant for the HIV and syphilis rapid testing. The rapid test kits that were used in our study included Colloidal Gold Device Rapid Test for Antibody to Human Immunodeficiency Virus (Beijing Wantai Biological Pharmacy Enterprise Co. Ltd., Beijing, China) and Colloidal Gold Device Rapid Test for Antibody to syphilis (Beijing Wantai Biological Pharmacy Enterprise Co. Ltd., Beijing, China). All participants screening positive for HIV or syphilis were encouraged to undergo confirmation testing at either local CDC or Lingnan Partner Community Support Centre. For those participants confirmed to be HIV positive after confirmation testing, CD4+ T-cell counts were also measured using FACSCalibur flow cytometer (BD-Bioscience, San Jose, CA, USA) based on a single-platform lyse-no-wash procedure using TruCOUNT tubes and TriTEST anti-CD4-FITC-CD8-PE-CD3-PerCP-reagents (BD,USA).
Statistical Analysis
Using responses from participants who purchased self-testing kits, descriptive analysis was performed to describe the socio-demographics, risk behaviors, willingness to complete HIVST, barriers and facilitators of HIVST.
Univariate and multivariate logistic regressions were used to compare people who did and did not apply for self-testing kits after finishing the online survey. The multivariate logistic regression models were adjusted for demographic characteristics including age (continuous), marital status, education and monthly income. Data analysis was completed using SAS version 9.3 (SAS Int. Cary, NC, USA).
Ethical Statement
Ethics review committees in Guangzhou Center for Disease Prevention and Control reviewed and approved the study prior to the launch.
Results
Study participants
Overall, the study banner link was clicked 738 times. From these, 222 withdrew from the survey prior to completing the consent form. Of the remaining 516 clicks, 21 did not meet eligibility requirements and 115 did not finish the online survey. Among the 380 participants who completed the online survey, a total of 198 persons bought the self-testing kits.
Demographic and behaviors of the participants
More than half of the people who finished the online survey were between 25 and 34 years old (54.2%) and had a monthly income of around 800 USD or less. In addition, the majority of participants were never married (88.7%) and had a college degree or higher (85.2%). Further information on demographic data can be found in Table 1.
Table 1.
Demographic characteristics and behaviors of the MSM who finished the online survey, and variables associated with final purchasing self-testing kits among MSM who are willing to perform HIVST in China, 2015(N=380)
| Variables | Total (N=380) | Purchased kits (n=198) | Not purchased kits (n=182) | Crude Model | Adjusted Model* | ||||
|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||
| Frequency | Percent | Frequency | Percent | Frequency | Percent | OR (95%CI) | OR (95%CI) | ||
| Age | Less than 25 | 111 | 29.2 | 54 | 27.3 | 57 | 31.3 | ||
| 25–34 | 206 | 54.2 | 113 | 57.1 | 93 | 51.1 | |||
| 35 and above | 63 | 16.6 | 31 | 15.7 | 32 | 17.6 | |||
| Marital status | Ever married | 43 | 11.3 | 16 | 8.1 | 27 | 14.8 | ||
| Never Married | 337 | 88.7 | 182 | 91.9 | 155 | 85.2 | |||
| Education | Senior high school or below | 56 | 14.8 | 22 | 11 | 34 | 18.7 | ||
| College/Bachelor | 273 | 71.8 | 152 | 76.8 | 121 | 66.5 | |||
| Masters or PhD | 51 | 13.4 | 24 | 12.2 | 27 | 14.8 | |||
| Monthly income | 300 USD or below | 79 | 20.8 | 37 | 18.7 | 42 | 23.1 | ||
| 301–800 USD | 125 | 32.9 | 62 | 31.3 | 63 | 34.6 | |||
| 801–1500 USD | 102 | 26.8 | 56 | 28.3 | 46 | 25.3 | |||
| Above 1500 USD | 74 | 19.5 | 43 | 21.7 | 31 | 17 | |||
| Venue | Internet | 350 | 92.1 | 186 | 94 | 164 | 90.1 | 1.70(0.80,3.64) | 1.53(0.69,3.42) |
| Others | 30 | 7.9 | 12 | 6.1 | 18 | 9.9 | Ref | Ref | |
| Sexual orientation | Homosexual | 298 | 78.4 | 158 | 79.8 | 140 | 76.9 | 1.19(0.73,1.93) | 1.17(0.70,1.93) |
| Bisexual | 82 | 21.6 | 40 | 20.2 | 42 | 23.1 | Ref | Ref | |
| Sexual role | Insertive | 113 | 29.7 | 57 | 28.8 | 56 | 30.8 | 0.91(0.57,1.47) | 0.89(0.54,1.46) |
| Acceptive | 100 | 26.3 | 53 | 26.8 | 47 | 25.8 | 1.01(0.62,1.67) | 0.95(0.57,1.59) | |
| No preference | 167 | 43.9 | 88 | 44.4 | 79 | 43.4 | Ref | Ref | |
| Engaged in anal sex with men in last 6 months | Yes | 310 | 81.6 | 164 | 82.8 | 146 | 80.2 | 1.19(0.71,2.00) | 1.18(0.69,2.02) |
| No | 70 | 18.4 | 34 | 17.2 | 36 | 19.8 | Ref | Ref | |
| Number of partners in the last six months | 0 | 70 | 18.4 | 34 | 17.2 | 36 | 19.8 | Ref | Ref |
| 1 | 91 | 24 | 41 | 20.7 | 50 | 27.5 | 0.87(0.47,1.62) | 0.80(0.42,1.53) | |
| 2 to 5 | 175 | 46.1 | 93 | 47 | 82 | 45.1 | 1.20(0.69,2.09) | 1.22(0.68,2.18) | |
| Above 5 | 44 | 11.6 | 30 | 15.2 | 14 | 7.7 | 2.27(1.03,4.99)# | 2.49(1.08,5.71)# | |
| Engaged in CAI in the last six months | Yes | 150 | 39.5 | 72 | 36.4 | 78 | 42.8 | 0.76(0.50,1.15) | 0.77(0.50,1.18) |
| No | 230 | 60.5 | 126 | 63.6 | 104 | 57.2 | Ref | Ref | |
| Used condom during last anal intercourse | Yes | 227 | 73.2 | 123 | 75 | 104 | 71.2 | 1.21(0.73,2.00) | 1.19(0.70,2.03) |
| No | 83 | 26.8 | 41 | 25 | 42 | 28.8 | Ref | Ref | |
| Have a regular partner in the last six months | Yes | 203 | 53.4 | 104 | 52.5 | 99 | 54.4 | 0.93(0.62,1.39) | 0.96(0.63,1.45) |
| No | 177 | 46.6 | 94 | 47.5 | 83 | 45.6 | Ref | Ref | |
| Engaged in CAI with regular partner in the last six months | Yes | 100 | 26.3 | 50 | 25.3 | 50 | 27.5 | 0.89(0.57,1.41) | 0.91(0.57,1.47) |
| No | 280 | 73.7 | 148 | 74.7 | 132 | 72.5 | Ref | Ref | |
| Number of casual partners in the last six months | 0 | 194 | 51.1 | 95 | 48 | 99 | 54.4 | Ref | Ref |
| 1 | 65 | 17..1 | 30 | 15.1 | 35 | 19.2 | 0.89(0.51,1.57) | 1.00(0.55,1.81) | |
| 2 or above | 121 | 31.8 | 73 | 36.9 | 48 | 26.4 | 1.59(1.00,2.51) | 1.59(0.99,2.57) | |
| Engaged in CAI with casual partner in the last six months | Yes | 84 | 22.1 | 39 | 19.7 | 45 | 24.7 | 0.75(0.46,1.21) | 0.82(0.49,1.37) |
| No | 296 | 77.9 | 159 | 80.3 | 137 | 75.3 | Ref | Ref | |
| Engaged in commercial sex with men in the last six months | Yes | 53 | 13.9 | 27 | 13.6 | 26 | 14.3 | 0.95(0.53,1.69) | 1.02(0.55,1.88) |
| No | 327 | 86.1 | 171 | 83.4 | 156 | 85.7 | Ref | Ref | |
| Engaged in group sex in the last six months | Yes | 24 | 6.3 | 12 | 6.1 | 12 | 6.6 | 0.91(0.40,2.09) | 1.03(0.43,2.45) |
| No | 356 | 93.7 | 186 | 93.9 | 170 | 93.4 | Ref | Ref | |
| Engaged in sex with women in last six months | Yes | 34 | 8.9 | 13 | 6.6 | 21 | 11.5 | 0.54(0.26,1.11) | 0.61(0.28,1.31) |
| No | 346 | 91.1 | 185 | 93.4 | 161 | 88.5 | Ref | Ref | |
| Engaged in condomless virginal sex with women in the last six months | Yes | 17 | 4.5 | 7 | 3.5 | 10 | 5.5 | 0.63(0.24,1.69 | 0.72(0.25,2.03) |
| No | 363 | 95.5 | 191 | 96.5 | 172 | 94.5 | Ref | Ref | |
| Ever tested for HIV | Yes | 262 | 68.9 | 143 | 72.2 | 119 | 65.4 | 1.38(0.89,2.13) | 1.24(0.79,1.97) |
| No | 118 | 31.1 | 55 | 27.8 | 63 | 34.6 | |||
| Ever performed HIV self-testing | Yes | 74 | 19.5 | 40 | 20.2 | 34 | 18.7 | 1.10 (0.66, 1.83) | 1.01 (0.60, 1.72) |
| No | 306 | 80.5 | 158 | 79.8 | 148 | 81.3 | Ref | Ref | |
| HIV testing frequency | Every 3 months or short | 48 | 18.3 | 26 | 18.2 | 22 | 18.5 | Ref | Ref |
| Every 6months | 70 | 26.7 | 37 | 25.9 | 33 | 27.7 | 0.95(0.45,1.98) | 0.97(0.45,2.11) | |
| Every year | 25 | 9.5 | 15 | 10.5 | 10 | 8.4 | 1.27(0.48,3.39) | 1.19(0.43,3.30) | |
| No regular frequency | 119 | 45.4 | 65 | 45.5 | 54 | 45.4 | 1.02(0.52,2.00) | 1.16(0.58,2.35) | |
Note:
Model adjusted for age, marital status, education and monthly income;
P<0.05
The majority of the participants found partners through Internet (92.1%), self-identified as homosexual (78.4%), and had engaged in anal sex with men in the last six months (81.6%). In addition, 57.6% of the participants reported that they had two or more partners in the last six months, and 39.5% of the participants had engaged in condomless anal intercourse in the last six months. The proportion of participants who had engaged in condomless anal intercourse in the last six months with regular and casual partners was 26.3% and 22.1%, respectively. In addition, 13.9% of the participants engaged in commercial sex in the last 12 months, 6.3% engaged in group sex in the last 12 months, 8.9% engaged in sex with women in the last six months, 68.9% had ever tested for HIV and 19.5% had ever performed HIVST. Further information on behavioral data can also be found in Table 1.
Among the 198 MSM who purchased HIVST kits, 72.2% (143) of them ever tested for HIV before, and 62.1% (123) of them ever tested at facility based sites. Overall, self-testing successfully reached about two-fifths (37.9%) of MSM not reached by facility based HIV testing.
Testing results and linkage to care
From those who purchased the kits, feedback was received from 192 (97.0%) participants. Among these, 178 (92.7%) of them had performed HIV and syphilis self-testing within four weeks after purchased the kits online (Figure 1). Reasons for not using the kits included: forgetting to use the kit, (n=7), having been tested for HIV recently through other ways (n=3), intent to use the kits later (n=3), and fear of the finger prick (n=1).
Of the 178 people who performed self-testing, HIV and syphilis positive results were reported by eight and six people, with HIV and syphilis prevalence of 4.5% (8/178) and 3.7% (6/178), respectively.
All of the screened HIV positive case sought further confirmation testing at either GZTZ (5 cases) or volunteer counseling testing sites of local CDC (3 cases). Among the eight cases, seven were newly identified HIV positive cases, while another one was identified three years ago. Of those eight cases, one case was syphilis positive. All the newly identified self-tested positive cases were confirmed to be HIV-positive, and they were linked to care and got their first CD4 count testing. CD4 counts were available from seven out of the eight cases from the case report system database of Guangzhou. The CD4 counts for the seven cases were: 37 cells/mm3, 285 cells/mm3, 340 cells/mm3, 387 cells/mm3, 489 cells/mm3, 797 cells/mm3, and 872 cells/mm3, respectively. All the six syphilis-positive cases were encouraged to undergo further confirmation testing at either local CDCs or hospitals.
Comparison between those purchased the self-testing kits and not
Table 1 gives the demographic and behavior data of participants who did and did not purchase the self-testing kits. The two groups are comparable except that participants reporting more sexual partners in the last six months were more likely to purchase the kits. The univariate and multivariate regression analysis further confirmed this finding. After adjusting for age, marital status, education and monthly income, participants with more than 5 partners in the last six months were more likely to purchase the kits than compared to participants reporting no partners in the last six months (adjusted OR=2.49, 95% CI: 1.08–5.71). A similar result was found comparing the same population to participants with two or more casual partners in the last six months, with adjusted OR of 1.59 (95% CI: 0.99–2.57) (Table 1).
Willingness of HIVST
The primary reason for choosing HIVST was convenience and to save time (46.3%), followed by protection of privacy (40.0%), ease of use (6.3%) and accuracy (5.8%). The top two places where participants would be willing to obtain the self-testing kits were online stores (71.6%) and pharmacies (35.3%). The majority of the participants purchased the kit for themselves (90.8), wanted to use the kits at home (95.0%), alone (72.1%) and thought blood sample collection was convenient (56.3%). Only 7.6% of the buyers reported that they would not seek counseling after HIVST, and 66.8% people reported that they would use HIVST in the future, if it was free (Table 2).
Table 2.
Self-testing features of the MSM who are willing to perform HIVST in China, 2015(N=380)
| Variable | Frequency | Percent |
|---|---|---|
| The main reason for choosing self-testing | ||
| Convenience, saving time | 176 | 46.3 |
| Similar accuracy as onsite testing | 22 | 5.8 |
| Can protect privacy | 152 | 40.0 |
| Easy to use | 24 | 6.3 |
| Others | 6 | 1.6 |
| Where would you want to get the self-testing kits? | ||
| Online store | 272 | 71.6 |
| Pharmacy | 134 | 35.3 |
| Hospital/clinics | 119 | 31.3 |
| Supermarket | 63 | 16.6 |
| Vander machine | 123 | 32.4 |
| Sex shop | 38 | 10.0 |
| Where will you use the self-testing kits? | ||
| Home | 361 | 95.0 |
| Others | 19 | 5.0 |
| Who will be with you when you use the self-testing kits? | ||
| Alone | 274 | 72.1 |
| With male partner | 106 | 27.9 |
| Do you think it is convenient to collect blood samples? | ||
| Yes | 237 | 62.4 |
| No | 36 | 9.5 |
| Not sure | 49 | 24.8 |
| Who will be tested for by this HIVST kit? | ||
| Myself | 345 | 90.8 |
| Regular male partner | 24 | 6.3 |
| Casual male partner | 2 | 0.5 |
| Friends | 9 | 2.4 |
| Which method would you prefer to use for blood sample collection? | ||
| Figure stick | 214 | 56.3 |
| Venous blood | 22 | 5.8 |
| Oral fluid | 144 | 37.8 |
| Do you think the accuracy for blood testing is higher than oral testing? | ||
| Yes | 290 | 76.3 |
| No, similar | 22 | 5.8 |
| Not sure | 68 | 17.9 |
| Would you seek confirmation testing after self-testing? | ||
| Yes | 139 | 36.6 |
| No | 131 | 34.5 |
| Not sure | 110 | 29.0 |
| Would you seek counseling after HIVST? | ||
| Yes | 227 | 59.7 |
| No | 29 | 7.6 |
| Not sure, will be based on the testing results | 124 | 32.6 |
| If HIVST is free, which method would you like to use in the future? | ||
| HIVST | 254 | 66.8 |
| Facility based testing | 24 | 6.3 |
| Either way | 90 | 23.7 |
| Not sure | 12 | 3.2 |
Facilitators and barriers for HIVST
The top five self-reported facilitators for HIVST among people who purchased the kits included anonymity (55.8%), ease of use (49.0%), ability to test alone (40.8%)saving time (37.1%), and good confidentiality (35.8%). Meanwhile, the top five self-reported barriers for HIVST among the people who purchased the kits included concern about the accuracy of the test (42.9%), potential cost (40.3%), concern about self-interpreting results (36.3%), fear of self-collecting samples (27.1%) and worry about loss of privacy (26.8%) (Table 3).
Table 3.
Self-reported Facilitators and barriers of HIVST for MSM who are willing to perform HIVST in China, 2015(N=380)
| Facilitators of HIVST | Barriers of HIVST | ||||
|---|---|---|---|---|---|
|
| |||||
|
Variables
|
Frequency | Percent | Variables | Frequency | Percent |
| Anonymity | 212 | 55.8 | Worry about the testing accuracy | 163 | 42.9 |
| Ease of use | 186 | 49.0 | Cost | 153 | 40.3 |
| Can test alone | 155 | 40.8 | Worry about self-interpreting results | 138 | 36.3 |
| Saving time | 141 | 37.1 | Afraid to self-collect samples | 103 | 27.1 |
| Good confidentiality | 136 | 35.8 | Worry about the loss of privacy | 102 | 26.8 |
| Low cost | 132 | 34.7 | Not familiar with the testing method | 100 | 26.3 |
| Do not need to face testing staff | 111 | 29.2 | Need to return the results | 46 | 12.1 |
| Do not worry about meet acquaintances | 69 | 18.2 | Afraid to face the results alone | 44 | 11.6 |
| Easy to get | 57 | 15.0 | Still need to do the conformation test | 38 | 10.0 |
| Partners are infected | 41 | 10.8 | Anxiety while waiting the self-testing results | 36 | 9.5 |
| Do not need counseling after testing | 19 | 5.0 | Afraid to face stigma if the testing result is positive | 29 | 7.6 |
Discussion
Our piloted study model successfully promoted HIVST among 178 MSM within three months in Guangdong, China. We found that a SET model is acceptable and feasible for promotion of HIV self-testing among MSM, and it adds a new useful platform to the current testing service system which could promote case identification and linkage to care. Promoting HIV testing among key populations is a major global health priority(22), and innovative HIV testing methods, including HIVST models, are urgently needed.(10, 23) Our study builds on previous research promoting HIVST among key populations by creating an inventive HIVST model, evaluating its acceptability and feasibility, reporting linkage to care results and answering concerns of HIVST (on linkage to care and counseling) raised by other researchers. Our study expands the limited literature on HIVST(24–26) and suggests that SET model could promote HIVST, return of testing results and linkage to care.
In our study, over 97% people reported the testing results back to the group, and all of the eight self-tested and confirmed HIV positive cases were linked to care. These high rates highlight the feasibility of the SET model. In addition, it disproved the concern that participants would avoid seeking healthcare if the result were positive(26),(27). Furthermore, the SET model provided evidence that using mobile health technologies to track self-testing and linkage to care is feasible, in response to the recommendations raised by Mavedzenge et al(26).
Our study indicated that about half of the people who completed the online survey and stated willingness to buy the kits did not purchase the kits. The reasons for refusal are unclear: the participants who did and did not purchase kits are comparable, except that the purchasers reported more partners. One potential explanation is the complicated process of the SET model, as steps include: giving informed consent, completing an online survey, making a deposit, applying for a kit, providing an address and phone number, self-testing, reporting results, applying for and receiving the refund. This long process may have reduced the enthusiasm of some of the participants. Another potential explanation is that participants needed to pay the deposit online, and some of them may have had no online payment experience. Culturally, there is a mistrust of online payment in China which may have worsened this scenario. Finally, the requirement of reporting the testing results to get the refund back could be another important reason. Further qualitative studies are needed, in order to explore and confirm these potential explanations, as well as to improve the acceptability of SET model.
Worry about the testing accuracy, worry about interpreting the results, and cost are the top three concerns of the participants. Ease of use, anonymity and saving time are the top three facilitators for HIVST. These findings are consistent with previous studies focusing on the acceptability of HIVST. (26) To reduce these barriers, our SET model included the most widely used HIV rapid testing kits in China, which have very good testing accuracy and are recommended by the China CDC. In addition, we provided very detailed testing instructions to the participants, and asked them to send the pictures back to allow the group to interpret the results. Though we asked the participants to deposit $23 USD when purchasing the kits, all deposits were refunded after receiving the testing results from the participants.
Our study has several limitations. First, the sample size of our study is small; only 380 people finished the online survey, and of these only 198 people purchased the kits. We will continue the project and further expand HIVST among MSM. We will also evaluate the impact of this project on overall HIV testing uptake and HIV transmission among MSM in Guangzhou, China through modeling. Second, we only asked that participants return the testing kits to us, but did not collect information during the follow-up period on user experience when using the kits. This may limit our ability to further improve the service of this SET model. Third, even though our study had an extremely high return/feedback rate, six people were still lost to follow up, which may have caused a self-selection bias for HIV epidemic evaluation among testers. Fourth, 115 people who met the inclusion criteria drop-out from the study before the online survey, and the demographic characteristics of these people may different from those finished the online survey, which may induce selection bias. One potential reason for this drop out is that these drop-outers may only want to get HIVST, but do not willing to fill the questionnaires. For implementation purpose, and to further promote HIVST, we may need to simplify the process and move online survey. Finally, since the online survey targeted people willing to take HIVST, we cannot determine what types of populations are less likely to test through our SET model.
Our results suggest that using the SET model to promote HIV testing using HIVST and linkage to care among Chinese MSM is feasible and acceptable. This new tool may be especially useful in low and middle-income countries where community organizations are very involved in HIV prevention, and where internet access is good. We anticipate that in an era of universal testing and treatment, such an innovative model will be one component of a comprehensive HIV intervention package.
Supplementary Material
Summary.
We built and evaluated a Social Entrepreneurship Model (SET) to promote HIVST linkage to care among Chinese MSM in Guangzhou. This model is acceptable and feasible, and it adds a new testing platform to the current testing service system.
Acknowledgments
The authors acknowledge the participants who participated in this study and staff members of Linnan Partner Service Center in Guangzhou. This study was supported by National Institutes of Health (NIAID 1R01AI114310, FIC 1D43TW009532), UNC Center for AIDS Research (National Institute of Allergy and Infectious Diseases 5P30AI050410), and NIH Fogarty International Center (5R25TW009340).
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