Strategies to Increase Human Immunodeficiency Virus Testing Among Men to Reach UNAIDS 90-90-90 Targets

To the Editor—We appreciated the review by Nachega et al [1] on the progress, challenges, and opportunities to achieve the viral suppression target of the Joint United Nations Program on human immunodeficiency virus (HIV)/AIDS (UNAIDS) in low- and middle-income counties (LMICs). Although viral suppression of HIV among those who are HIV infected is necessary to meet UNAIDS targets, those targets will not succeed without increasing HIV testing among men and linking HIV-infected men with healthcare [2].

Consider South Africa, the country that has the largest HIV epidemic in the world, as a case study. A recent study from KwaZulu-Natal, one of the providences in South Africa most heavily affected by HIV, estimated that only 52% of HIV-infected men knew their status, whereas 65% of HIV-infected women knew their status, [3]. Those findings of worse HIV testing rates among men echo what has been observed in many other LMICs [2, 4]. Furthermore, men have worse antiretroviral therapy uptake and health outcomes after antiretroviral therapy initiation than women [5]. To reach UNAIDS 90-90-90 targets, testing among men needs to be improved.

Currently, South African National HIV testing programs, which link HIV-infected persons to care, commonly focus on key populations, including pregnant women [5]. South African guidelines aim to increase community-based testing in men because men are less likely than women to use clinical health services [5]. However, that testing strategy does not address the underlying barrier to HIV testing among men—stigma.

Stigma, due to concerns of prejudice and discrimination, remains a critical barrier to healthcare engagement and HIV testing among South African men [6]. A study from KwaZulu-Natal, South Africa found that cultural views of masculinity and the fear of knowing their HIV status contribute to men’s reluctance to undergo testing [7]. In addition, men reported feeling that primary health centers, which are generally staffed by female nurses, were not welcoming [7].

Among HIV testing interventions conducted in LMICs in sub-Saharan Africa, most interventions tried to reach men through women [8]. That approach must be changed to address HIV-related stigma among men. Evidence-based strategies were developed to increase HIV testing and decrease HIV-related stigma in other key populations (Table 1). Those strategies need to be adapted for South African men. Three main strategies need to be implemented: (1) “men-oriented” clinical health services, (2) widely offered and available HIV testing, and (3) home-based, HIV self-testing kits distributed in venues that men frequent. Targeted community-level education campaigns are also needed for men.

Table 1.

Evidence-Based Strategies Implemented in Key Populations and Other Epidemics That Could Be Adapted to Increase Human Immunodeficiency Virus Testing Among Men in Low- and Middle-Income Counties

Problem	Solutions
Men do not feel welcome at primary care centers	Create “men-oriented” primary care centers that offer free HIV and sexually transmitted infections services staffed by men for men [9].
Stigma connected to HIV testing	Normalize HIV testing: require that HIV testing is made available and offered to newly married couples, government document and license applicants, prisoners, new employees, those opening bank accounts, those receiving a cellular phone SIM card, those entering military service, those entering government work, those entering government training programs, and those entering educational institutions [10, 11].
HIV testing is primarily conducted in government facilities	Distribute home-based HIV self-tests kits in venues that men frequent (eg, shebeens, churches, bars, clubs, sports facilities) [12, 13].

Abbreviations: HIV, human immunodeficiency virus; SIM, subscriber identity module.

Although HIV testing and treatment has increased among South Africans, men are being left behind with the current HIV testing approach, similar to the situation in other LMICs. We hope that our proposed evidence-based strategies can be adapted for men and reduce HIV-related stigma. Better engagement and increased HIV testing among men is needed to reach the UNAIDS 90-90-90 targets and end the HIV epidemic.

Notes

Acknowledgments. J. D. K. was the US Centers for Disease Control and Prevention Branch Chief for HIV and TB, South Africa, from 2009 to 2011

Disclaimer. No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH) or the University of California Global Health Institute.

Financial support. This work was supported by the Fogarty International Center, NIH and the University of California Global Health Institute Training Program (grant D43TW009343 to N. K.); the NIH (grant P30MH058107 to the Center for HIV Identification, Prevention, and Treatment Services); and the National Institute of Allergy and Infectious Diseases (grant AI028697 to the UCLA Center for AIDS Research).

Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.