“Just felt so convenient and warm by the non-profit help.” Optimizing HIV self-test secondary distribution among men who have sex with men in China

Abstract

Secondary distribution of HIV self-test is promising to increase testing uptake while the facilitators and barriers of secondary distribution remain unclear. In-depth interviews were conducted with 22 MSM who had participated in secondary distribution of HIVST in southern China. Data were thematically analyzed to capture participants’ motivations, procedures, and challenges when accessing and distributing self-tests. MSM in China are willing to distribute HIVST to members in their social network, but their decision-making is impacted by their ability to broach sexual health conversations, evaluations of the recipients, and perceived trustworthiness of the self-test. Our study suggested that several strategies, including creating a friendly environment for sexual health conversations and establishing nationwide policies related to quality assured self-tests and standardized self-testing protocols, may be helpful to advance this approach in China.

Introduction

Awareness of HIV serostatus is crucial to meet the UNAIDS “95–95-95” targets by 2030.(UNAIDS, 2014) HIV self-testing can facilitate testing behaviors among key populations in both high- and low-income settings and is recommended by the World Health Organization. (Rosengren et al., 2016; Qin et al., 2017) Secondary distribution of HIV self-testing, whereby a group of people (indexes) are offered and encouraged to distribute HIVST kits to members of their social network (alters), is feasible and effective to overcome barriers for at-risk populations to access testing and diagnose new infections. (Thirumurthy et al., 2016; Okoboi et al., 2020) However, given the potential adverse events and ow rates of linkage to care usually associated with secondary distribution of HIVST, (Rael et al., 2020) implementation research is needed to understand how this approach can be advanced.

China provides an ideal setting to examine HIVST secondary distribution among key populations. There is a surge of self-testing use among men who have sex with men, as MSM are willing to take HIVST regardless of whether they had prior experience of facility-based testing. (UNAIDS, 2018; Qin et al., 2016) In one pilot study in southern China, 331 MSM accessed HIVST and 116 (31.3%) distributed at least one HIVST kit to their social contacts, suggesting secondary distribution could promote testing uptake and case identification. (Wu et al., 2020) However, what drove testers to access self-tests remained unclear, and more research is needed to understand how to enhance the number of kits distributed and increase test uptake.

This qualitative study aimed to examine motivations to access HIVST, facilitators and barriers shaping distribution decisions, and distribution procedures among MSM in order to advance secondary distribution of HIVST among MSM in China.

Methods

Participants in two secondary distribution pilot studies in China were recruited for this qualitative investigation. The two pilots similarly provided free HIV self-testing kits to participants and encouraged them to distribute HIVST to members in their social network (Fig. 1). Participants in both studies were 18 years old or older, born biologically male, ever had sex with another man, and were willing to provide a phone number.

Figure 1.

HIVST application procedures and incentive structures in pilot studies in Zhuhai (from June 2018 to March 2019) and Guangzhou (from May to September 2019), China.

Participants who completed a follow-up survey were eligible for this qualitative interview. Thirty-eight participants were approached and 22 agreed to participate. Participants were purposely selected based on whether they distributed any HIVST, the number of HIVST distributed, and the type of HIVST recipients (friend or sexual partner) to achieve maximum variation. All participants received an incentive of USD$7.

Potential participants were contacted through phone or social media. Semi-structured interview guide asked participants why they requested self-tests, how they selected recipients, how they distributed self-tests, and challenges during distribution (See supplement 1). Each question was discussed and finalized in consensus with the CBO interviewer. Interviews were conducted in Mandarin Chinese between August and November 2019, in-person or via phone as the participant preferred. All five interviewers are native speakers. Each interview lasted 30–70 minutes. Interviews were audio recorded with consent and transcribed for analysis.

Thematic framework was used for data analysis.(Gale et al., 2013) Two members of the study team first coded the same five transcripts and developed an analytical framework based on the research question and participants’ narratives. The analytical framework included 30 deductive codes and brief introductions to each code, and was then applied to all 22 transcripts by a single coder using MAXQDA. A matrix was created for each code by abstracting and charting data for each case and each code. The matrix helped identify emerging patterns within the topics of interest and compare the patterns across the MSM participants. Quotations presented herein were translated into English by one researcher.

Ethical Approval and Informed Consent

The study was approved by the ethics review committees at the Guangdong Provincial Centre for Skin Diseases and STI Control and the University of North Carolina at Chapel Hill. Verbal consent was obtained from each participant.

Results

Twenty-two participants were recruited for interviews. The mean number of self-test kits distributed by the participants was 1.95. Table 1 summarizes the participants’ demographic characteristics. Table 2 summarizes secondary distribution outputs.

Table 1.

Participants’ demographic characteristics, N = 22, 2019–2020, China.

Age
18–24	8/22 (36.4%)
25–29	7/22 (31.8%)
>30	7/22 (31.8%)
Gender
Men	21/22 (95.5%)
Unsure	1/22 (0.5%)
Sexual orientation
Gay	19/22 (86.4%)
Bisexual	2/22 (9.1%)
Unsure	1/22 (4.5%)
Marital status
Unmarried	20/22 (90.9%)
Engaged/married	2/22 (9.1%)
Education
High school or less	5/22 (22.7%)
Technical school	6/22 (27.3%)
Bachelor’s degree	10/22 (45.5%)
Graduate degree	1/22 (4.5%)
Student
Yes	6/22 (27.3%)
No	16/22 (72.7%)

Table 2.

Secondary distribution results, N = 22, 2019–2020, China.

Number of kits distributed
0	6/22 (27.3%)
1	8/22 (36.4%)
2	2/22 (9.1%)
3	1/22 (4.5%)
4	1/22 (4.5%)
≥5	4/22 (18.2%)
Type of recipients the index participants distributed to *
Romantic sexual partner	4/16 (25%)
Casual sexual partner	7/16 (37.5%)
Friend	9/16 (56.25%)
Number of recipients who accepted and used self-tests
Friend	25 (65.8%)
Romantic sexual partner	4 (10.5%)
Casual sexual partner	9 (23.7%)
Type of recipients to whom the distribution didn’t successfully happen *
Romantic sexual partner	1/6 (16.7%)
Casual sexual partner	1/6 (16.7%)
Friend	3/6 (50%)
Not clear	3/6 (50%)

^*Numbers may not add up due to different types of recipients linked to the same index.

Motivations to access and distribute HIV self-tests

Free self-testing and monetary incentives as well as trust in the self-test accessed from non-profit sources compared to tests purchased online are important motivating factors for accessing and distributing HIVST. The influence of financial benefit holds especially true for student participants. (See table 3 for emergent themes and interview quotes and supplement 2 for more interview data). Confidentiality is another factor that motivates participants to access the self-tests.

Table 3.

Facilitators and barriers to HIVST secondary distribution among MSM in China, N = 22, 2019–2020.

Subject	Emergent themes	Strategies proposed to advance secondary distribution	Quotes
Motivations to access and distribute HIVST	Facilitators: 1. Free test & monetary incentives for participation in the research 2. Trust in the quality and privacy of HIVST from non-profit sources 3. Reciprocal support for CBO who offers charitable non-profit HIVST and shows care to the minority	1. Reduce financial barriers to HIVST 2. Develop quality assured HIVST nationwide 3. Engage non-profit organizations to channel HIVST	• This project could do free test, and also had incentives. I think it’s pretty nice. (21-year-old, 5 kits to friends, Guangzhou) • Because you are an official organization, unlike those who hoodwink. So, I think you’re more authentic, after all you are a third-party non-profit organization. (35-year-old, 0 kit, Guangzhou)
Distributing to friends	Facilitators: 1. Risk assessment-based distribution 2. Index explain self-testing 3. Index aid recipients to self-test at point of care 4. Close friends are willing to accept HIVST from index 5. Financial benefit of free test and incentives for participation to the recipients 6. Index assured quality of self-test	1. Develop skills to broach sexual health conversations among MSM 2. Increase knowledge about HIVST among MSM 3. Develop skills to expand sexual orientation disclosure network	• He had high-risk (behaviors) and history of exposures, but he didn’t dare to get a test. Then I said you have to take a test. He still didn’t seem very willing when he came here. Then I said I would do the test for him. (27-year-old, 1 kit to friend, Zhuhai) • I would definitely offer to friends that get along with me, sometimes just one sentence is enough and he would believe me without any doubt. (28-year-old, 1 kit to friend, Guangzhou) • I just told them that my friends and I have all used it for test so it should be safe. I also told them this was an ongoing study project and the test was easy to use, usually done in 20 mins. I generally watched them complete the self-test by their side. (22-year-old, 5 kits to friends, Guangzhou)
Distributing to romantic sexual partners	Facilitators: 1. Index explain self-testing 2. Index aid recipients to self-test at point of care 3. Recipients willing to accept HIVST from close partner Barrier: 1. Couple having no experience discussing sexual health or HIV testing	1. Develop skills to broach sexual health conversations among romantic sexual partners	• He found testing normal and acceptable. When I was offering the self-test to him, he just asked about my testing result. After I told him my result, I said maybe he should take the test as well, he agreed without hesitation. (22-year-old, 3 kits to romantic sexual partner and friends, Guangzhou) • I brought up I tested and asked if he would like to test as well. But he just kept silent. (20-year-old, 0 kit, Guangzhou)
Distributing to casual sexual partners	Facilitators: 1. Index direct test the recipients using HIVST 2. Index are unsure of casual sexual partner’s infection status 3. Index explain self-testing Barriers: 1. Index willing to have sex even if recipients refuse to take a test 2. Index refer online application link to potential recipients	1. Develop skills to increase HIVST secondary distribution at point of casual sex 2. Develop infrastructure to increase follow-up on application link referral	• When I felt that person might have had high-risk sexual behaviors or he seemed to have slept around, I would recommend him to use. (29-year-old, 0 kit, Zhuhai) • I would try to persuade him (to take the self-test) if he was not too reluctant, otherwise I have no way but just give up…I did the test for him. He didn’t do it before. (25-year-old, 1 kit to casual sexual partner, Zhuhai)
Infrastructure-level challenges to distribute	Barriers: 1. Doubt of the reliability of self-test 2. Unfamiliarity with self-testing procedures 3. Inaccurate interpretation of test result 4. Confidentiality bleach during reporting a test result 5. Little instructions in terms of linkage to care	1. Produce quality assured self-test nationwide 2. Establish nationwide guidelines for self-testing 3. Increase MSM’s knowledge of self-testing 4. Develop better systems for self-test result report 5. Train self-testers and distributors about post-test services and linkage to care	• They may worry if it (the self-test) is not official, like it usually cost them several hundred to buy one, but why is it free here? Is the distribution channel official? If the self-test you offered me was not picked up from a hospital, but some promotion vendors on the street, then maybe they won’t believe it. (22-year-old, 3 kits to friends, Guangzhou)
Individual-level challenges to distribute	Barriers: 1. Lack of skills to broach topics related to sexual health and HIV testing 2. Worries about causing misunderstandings 3. Small social circle for distribution 4. Little risk assessed on behalf the potential recipients 5. Alternatives to access HIV test	1. Develop skills to broach sexual health conversations among MSM 2. Develop skills to expand sexual orientation disclosure network	• I have thought about it (distributing HIVST), but for some people, if you distribute to them, they might have a misunderstanding, like ‘are you suspicious that I’m infected?’ They would be dubious and reluctant. (27-year-old, 0 kit, Zhuhai) • I usually just use it (the self-test) myself rather than also applying for others. I think if the person was conscious of his health, he would apply himself. If I tell him about the link or this non-profit project, he would just apply himself. (27-year-old, 0 kit, Zhuhai)

Distributing HIVST to friends

Assessing the need for testing on behalf of potential recipients is common among participants who distributed to friends. Many successful distributors have close MSM friends and were aware of their friends’ sexual activities. Close MSM friends were believed to be open-minded, meaning they won’t see distribution as an invitation to sex, and therefore were favored. Having no such friends posed difficulty in distribution, including having straight friends or having gay MSM acquaintances who were not close.

Distributors resorted to different methods to prove the trustworthiness of the self-test, including providing information on its sources, usage, reliability and confidentiality, or sharing their own personal experience using the self-test. Many instructed or directly performed the test for the recipient. Some framed accepting the free test as financially beneficial. Those measures were generally helpful to convince the close friends recipients to take the self-test.

Distributing HIVST to sexual partners

Many participants who distributed to casual sexual partners wanted to know the recipient’s serostatus before sex. Explanation of self-test was less common. Instead, participants brought up the topic online or offered self-test when meeting offline before sex. Most said they would try to persuade the potential recipient to take the test, but would not insist if they refused. Not taking a test did not necessarily preclude participants from having sex.

Among participants who wanted their romantic sexual partners to self-test, since most participants and their partners took regular HIV test or had prior experience talking about sexual health, they had no difficulty persuading their partner to take the self-testing kit.

Barriers to distribute HIVST

False results due to not correctly following self-testing procedure and privacy breach for participating in a scientific study were concerns for secondary distribution. Lack of skills to talk about self-testing, alternative access to testing, and evaluation of friends’ need to testing based on familiarity with their sexual activity are also barriers to distributing HIV self-tests.

Discussions

This study examined the facilitators and barriers of distributing HIVST among MSM in China. MSM were generally willing to distribute self-tests to their social networks, but their decision-making is impacted by factors related to the individuals, relationships and the self-test, suggesting strategies that develop communication skills and establish standardized self-testing guidelines may be helpful for future scale-up.

Participants who knew few MSM friends or had little skills to talk about testing had difficulty distributing HIVST had difficulty distributing HIVST. This is consistent with studies showing that sexual orientation disclosure networks can impact HIV testing behaviors and the ability to broach topics regarding sexual health is vital to increase self-testing uptake in distribution. (Cao et al., 2019; Lentz et al., 2020) As Chinese MSM are mostly likely to disclose sexual orientation to friends, (Cao et al., 2019) peer-based interventions could potentially increase self-testing distributions by developing skills to broach topics regarding sexual orientation and sexual health.

Participants’ doubts about potential recipients’ ability to independently implement self-testing and interpret test result appeared to be another barrier to distributing self-tests. Research has shown that although self-testing is highly acceptable and accurate, (Choko et al., 2011) self-testers could find instructions hard to understand and made errors that may cause incorrect test results, (Choko et al., 2011; Simwinga et al., 2019) which is concerning because self-testers also tend to trust self-testing results. (Ickenroth et al., 2010) In China, there is no nationwide quality-assured self-tests or self-testing protocols. (Tang & Wu, 2018) Educational training to familiarize the community with self-test use and self-testing procedures as well as standardized linkage to care for self-testers is needed.

Our study has policy and research implications. As one’s ability to develop sexual orientation disclosure networks and open conversations about sexual health could increase self-testing uptake among social contacts, policy can address these barriers by creating a friendly environment for sexual minorities to empower them on sexual orientation and sexual health conversations. Furthermore, the self-tests and self-testing procedures should be quality assured nationwide to make sure the self-tests are accurate, instructions of use are easy to follow, and proper linkage to care is available.

Our study has limitations. Because we purposefully sampled MSM who participated in secondary distribution in Southern China, the data may not represent all MSM and those who are not MSM. Furthermore, this study is unable to derive information on barriers and facilitators of secondary distribution from the perspective of those who received (or declined) the self-testing kits, which may raise other issues with secondary distribution such as co-testing and confidentiality.

Conclusions

MSM in China are willing to distribute HIVST to members in their social network, but their decision-making is impacted by their abilities to broach sexual health conversations, evaluations of the recipients, and perceived trustworthiness of the self-test. Future strategies that focus on creating a friendly environment for sexual health conversations and establishing national guidelines on HIV self-testing may be helpful to improve HIVST secondary distribution among this population.

Geolocation information

This study was conducted in China, a low-middle income country.