Men’s comfort in distributing or receiving HIV self-test kits from close male social network members in Dar Es Salaam, Tanzania: baseline results from the STEP project

In many settings, HIV testing rates and linkage to HIV care among people living with HIV (PLWH) remain much lower among men than women [1]. Consequently, a report from the Joint United Nations Programme (UNAIDS) on HIV/AIDS referred to men and boys as the ‘blind spot’ in the HIV prevention response [2]. Citing survey and program reports from 25 sub-Saharan African countries, the report indicated that in nearly half (12) of these countries, men living with HIV were leas likely to know their HIV status and knowledge of HIV status among men living with HIV was about half the rate found among women [2]. Thus, while HIV testing uptake among men has generally improved in recent years [3‐5], it remains below the first “95” of UNAIDS 95–95-95 targets [6]. Hegemonic masculinity norms [7], coupled with high levels of stigma and discrimination around HIV testing [8], continue to keep some men away from getting tested for HIV, coming to terms with their HIV-positive status, taking instructions from nurses, and engaging in health enabling behaviors. These dynamics contribute to poorer HIV testing uptake and treatment outcomes for men compared to women in high prevalence settings, calling for innovative approaches to reach men with HIV testing and linkage to HIV care services.

Evidence from prior studies has demonstrated that HIV self-testing is an acceptable and efficacious to increase uptake of testing services and facilitate linkages to care, especially among persons who are at high risk of HIV infection [9‐11]. Several approaches have been employed to reach men with HIV self-testing services, including household visits by community HIV care providers [12], female-delivered HIV self-testing kits [4, 13‐15], delivery through existing social networks [16], and distribution through the internet; particularly among men who have sex with men [17‐19]. Using a social network strategy to distribute HIV self-test kits to African American and Latino men who have sex with men in Alameda County, California, in the United States of America, Lightfoot et al. [17] found that individuals reached through a peer-based HIV self-testing strategy were significantly more likely to have never tested for HIV than men who have sex with men reached through community-based HIV testing programs. Similarly, Lippman et al. [18] found that network distribution of HIV self-test kits not only reached men who have sex with men who were testing for the first time but also increased the frequency of HIV testing from 37.8 to 84.5% after the introduction of HIV self-test kits in South Africa. MacGowan et al. [20] reported 34 (1.6%) infections among 2152 social network members who received HIV self-test kits from study participants in the United States of America. Tun et al. [19] reported 100% linkage to HIV care among men who have sex with men who were identified through an intervention that involved HIV self-testing through key opinion leaders in Nigeria.

Collectively, these studies indicate that men are willing to use HIV self-test kits to test for HIV [9, 11, 21], with additional evidence suggesting that men are willing to self-test for HIV if they receive HIV self-test kits from their friends or sexual partners [16, 22]. Fleming and other scholars have argued that use of gender-transformative approaches in which men are engaged to reach fellow men with HIV prevention interventions can create safety nets within which men can discuss issues that affect their own health, including HIV testing [6, 23]. Studies among existing social networks of heterosexual men from the general population in Tanzania have found that men already engage in HIV testing conversations with friends in their social networks [21, 24] and that discussing HIV testing with a sexual partner and having been encouraged to test for HIV by a close friend were associated with higher odds of being willing to self-test among men [9, 21]. While these studies have provided preliminary evidence for the potential to leverage men’s social networks to deliver HIV self-test kits, no research has been conducted to examine heterosexual men’s willingness to distribute HIV self-test kits to fellow men or receive HIV self-test kits from fellow men in Tanzania, where 51% of men living with HIV were not aware of their HIV status in 2017 [25].

In 2018, there were 72,000 new cases of HIV infection among adults aged 15 years and older in in Tanzania [25]. The population which is significantly affected by HIV in Tanzania include people who inject drugs, mobile populations, young people, and men who have sex with men [26]. Mobile male populations, including truck drivers, plantation workers, and fishermen have also been found to be at increased risk of HIV infection [24]. In response, the government of Tanzania developed national HIV prevention strategies, including HIV self-testing, [27] and launched a national Test and Treat campaign focused on increasing HIV testing among men [28]. However, in Tanzania as well as elsewhere, the majority of male peer-delivered HIV self-testing studies have been conducted with men who have sex with men [18, 29‐31]. Thus, there is limited evidence on how best to reach heterosexual men with HIV self-testing through male peer-delivered approaches.

In this study, we use baseline data from the Tanzania STEP (Self-Testing Education and Promotion) project [32] to investigate factors associated with men’s comfort to distribute or receive HIV self-test kits from close male friends among heterosexual men who socialize in networks locally referred to as “camps” in Dar es Salaam, Tanzania in order to inform implementation of social network-based HIV self-test kits distribution among heterosexual men.

Our results from the baseline study of the STEP Project showed a high level of comfort among men with distributing to and/or receiving HIV self-test kits from close male friends: 68% of participants indicated that they would be willing to distribute to and receive HIV self-test kits from their close male friends. These findings suggest the potential for peer-led HIV self-testing to reach men through fellow social network members and improve HIV testing rates among men who have never tested for HIV as well as among HIV-negative repeat HIV testers. The need for repeat HIV testing is particularly important because, compared to prior studies documenting low HIV testing rates among men in Tanzania [24, 37], most of the men in this study had been tested for HIV due to the ongoing national Test and Treat campaign focused on increasing HIV testing rates among men [28]. Formative qualitative research revealed that men perceived HIV self-testing as a facilitator for repeat HIV testing among HIV-negative testers because testing at home would save time compared to the commute and long queues associated with facility-based HIV testing [32].

Although we found that a high proportion (68%) of men were willing to distribute HIV self-test kits to their friends, another study conducted among men who have sex with men in the U.S. found a much higher proportion, with at least 90% of men who have sex with men reporting they would be comfortable to distribute HIV self-test kits within their social networks [30]. The lower proportion of men in our study who reported being comfortable to distribute an HIV self-test kit to their social network peers may be explained by the lack of familiarity with HIV self-testing for some of the men. This is supported by the fact that among men who had received peer-led HIV self-testing education and promotion, a much higher proportion (88%) of them reported being willing to distribute an HIV self-test kit to their peers compared to only 48% of men who had not been exposed to peer-led HIV self-testing education and promotion. These findings are supported by past research demonstrating that prior engagement with peer educators was associated with willingness to use pre-exposure prophylaxis among male sex workers in Vietnam [38].

Peer educators have been engaged in promoting uptake of HIV self-testing in several prior studies. Chanda et al. used peer educators for an HIV self-test cluster randomized controlled trial [39]. In the study, peer educators served to either directly distribute HIV self-test kits or distribute an HIV self-test coupon for female sex workers to collect the HIV self-test kit at a certain distribution point [39]. The peer educators, who were current or former female sex workers, were recruited by the study staff and participated in a two-day training. Throughout the study, the peer educators met with participants a minimum of four times in order to provide general related health education, provide knowledge on how to use the kits, and conduct follow-up visits after the women had tested [40]. Peer educators proved to have a positive effect on HIV self-testing among this population, pointing to the possibility that they served to decrease participants’ concerns about HIV-related stigma [40]. Results from another study conducted to assess the effect of peer-based distribution of HIV self-test kits among fishermen in Buliisa, Uganda, found that 82% (n = 95) of the fishermen accepted to receive HIV self-test kits from their peers; of these, 29 (25.8%) had never tested for HIV while 42 (44.2%) had tested more than a year ago [16]. In this study, 19 peers were recruited from patients attending health services at a facility as well as from community members and trained in how to distribute HIV self-test kits. Each peer received up to five HIV self-test kits for distribution to eligible social network members (i.e. those aged 18 years and above and who had not recently tested for HIV).

Taken together, these studies demonstrate that network-based distribution of HIV self-test kits can improve HIV testing rates, particularly in hard-to-reach populations, including men. However, the majority of peer-led HIV self-test kits distribution studies have not assessed the willingness to distribute HIV self-test kits among the peers who are reached by peer educators. Engaging peers who are reached by trained peer educators provides an opportunity to not only assess the effect of receiving peer-led HIV self-testing promotion but also an opportunity to leverage their knowledge of and use of HIV self-test kits to reach additional social and sexual network members that originally trained peer educators may not be able to reach. For example, we found that men who reported that their close male friends had encouraged them to self-test for HIV were more comfortable with receiving an HIV self-test kit from a close male friend than their counterparts. In the event that a close male friend is not a peer educator but may know the peer educator, this close male friend can receive two to three HIV self-test kits from a peer educator and then distribute them among his other friends who may not be close to the peer educators. Qualitative findings from the same group of men revealed that men, who were not peer educators, engage in HIV testing conversations with their friends and were willing to distribute HIV self-test kits to their close friends who may not want to seek HIV testing at the clinic [21]. Thus, more research is needed to explore the feasibility of expanding peer-based HIV self-test distribution to peers who are not reached by the peer educators.

We also found that men who were willing to use an HIV self-test kit in front of a sexual partner were more likely to be comfortable to receive an HIV self-test kit from a close male friend than their counterparts. This finding supports the potential for men to receive multiple HIV self-test kits from a close friend instead of only a peer educator for them to use with their sexual partners. A close male friend compared to a peer educator may have more information about another friend’s risky sexual behavior. This knowledge of close friend’s risky sexual behavior played a role in men encouraging their friends to test for HIV in Tanzania [21] and can be leveraged to have men distribute HIV self-test kits to their friends to also test their sexual partners. To our knowledge, there are no network-based studies that have provided heterosexual men with multiple HIV self-test kits to use with their female sexual partners. Rather, the existing studies have focused only on providing women multiple HIV self-test kits to use with their male sexual partners [4, 5, 13, 15]. These studies have shown that providing women with HIV self-test kits to use with their male partners can help to identify men who are unaware of their positive HIV status and reduce HIV risk for the female partner [4, 15]. Similarly, if men receive multiple HIV self-test kits to use with their sexual partners, it can help them assess their female partner’s HIV status and potentially prevent HIV acquisition from female partners who may be unaware of their positive HIV status. This is particular important because an earlier study conducted among men in Tanzania found that the majority of them were not aware of their sexual partner’s HIV status and that men who had two or more sexual partners were significantly less likely to be aware of their partner’s HIV status [37]. In addition, men who use condoms inconsistently were less likely to be aware of their sexual partner’s HIV status [37]. Thus, men, especially those with multiple sexual partners, can benefit from receiving multiple HIV self-test kits and proper guidance on how to self-test with their sexual partners as an HIV prevention strategy.

Although our study has several strengths, there are a few limitations worth highlighting, including the fact that data originated from a cross-sectional survey and were not collected to assess the causal relationship between variables of interest. Given the hypothetical nature of the outcome variables examined, the responses may vary in future studies with more or fewer men willing to distribute to or receive HIV self-test kits from close male friends. In addition, these findings are not generalizable to other men in the country since they were collected among men who are members of social networks called camps. However, this is one of the first studies to reach men who were exposed to peer-led HIV self-testing education and promotion to assess their willingness to distribute to or receive HIV self-test kits from close male social network members. The findings support the potential for network-based HIV self-testing distribution strategies to reach men who may not be close friends with peer educators.

Our study showed that nearly seven out of ten men were comfortable to distribute to and receive HIV self-test kits from their close male friends within a social network setting. Having ever heard about HIV self-testing, willingness to self-test in front of one’s sexual partner, and exposure to peer-led HIV self-testing education and promotion were significantly associated with being comfortable to distribute to or receive HIV self-test kits from close male friends within the social network. These findings suggest that distribution of HIV self-test kits through close male friends could improve the proportion of men reached with HIV self-testing services and improve HIV testing rates in this population where uptake of HIV testing among men remains low.