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Late HIV diagnosis remains frequent among the gay, bisexual, and other men who have sex with men (GBMSM) population across Europe. HIV self-sampling could help remove barriers and facilitate access to testing for this high-risk population.
We assessed the capacity of HIV self-sampling to increase the testing frequency among GBMSM living in Denmark, Germany, Greece, Portugal, Romania, and Spain, and evaluated the role of new technologies in the result communication phase.
We analyzed a convenience sample of 5019 GBMSM with prior HIV testing experience who were recruited during 2016 through gay dating websites. We estimated the proportion of GBMSM who reported that the availability of self-sampling would result in an increase of their current testing frequency. We constructed a Poisson regression model for each country to calculate prevalence ratios and 95% CIs of factors associated with an increase of testing frequency as a result of self-sampling availability.
Overall, 59% (between country range 54.2%-77.2%) of the participants considered that they would test more frequently for HIV if self-sampling was available in their country. In the multivariate analysis, the increase of testing frequency as a result of self-sampling availability was independently associated with reporting a higher number of unprotected anal intercourse events in all countries except for Greece. Independent associations were also observed among GBMSM who were not open about their sex life in Germany, Greece, Portugal, and Spain; those with a lower number of previous HIV tests in Denmark, Greece, Portugal, and Spain; and for those that took their last test more than 3 months previously in Germany, Portugal, Romania, and Spain. In addition, 58.4% (range 40.5%-73.6%) of the participants indicated a preference for learning their result through one-way interaction methods, mainly via email (25.6%, range 16.8%-35.2%) and through a secure website (20.3%, range 7.3%-23.7%). Almost two thirds (65%) of GBMSM indicated preferring one of these methods even if the result was reactive.
Availability of HIV self-sampling kits as an additional testing methodology would lead to a much-needed increase of testing frequency, especially for the hidden, high-risk, and undertested GBMSM population. Online-based technologies without any personal interaction were preferred for the communication of the results, even for reactive results.
HIV remains a significant public health problem in Europe. In 2017, 26,614 individuals were diagnosed as having HIV in the European Union/European Economic Area. Sex between men remains the most common transmission route and accounts for half of all new diagnoses [
The promotion of HIV testing is in fact a vital point of the 90-90-90 UNAIDS plan to end the AIDS epidemic. According to this plan, by 2030, 90% of all people living with HIV should have a diagnosis, 90% of the diagnosed population should be on treatment, and 90% of these should achieve viral suppression [
In light of the importance of HIV testing, several strategies have been implemented in the last decade both in clinical and nonclinical settings [
With the exception of examples in the United Kingdom [
In this study, we analyzed how self-sampling would contribute to the increase of testing frequency among GBMSM who were recruited online in 6 European countries where this testing option is yet to be introduced at a national scale. Additionally, we assessed the preferred methods of communicating test results taking into account the reactiveness of the self-tested sample.
In the context of the EURO HIV EDAT project (Operational Knowledge to Improve HIV Early Diagnosis and Treatment Among Vulnerable Groups in Europe; Grant Agreement number 2013 11 01), we conducted an online cross-sectional study in 8 European countries (Belgium, Denmark, Greece, Germany, Portugal, Romania, Slovenia, and Spain) between April and December 2016. The working team included members of academia and local organizations that ran community-based voluntary counseling and testing sites. Further information on this project can be found elsewhere [
We aimed at recruiting a large convenience sample of GBMSM. The dissemination of an open survey was largely performed through GBMSM geospatial dating apps and websites that were previously identified by the local community-based voluntary counseling and testing organizations in each participating country. Likewise, we made an effort to disseminate the survey in websites of GBMSM-oriented associations and supportive organizations. Advertisement was performed through banners, direct messages, and mailing lists. Those who clicked on the promotional banner or link were directed to an introductory screen that included brief information on the aims of the project, its anonymity, funding, and the partners involved. It also included a link to the EURO HIV EDAT project website for those interested in more information. To ensure complete anonymity, no cookies or internet protocols were collected. Participation was voluntary and those who decided to go ahead gave their informed consent by checking a box with the message “I have read and understood the above information, in the country I live in I am old enough to legally have sex, and I want to participate” before moving on to the first question. No incentives were offered for participation.
A total of 5799 HIV-negative GBMSM who resided in one of the participating countries accessed the questionnaire. We excluded 496 participants who had missing data on the question assessing our main outcome (potential of self-sampling to increase current testing frequency). Thus, the response rate was 91.45% (5303/5799). Additionally, we had to exclude participants from Slovenia (n=175) and Belgium (n=109) since the chosen dissemination websites in these two countries were not appropriately efficient, and the sample size was insufficient to run the multivariate analysis. Our final sample therefore comprised 5019 GBMSM from 6 countries.
Data were collected through a self-administered online questionnaire. The questionnaire was designed in English and translated to the language of each of the analyzed countries: Danish, German, Greek, Portuguese, Romanian, and Spanish. The translation was carried out by the partners of each participating country, all of whom were native speakers. Upon completion, questionnaires were back-translated using Google Translate to check for mistakes and inconsistencies with the English version.
The questionnaire included 90 items (1 item per page) although not every participant had to answer all questions. The completion time was approximately 20 minutes, which included sections to assess sociodemography, HIV testing history, outness about sex life with other men, sexual risk behaviors, and past diagnosis of sexually transmitted infections. To assess outness, we asked the participants “How would you describe the way you live your sex life with men?” This question had four response options: “openly,” “discreetly,” “hidden,” “in total secrecy.” The questionnaire also included a section that assessed several aspects related to HIV self-sampling. Before starting this section, the following definition was presented to participants: “Regarding self-sampling, sometimes referred to as ‘Postal Tests,’ you use a ‘kit’ to take either a blood or a saliva sample. This will then be posted to a laboratory for analysis and the results will be fed back to you.” Our main outcome was the potential of self-sampling to increase current testing frequency, which was assessed through the following question: “If HIV self-sampling was to be made available, you would test…”: (1) more times/more frequently than now, (2) about the same, or (3) less than now. This question was answered only by HIV-negative GBMSM.
We also assessed the role of new technologies in the delivery of test results using the following question: “When the laboratory has your results, how would you like to receive them?” Participants could choose one of the following answers: (1) by email, (2) through a secure website, (3) By SMS text messaging, (4) through a face-to-face consultation at a medical office, (5) through a face-to-face consultation at a community-based organization or a nongovernmental organization, (6) by phone call, and (7) other. Those who chose options 1 to 3 were also asked: “What if the result was reactive, how would you prefer to receive it then?” They then had to choose between the following options: (1) I would choose the same option, (2) I would rather receive a phone call, (3) I would rather attend a face-to-face consultation at a medical office, (4) I would rather attend a face-to-face consultation at a community-based organization, and (5) other. Respondents were able to review and change their answers through use of a “Back” button. The contents of the instrument can be found in
We performed a descriptive analysis of the main characteristics of the sample by country of residence. The data for the total number of participants were weighted to adjust for the disproportionate distribution of the sample by country of recruitment. Weighting coefficients were calculated using the male population between 18 and 65 years old living in the participating countries in 2016. Data were extracted from EUROSTAT [
For each country, we calculated the prevalence of participants who reported that the availability of HIV self-sampling kits would result in an increase of their testing frequency by relevant sociodemographic, behavioral, and HIV testing history variables. To estimate the factors associated with an increase of the testing frequency due to HIV self-sampling, we conducted a Poisson regression with robust variance multivariate analysis to estimate the crude and adjusted prevalence ratios (PRs) with their 95% CIs. A multivariate model was built for each country. We chose Poisson regression with robust variance because it is a better alternative than logistic regression when working with frequent outcomes [
Finally, we assessed the preferred methods of result communication by country. We grouped methods in two groups depending on the information flow they allowed: (1) unidirectional methods, in which communication flows only toward the user with no possibility of asking questions or giving direct feedback (email, secure website, SMS text messaging); and (2) bidirectional methods, in which communication can flow two ways (medical office, community-based organizations/nongovernmental organizations, phone call).
For those who chose a unidirectional method, we estimated the proportion that would have chosen the same testing method even if the result was reactive. Data on the total number of participants were also weighted using the aforementioned method.
The main demographic and HIV-related characteristics are summarized in
Overall, 20.2% of the participants indicated that they kept their sex life with other men hidden or in total secrecy, with the lowest proportion in Denmark and the highest in Romania. Regarding sexual risk indicators, 64.2% reported having had unprotected anal intercourse in the last 12 months with at least one partner, ranging from 48% (172/358) in Greece to 76.5% (186/243) in Denmark, and 41.8% had previously been diagnosed with a sexually transmitted infection, ranging from 31.2% (60/192) in Romania to 55.2% (134/243) in Denmark.
Overall, 19.9% self-reported having been tested for HIV at least once in the past, ranging from 13.1% (42/320) in Denmark to 28% (86/307) in Romania, and 39.1% had received their last test more than 12 months previously, ranging from 27% (136/502) in Greece to 43.1% (404/938) in Germany.
Sociodemographic profile, outness, sexual behaviors, history of sexually transmitted infections (STIs), and testing history of the participants.
Characteristic | Denmark |
Germany |
Greece |
Portugal |
Romania |
Spain |
Totala |
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<25 | 35 (10.9) | 57 (6.1) | 79 (15.7) | 46 (8.7) | 44 (14.3) | 255 (10.6) | 9.1 | |||||||
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25-29 | 48 (15.0) | 108 (11.5) | 78 (15.5) | 66 (12.4) | 59 (19.2) | 395 (16.3) | 14.1 | |||||||
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30-34 | 41 (12.8) | 132 (14.0) | 81 (16.1) | 84 (15.8) | 64 (20.8) | 388 (16.1) | 15.5 | |||||||
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35-39 | 54 (16.9) | 149 (15.8) | 111 (22.1) | 95 (17.9) | 45 (14.7) | 364 (15.1) | 16.0 | |||||||
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40-49 | 93 (29.1) | 276 (29.3) | 104 (20.7) | 139 (26.2) | 62 (20.2) | 636 (26.3) | 26.8 | |||||||
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≥50 | 49 (15.3) | 219 (23.3) | 50 (9.9) | 101 (19.0) | 33 (10.7) | 379 (15.7) | 18.5 | |||||||
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In country of current residence | 275 (86.2) | 844 (90.5) | 475 (97.3) | 463 (87.5) | 299 (98.0) | 2076 (86.8) | 90.5 | |||||||
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Europe | 26 (8.2) | 58 (6.2) | 7 (1.4) | 17 (3.2) | 4 (1.3) | 100 (4.2) | 4.7 | |||||||
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Other | 18 (5.6) | 31 (3.3) | 6 (1.2) | 49 (9.3) | 2 (0.7) | 215 (9.0) | 4.8 | |||||||
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≥1,000,000 | 111 (34.8) | 260 (27.7) | 269 (53.9) | 104 (19.7) | 87 (28.5) | 865 (35.9) | 31.3 | |||||||
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100,000-999.999 | 104 (32.6) | 336 (35.8) | 98 (19.6) | 177 (33.5) | 130 (42.6) | 844 (35.0) | 35.2 | |||||||
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10,000-99,999 | 66 (20.7) | 233 (24.8) | 98 (19.6) | 169 (32.0) | 58 (19.0) | 515 (21.4) | 23.2 | |||||||
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<10,000 | 38 (11.9) | 110 (11.7) | 34 (6.8) | 78 (14.8) | 30 (9.8) | 186 (7.7) | 10.3 | |||||||
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Upper secondary education | 140 (43.9) | 309 (32.9) | 72 (14.3) | 170 (32.1) | 84 (27.7) | 632 (26.2) | 29.7 | |||||||
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Postsecondary/nontertiary education | 11 (3.4) | 221 (23.6) | 93 (18.5) | 30 (5.7) | 35 (11.6) | 331 (13.7) | 17.6 | |||||||
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University education | 168 (52.7) | 408 (43.5) | 338 (67.2) | 330 (62.3) | 184 (60.7) | 1450 (60.1) | 52.6 | |||||||
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Openly | 244 (76.3) | 498 (53.0) | 94 (18.7) | 107 (20.2) | 38 (12.4) | 1110 (45.9) | 43.3 | |||||||
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Discreetly | 56 (17.5) | 267 (28.4) | 239 (47.5) | 285 (53.7) | 158 (51.5) | 977 (40.4) | 36.4 | |||||||
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Hidden/In total secrecy | 20 (6.3) | 175 (18.6) | 170 (33.8) | 139 (26.2) | 111 (36.2) | 329 (13.6) | 20.2 | |||||||
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None | 57 (23.5) | 255 (36.2) | 186 (52.0) | 136 (33.4) | 54 (27.6) | 692 (37.1) | 35.8 | |||||||
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1 | 63 (25.9) | 208 (29.5) | 116 (32.4) | 127 (31.2) | 73 (37.2) | 613 (32.8) | 31.4 | |||||||
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2-4 | 66 (27.2) | 153 (21.7) | 43 (12.0) | 100 (24.6) | 49 (25.0) | 372 (19.9) | 21.4 | |||||||
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≥5 | 57 (23.5) | 89 (12.6) | 13 (3.6) | 44 (10.8) | 20 (10.2) | 190 (10.2) | 11.4 | |||||||
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Last 12 months | 34 (14.0) | 70 (10.0) | 41 (11.6) | 59 (14.8) | 15 (7.8) | 203 (11.0) | 10.5 | |||||||
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>12 months ago | 100 (41.2) | 229 (32.8) | 90 (25.6) | 111 (27.9) | 45 (23.4) | 608 (32.9) | 31.3 | |||||||
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None | 109 (44.9) | 399 (57.2) | 221 (62.8) | 228 (57.3) | 132 (68.8) | 1038 (56.1) | 58.2 | |||||||
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1 | 42 (13.1) | 176 (18.7) | 95 (18.9) | 97 (18.3) | 86 (28.0) | 484 (20.0) | 19.9 | |||||||
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2-5 | 122 (38.1) | 447 (47.5) | 239 (47.5) | 243 (45.8) | 154 (50.2) | 1144 (47.3) | 47.4 | |||||||
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6-9 | 64 (20.0) | 148 (15.7) | 71 (14.1) | 87 (16.4) | 31 (10.1) | 382 (15.8) | 15.2 | |||||||
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≥10 | 92 (28.8) | 170 (18.1) | 98 (19.5) | 104 (19.6) | 36 (11.7) | 407 (16.8) | 17.5 | |||||||
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≤3 months | 84 (26.3) | 197 (21.0) | 184 (36.7) | 112 (21.1) | 69 (22.5) | 611 (25.4) | 23.4 | |||||||
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3-12 months | 125 (39.2) | 337 (35.9) | 182 (36.3) | 238 (44.9) | 117 (38.1) | 921 (38.2) | 37.4 | |||||||
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1-2 years | 57 (17.9) | 165 (17.6) | 69 (13.7) | 87 (16.4) | 60 (19.5) | 433 (18.0) | 17.6 | |||||||
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>2 years | 53 (16.6) | 239 (25.5) | 67 (13.3) | 93 (17.5) | 61 (19.9) | 445 (18.5) | 21.5 |
a Weighted percentages, calculated exclusively using valid data.
Regarding the potential of self-sampling for increasing the current frequency of HIV testing, 59% (54.2% in Spain, 55.9% in Germany, 59.1% in Denmark, 63.0% in Greece, 66.7% in Portugal, and 77.2% in Romania) indicated that, if available in their country of residence, they would test more frequently. Proportions of participants reporting an increase of testing frequency as a result of the availability of self-sampling by relevant variables can be found in
With the exception of GBMSM living in Denmark and Romania, the potential of self-sampling to increase testing frequency was higher among those who lived their sex life discreetly or “hidden/in total secrecy” than among participants who were open about their sex lives.
The number of partners with whom participants reported having engaged in unprotected anal intercourse was also associated with the capacity of self-sampling to increase testing frequency in all countries except for Greece. We found significant adjusted PRs among Spain-based respondents who reported having engaged in unprotected anal intercourse with only one partner. In all countries, the adjusted PRs were statistically significant among those who reported being involved in unprotected anal intercourse with 2-4 partners and the PRs increased further among those who reported having had ≥5 partners in the last 12 months. The adjusted PR decreased with the lifetime number of HIV tests. This pattern was the same in all countries except for Germany and Romania, in which no statistical significance was found.
Finally, apart from Denmark and Greece, the potential of self-sampling to increase testing frequency was independently associated with time elapsed since the last HIV test. Compared to those tested ≤3 months ago, the adjusted PR gradually increased among GBMSM who were last tested between 3 and 12 months prior and peaked among those tested >12 months previously.
Factors associated with a potential increase of testing frequency if self-sampling was made available.
Variable | Denmark (N=320), PRa (95% CI) | Germany (N=941), PR (95% CI) | Greece (N=503), PR (95% CI) | Portugal (N=531), PR (95% CI) | Romania (N=307), PR (95% CI) | Spain (N=2417), PR (95% CI) | |
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≥50 | 1.0 (0.7-1.4) | 1.0 (0.8-1.3) | 1.2 (1.0-1.5) | 1.1 (0.8-1.4) | 1.0 (0.8-1.2) | 1.1 (0.9-1.3) |
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25-49 | 1.0 (0.8-1.3) | 1.1 (0.8-1.4) | 1.1 (0.9-1.3) | 1.3 (1.0-1.6) | 1.0 (0.9-1.2) | 1.2 (1.0-1.3) |
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<25 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
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No university education | 1.3 (1.1-1.5) | —b | — | — | — | — |
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University education | 1.0 | — | — | — | — | — |
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Hidden/Total secrecy | — | 1.4 (1.2-1.6) | 1.4 (1.1-1.8) | 1.2 (1.0-1.5) | — | 1.3 (1.1-1.4) |
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Discreetly | — | 1.3 (1.1-1.4) | 1.2 (0.9-1.5) | 1.0 (0.9-1.3) | — | 1.2 (1.1-1.3) |
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Openly | — | 1.0 | 1.0 | 1.0 | — | 1.0 |
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≥5 | 1.5 (1.1-2.1) | 1.3 (1.0-1.6) | — | 1.3 (1.1-1.7) | 1.3 (1.1-1.6) | 1.5 (1.3-1.7) |
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2-4 | 1.4 (1.0-2.0) | 1.3 (1.1-1.5) | — | 1.3 (1.1-1.5) | 1.3 (1.1-1.6) | 1.3 (1.2-1.5) |
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1 | 1.1 (0.8-1.6) | 1.1 (0.9-1.3) | — | 1.1 (0.9-1.4) | 1.1 (0.9-1.3) | 1.1 (1.0-1.3) |
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None | 1.0 | 1.0 | — | 1.0 | 1.0 | 1.0 |
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1 | 1.5 (1.2-2.0) | — | 1.7 (1.3-2.2) | 1.7 (1.3-2.1) | — | 1.5 (1.3-1.8) |
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2-5 | 1.3 (1.0-1.7) | — | 1.7 (1.3-2.1) | 1.5 (1.2-2.0) | — | 1.4 (1.2-1.6) |
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6-9 | 1.2 (0.9-1.6) | — | 1.3 (0.9-1.8) | 1.3 (1.0-1.8) | — | 1.1 (1.0-1.3) |
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≥10 | 1.0 | — | 1.0 | 1.0 | — | 1.0 |
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>12 months | — | 1.3 (1.1-1.6) | — | 1.4 (1.1-1.8) | 1.4 (1.1-1.7) | 1.3 (1.1-1.4) |
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3-12 months | — | 1.1 (0.9-1.3) | — | 1.3 (1.1-1.6) | 1.4 (1.1-1.7) | 1.1 (1.0-1.3) |
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≤3 months | — | 1.0 | — | 1.0 | 1.0 | 1.0 |
aPR: adjusted prevalence ratio.
bVariable not included in multivariate analysis.
Preferred HIV test result communication method in general and for a reactive result.
Communication Method | Denmark |
Germany |
Greece |
Portugal |
Romania |
Spain |
Totala |
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All | 151 (52.8) | 467 (53.6) | 195 (40.5) | 377 (73.6) | 187 (62.5) | 1518 (66.4) | 58.4 | |
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Overall | 48 (16.8) | 179 (20.6) | 88 (18.3) | 180 (35.2) | 96 (32.1) | 738 (32.3) | 25.6 |
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Same response if result is reactive | 30 (62.5) | 126 (70.4) | 52 (59.1) | 120 (66.7) | 61 (63.5) | 437 (59.2) | 65.7 |
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Overall | 48 (16.8) | 206 (23.7) | 35 (7.3) | 109 (21.3) | 46 (15.4) | 445 (19.5) | 20.3 |
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Same response if result is reactive | 35 (72.9) | 144 (69.9) | 20 (57.1) | 73 (67.0) | 29 (63.0) | 254 (57.1) | 65.0 |
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Overall | 55 (19.2) | 82 (9.4) | 72 (14.9) | 88 (17.2) | 45 (15.1) | 335 (14.7) | 12.5 |
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Same response if test is reactive | 33 (60.0) | 53 (64.6) | 38 (52.8) | 57 (64.8) | 30 (66.7) | 186 (55.5) | 62.1 |
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All | 132 (46.2) | 371 (42.6) | 282 (58.5) | 131 (25.6) | 105 (35.1) | 729 (31.9) | 39.0 | |
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Medical office | 55 (19.2) | 220 (25.3) | 139 (28.8) | 66 (12.9) | 75 (25.1) | 522 (22.8) | 23.9 | |
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At a CBOb/NGOc | 33 (11.5) | 90 (10.3) | 82 (17.0) | 52 (10.2) | 10 (3.3) | 80 (3.5) | 8.1 | |
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Phone call | 44 (15.4) | 61 (7.0) | 61 (12.7) | 13 (2.5) | 20 (6.7) | 127 (5.6) | 6.9 | |
Other | 3 (1.0) | 33 (3.8) | 5 (1.0) | 4 (0.8) | 7 (2.3) | 39 (1.7) | 2.7 |
aWeighted percentages, calculated exclusively using valid data.
bCBO: community-based organization.
cNGO: nongovernmental organization.
Our study shows that HIV self-sampling has high potential to increase the frequency of HIV testing among GBMSM in the 6 European countries studied. More than half of the respondents reported that, if made available, self-sampling would increase their testing frequency. This potential was found to be especially high among those who are not open about their sexuality, who had a greater number of sexual partners, and for those who are undertested. Based on the preferences expressed by the participants, online technologies should play a key role in communicating test results.
The evidence base on HIV self-sampling kits is still very weak. Two studies from Belgium [
Subpopulations who do not live their sex life openly are hard to reach and are the least likely to encounter or access health promotion interventions [
The ultimate goal of the introduction of strategies such as self-sampling is to promote testing and facilitate testing to undertested populations. Current testing recommendations for GBMSM are demanding, and barriers such as fear of stigma and discrimination, lack of anonymity or confidentiality, and waiting times at testing sites [
From a public health perspective, shortening the time from infection to diagnosis by increasing testing frequency is particularly relevant in populations with a high number of sexual partners. Those who reported being involved in unprotected anal intercourse with a higher number of partners presented higher probabilities of unknowingly transmitting or acquiring HIV from partners of a serodiscordant status. According to our results, the introduction of self-sampling would increase testing frequency precisely in this key population. In this study, we only considered condom use during anal intercourse and we did not assess other risk reduction strategies such as serosorting. Those reporting a higher number of unprotected anal intercourse events could be having unprotected anal sex only with partners of a presumably equal (negative) serostatus (serosorting) or with HIV-positive partners with a presumably undetectable viral load to avoid infection [
Additionally, we did not assess HIV pre-exposure prophylaxis (PREP). Those involved in unprotected anal intercourse could be receiving PREP but this is unlikely since it was not widely available at the time of data collection (2016). Nevertheless, PREP has now been incorporated into the preventive options among GBMSM, and the role that HIV self-sampling could play in the follow-up of patients on PREP merits further study. Conversely, postexposure prophylaxis is an available option and is an effective means of protection against HIV. We also did not assess if some of those involved in unprotected sex could be doing so with the intention of taking postexposure prophylaxis after the risk exposure; however, this is highly unlikely since uptake is very low among GBMSM across Europe [
When assessing the introduction of self-sampling, it is important to consider several steps along the testing process, namely the distribution of the testing kits and the consultation of the test result. The aforementioned examples of studies assessing self-sampling kits distributed during outreach activities in locations frequented by GBMSM, such as saunas or gay venues, were able to conduct a modest number of tests [
Timely linkage to care following an HIV diagnosis is also critical since late access can result in worse patient outcomes [
Our results are not without limitations. Our sample was mainly recruited via gay dating apps and websites. Although these platforms are increasingly used by GBMSM as a way of socializing and meeting new sexual partners, generalization of these results to the overall GBMSM population needs to be made with caution, especially given the limited sample size in some countries. In this sense, GBMSM identifying as gay and reporting more sexual risk behaviors could be overrepresented in our sample as has been previously reported [
As a way of ensuring complete anonymity and confidentiality, we did not collect internet protocols or cookies, and therefore could not assess the possibility of an individual answering the questionnaire more than once. However, the overall objective of the survey was clearly explained in the access screen, and given that no compensation was provided in exchange for participation, this situation was highly unlikely. An important strength is that the assessment of HIV self-sampling was performed in a set of countries that had not introduced this testing option at the time of conducting the survey. This provides baseline information to policymakers that could guide them in the introduction of this methodology.
Based on our results, national HIV testing policies in the 6 countries evaluated in this study should consider the incorporation of HIV self-sampling as an additional testing option, since its introduction could increase the testing frequency in a high proportion of GBMSM, especially among those who are not open about their sex lives, who remain undertested, and who report a high frequency of high-risk sexual behaviors. When designing its implementation, priority needs to be given to online methods of result communication, accompanied by clear referral pathways to HIV care for those obtaining a reactive result.
Questionnaire.
Proportion of participants who reported that HIV self-sampling would increase their testing frequency by relevant variables.
gay, bisexual, and other men who have sex with men
prevalence ratio
pre-exposure prophylaxis
The members of the Euro HIV EDAT group are Sonia Fernández-Balbuena, Laura Fernández-López, Tom Platteau, Lieselot Oms, Per Slaeen-Kaye, Bojan Cigan, and Mitja Cosic.
We would like to thank Planet Romeo for their collaboration and effort in the recruitment process free of cost. We would also like to thank the following websites, companies, and institutions who collaborated in the recruitment process at no cost: Antivirus magazine, Bareback city, Boyfriend, Cavaria, Chico Oniırico, COBATEST network, Fiesta en el Jardın, Fundacion Triangulo, Fresh Magazine, Gay Hellas, Gayworld, Holebi, Mannenseks, Mannschaft, Mavricni-forum, the Telemedicine department of the Institute of Health Carlos III, Positive Voice, and Scruff. We would also like to thank all of the institutions of the collaborating partners: Checkpoint Athens, AIDS Fondet, AIDS Hilfe, Legebitra, GAT-Grupo de Ativistas em Tratamentos, Institute of Tropical Medicine, and ARAS-Asociatia Romana Anti-SIDA. This study was supported by the Consumers, Health and Food Executive Agency (CHAFEA: 20131101) and Acción Estratégica Intramural (PI17CIII/00037). The funding sources were not involved in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
CA has received financial support for research and travel reimbursements from Gilead Sciences and ViiV Healthcare. All other authors declare no conflicts of interest.