Facilitators, Barriers, and Recommendations for Overcoming Challenges to HIV Self-Testing Uptake among Homosexual Men in Asia: A Meta-Synthesis

By Safdar Kamal Pasha¹, Usman Ali²

Affiliations

1. Department of HIV, Viral Hepatitis and STIs, World Health Organization, Pakistan
2. Department of Psychiatry, King Edward Medical University, Lahore, Pakistan

doi: 10.29271/jcpsp.2025.12.1597

ABSTRACT
This paper aimed to identify the facilitators, barriers, and recommendations for overcoming challenges to HIV self-testing (HIVST) uptake among men who have sex with men (MSM) and transgender (TG) people in Asia. Using a systematic search strategy, databases including PubMed, OCLC, EBSCOhost, Google Scholar, SABINET Online, Union Catalogue of Theses and Dissertations, WorldCat Dissertations, and ERIC were searched. The Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach was used to analyse the findings. The results suggest that HIVST is perceived as a more confidential and easier method compared to traditional HIV testing among MSM and TG individuals. HIVST can increase the reach of HIV testing services for MSM and TG individuals in Asia. Community-based organisations and community workers can facilitate HIVST among MSM and TG in Asia. However, the cost of test kits is a significant barrier to HIVST uptake. Additionally, counselling services make traditional HIV testing preferable than HIVST method among these populations. Overall, there is a lack of policy for supporting HIVST for MSM and TG in many Asian countries. There are concerns among users and stakeholders that HIVST may lead to mental distress, promoting recommendations to link mental health services in a way that protects users’ privacy.

Key Words: HIV self-testing, Uptake, Health system, Multi-stakeholder, Men who have sex with men.

INTRODUCTION

Complex health interventions cannot be holistically evaluated based only on cost-effectiveness and efficacy data. Quantitative evidence needs to be complemented by qualitative evidence.¹ Qualitative evidence synthesis, also known as meta-synthesis, is a systematic review of qualitative evidence used to evaluate complex health interventions, including the barriers and facilitators to their implementation.² It allows a holistic view of the intervention by incorporating perspectives from multiple stakeholders.³

HIVST is a World Health Organisation (WHO)-recommended method for HIV screening, whereby a person can collect their own sample and interpret the results with minimal supervision.⁴ The effectiveness of HIVST is well established compared to standard HIV testing.^5,6 Johnson et al. reported that HIVST increases the frequency of HIV testing by 1.88 and enhances HIV detection by 2.02 times among men who have sex with men (MSM).⁵

Vashisht et al. reported that HIVST increases the mean number of HIV tests by 2.34 times, doubles the HIV detection rate, and increases repeat HIV testing.⁶

However, despite the introduction of HIVST and increasing endorsement of HIV testing, the world target of diagnosing 90% HIV infections by 2020 was not achieved. None of the United Nations Joint Programme on AIDS (UNAIDS) regions met this goal.⁷ There are three UNAIDS regions in Asia: the Asia Pacific, the Middle-East and North Africa (MENA), and Eastern Europe and Central Asia. These regions reported 76%, 61%, and 70% of people living with HIV, respectively, who are aware of their HIV status. This highlights the need to strengthen HIV prevention and diagnostics strategies in these regions.⁷

While the effectiveness of HIVST is well established, no quali- tative evidence synthesis (QES) has examined HIVST from a multi-stakeholder perspective to identify the facilitators, barriers, and recommendations for improving HIVST uptake in Asia. A suggested reason may be the criminalisation of HIV key populations in Asia. According to the Human Dignity Trust (www.humandignitytrust.com), nine Asian countries criminalise transgender people, and twenty-two Asian countries criminalise same-sex behaviours.⁸ To date, only three QES have been published on this topic; two focused on studies from Africa, and one included studies conducted across the globe.^9-11 The purpose of this QES is to identify the facilitators, challenges, and recommendations for overcoming challenges to HIVST uptake for MSM and transgender (TG) people in Asia, thereby enhancing community access to HIVST. To the best of the authors’ know- ledge, this theme remains unexplored in previous QES.

METHODOLOGY

Using a systematic search strategy, databases including PubMed, OCLC, EBSCOhost, Google Scholar, SABINET Online, Union Catalogue of Theses and Dissertations, WorldCat Dissertations, and ERIC were searched. The search strategy followed the guidelines instructed in the Cochrane Handbook. All databases were searched on 11 May 2024, using the following terms: HIVST OR HIV self-testing OR HIV self-testing OR HIV self-test OR HIV self-test.

Qualitative or mixed-method studies with the objectives of identifying multi-stakeholders’ review of HIVST uptake or implementation, published in the last ten years from Asian countries and focused on MSM and TG, were included. MSM and TG were defined as per the definition given by the United Nations Joint Programme on HIV/ AIDS.¹² Quantitative studies focusing on HIV or STI testing other than HIVST were excluded. Quality assessment of the included studies was conducted using the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies. The CASP checklist consists of ten items, with responses recorded as ‘yes’, ‘no’, or ‘cannot tell’.¹³ Two authors independently appraised all the included articles using the CASP checklist, and any disagreements were resolved through discussion and mutual consensus. Thematic framework synthesis was employed. Verbatim transcripts from the included studies were coded using open coding, followed by second-order coding as described by Saldana.¹⁴ Second-order codes were sorted into facilitators, barriers, and recommendations for overcoming challenges. Data were uploaded and analysed using NVIVO version 14.0. Two authors independently coded the data. Coding was then discussed by a team to reach a consensus. The Confidence in the Evidence from Reviews of Qualitative Research (CERQual) approach  was  used  to  analyse  the  findings.¹⁵

RESULTS

A total of 1,031 articles were retrieved from PubMed, and an additional five were identified from other sources, including theses for research degrees. After removing duplicates, 1,034 articles were screened thoroughly against the inclusion and exclusion criteria. Following the initial screening, 996 articles were excluded. The full text of 70 articles were reviewed, and 13 qualitative studies were identified from the literature search. Finally, nine studies that met the inclusion criteria were included in this QES (Figure 1).

The characteristics of the final nine included study are summarised in Table I.^16-24 There were three studies from China and two from Myanmar. Only one study was reported from Muslim countries (Malaysia). No study was identified from the Middle East or Central Asia. All nine included MSM, four studies included TG women (TGW), and three studies included implementers  for  interviews  in  their  study.

The quality appraisal of the nine included studies was con- ducted using the CASP tool. The results of this assessment are presented in Table II. None of the researchers considered their relationship with participants during study formulation or interpretation. One study interpreted findings based on interviews but did not provide verbatim transcripts of the participants  in  their  article.

Based on the study analysis, twelve themes were observed repeatedly: four were related to facilitators of HIVST, five were related to barriers, and three were recommendations for overcoming  challenges.

Seven studies contributed to the theme of HIVST being a confidential method of testing. HIVST was identified as a confidential method of HIV testing in seven of the nine studies included in this QES. Excerpts from these studies are presented in the codebook attached as a supplementary file. Since HIVST could protect the disclosure of sexual orientation of MSM and TG individuals, it was one of the key reasons for opting HIVST over traditional  facility-based  HIV testing.²¹

Likewise, seven studies contributed to the theme of HIVST being easy to use for HIV testing. For instance, in the study by Pal et al., participants were provided with video demonstrations for both blood  and  oral  fluid-based  HIVST.¹⁶

Five of the included studies reported that HIVST can improve testing outreach to MSM. This included three studies where MSM reported that HIVST is more suitable for MSM individuals from certain social statuses, such as Ah Pones in Myanmar, as well as for MSM who remain closeted.¹⁷ In two studies, participants also stated that HIVST makes it easier to offer HIVST to their partners or  to  TGW  who  live  far  from  HIV  testing  centres.

Five of the nine included studies reported that community- based organisations or volunteers can facilitate HIVST. Zhao et al. reported the impact of mobile health interventions on the uptake of HIVST. The findings stated that an official online platform facilitates the operation of HIVST services in stigmatising social settings, especially where protection from governmental public health organisations is needed.¹⁸ Another method through which community volunteers can help is by providing counselling and  linkage  to  care.¹⁶

Barriers to HIVST included high cost, mental distress, and lack of counselling and public policy. Four of the nine included studies cited cost as a barrier to HIVST. Participants suggested that HIVST should be made available at affordable prices, similar to condoms, urine pregnancy kits, and other commodities provided through sexual and reproductive health services.²² Five of the included studies contributed to the theme that HIVST might lead to mental distress. However, analysis of the extracted data shows that this concern stemmed from community fears rather than from observed or reported experiences. The theme was centred around people finding their HIV status through self-testing. However, two studies also had contradictory findings, where participants quoted that MSM would not have any issue or mental  distress  from  HIVST.²¹

Figure 1: PRISMA flow diagram of literature search.

Table I: Characteristics of qualitative studies on HIVST published from Asia.

Authors	Country	Objectives	Study design	Study population	Data collection method
Pal et al.16	Cambodia	Acceptability of HIVST	Qualitative study	Total 144 MSM, TGW, and female entertainment workers	24 focus group discussions (FGDs)
Wirtz et al.17	Myanmar	Acceptability of HIVST	Qualitative study	12 MSM, 13 TGW, and 35 community key informants	FGDs
Zhao et al.18	China	Feasibility and potential concerns of using the online HIVST platform	Qualitative study	36 MSM	In-depth interviews
Liu et al.19	China	Evaluation and implementation of HIVST	Qualitative study	42 MSM and 6 stakeholders	In-depth interviews
Tan et al.20	Singapore	Perceptions of HIVST	Qualitative study	30 MSM	In-depth interviews
Zhang et al.21	China	Facilitators and barriers to HIVST	Qualitative study	23 MSM, 7 officials of the HIV programme, and 4 workers	In-depth interviews with MSM, FGD workers, and stakeholders of HIV programme
Dinglasan et al.22	Philippines	Barriers and facilitators to HIVST implementation	Qualitative study	20 MSM or TGW	In-depth interviews
Wirtz et al.23	Myanmar	Acceptability of HIVST	Mixed-methods study	20 MSM and TGW	In-depth interviews
Shrestha et al.24	Malaysia	Usability and acceptability of smart- phone application to deliver HIV prevention services for MSM in Malaysia.	Mixed-methods study	20 MSM	In-depth interviews
MSM: Men who have sex with men; TGW: Transgender women.   Table II: Quality appraisal of the included studies according to the CASP tool.   Study Clear aims Appropriate methodology Appropriate research design Appropriate recruitment strategy Appropriate data collection method Reflexivity Ethical considerations Sufficiently rigorous data analysis Clear statement of findings Research is valuable Pal et al.16 Yes Yes Yes Yes Yes Cannot tell Yes No Cannot tell Yes Wirtz et al.17 Yes Yes Yes Yes Yes Cannot tell Yes Yes Yes Yes Zhao et al.18 Yes Yes Yes Yes Yes Cannot tell Yes Yes Yes Yes Liu et al.19 Yes Yes Yes Yes Yes Cannot tell Yes No No Yes Tan et al.20 Yes Yes Cannot tell Yes Yes Cannot tell Yes Cannot tell Yes Yes Zhang et al.21 Yes Yes Yes Yes Yes Cannot tell Yes Yes Yes Yes Dinglasan et al.22 Yes Yes Yes Yes Yes Cannot tell Yes Yes Yes Yes Wirtz et al.23 Yes Yes Cannot tell Yes Cannot tell Cannot tell Yes No Cannot tell Yes Shrestha et al.24 Yes Yes Yes Cannot tell Yes Cannot tell Yes No Yes Yes

Table III: Summary of the findings with GRADE-CERQual assessments.

Summarised review findings	GRADE-CERQual assessment of confidence	Explanation of GRADE-CERQual assessment	References
Facilitators of HIVST for MSM and TG in Asia
HIVST is perceived as a more confidential method of HIV testing compared to traditional HIV testing among MSM and TG in Asia.	Moderate confidence	Moderate concerns regarding methodological limitations, No / Very minor concerns regarding coherence, minor concerns regarding adequacy, and No/Very minor concerns regarding relevance	Zhang et al., Wirtz et al., Wirtz et al., Tan et al., Dinglasan et al., Pal et al., Liu et al.
HIVST is perceived as an easy-to-use method for HIV testing compared to traditional HIV testing among MSM and TG in Asia.			Zhang et al., Wirtz et al., Wirtz et al., Tan et al., Dinglasan et al., Pal et al., Liu et al.
HIVST can increase outreach services of HIV testing for MSM and TG in Asia.			Zhang et al., Wirtz et al., Wirtz et al., Liu et al.
Community-based organisations / community workers can facilitate HIVST among MSM and TG in Asia.			Zhao et al., Dinglasan et al., Pal et al., Liu et al.
Bariiers to HIVST for MMS, TG, and TGW in Asia
High cost of HIVST kits is a barrier to HIVST uptake among MSM and TG in Asia.	Moderate confidence	Moderate concerns regarding methodological limitations, No / Very minor concerns regarding coherence, minor concerns regarding adequacy, and No/Very minor concerns regarding relevance	Zhang et al., Dinglasan et al., Pal et al., Liu et al.
Counselling makes traditional HIV testing preferable over HIVST among MSM and TG in Asia.		No/Very minor concerns regarding methodological limitations, moderate concerns regarding coherence, No/Very minor concerns regarding adequacy, and No/Very minor concerns regarding relevance	Zhang et al., Wirtz et al., Dinglasan et al.
Lack of policy related to HIVST for MSM and TG in Asia.		No/Very minor concerns regarding methodological limitations, No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and No/Very minor concerns regarding relevance. Only two studies supported the findings.	Zhang et al. and Dinglasan et al.
HIVST can lead to mental distress among MSM and TG in Asia.	Low confidence	Moderate concerns regarding methodological limitations, Moderate concerns regarding coherence, Minor concerns regarding adequacy, and No/Very minor concerns regarding relevance	Zhang et al., Wirtz et al., Dinglasan et al., Pal et al., Liu et al.
Monitoring HIVST services for MSM and TG can be difficult for programme implementers in Asia.		Moderate concerns regarding methodological limitations, No/Very minor concerns regarding coherence, Moderate concerns regarding adequacy, and No/Very minor concerns regarding relevance. Only two studies supported the finding.	Zhang et al. and Liu et al.
Overcoming challenges to HIVST for MSM and TG in Asia
HIVST should be linked with mental health services for MSM and TG in Asia.	Moderate confidence	Moderate concerns regarding methodological limitations, No/Very minor concerns regarding coherence, Minor concerns regarding adequacy, and No/Very minor concerns regarding relevance	Zhao et al., Wirtz et al., Dinglasan et al., Pal et al., Shrestha et al., Liu et al.
HIVST should be available in a manner that protects the privacy of MSM and TG users in Asia.			Zhao et al., Dinglasan et al., Shrestha et al., Liu et al.
HIVST should be available through multiple outlets to MSM and TG in Asia.			Dinglasan et al. and Pal et al.

However, counselling services made traditional HIV testing preferable over HIVST. Not all participants in the included studies preferred HIVST over facility-based HIV testing. Participants from the three included studies contributed to this theme. In all studies, counselling was one reason for preferring facility-based HIV testing over HIVST. Two studies, one from China and one from the Philippines, reported the absence of policies as a barrier to HIVST. Participants also reported that traditional HIV test kits were being sold and used as HIVST kits, highlighting the lack of regulatory approval for HIVST kits from the Chinese Food and Drug Administration (FDA).²¹

Since HIVST reporting is dependent on the HIVST user, two studies quoted that monitoring of HIVST services might be difficult. Both studies were from China. A CDC staff member from China reported the struggles related to monitoring HIVST.²¹

One of the themes focused on the solutions to the barriers of HIVST. It should be linked with mental health services. Six of the nine included studies proposed that mental health services should be provided to HIVST users, either through online, counsellors, or mental health professionals.

Four of the nine included studies proposed that HIVST services should be discreet, either through discreet packaging of HIVST kits or through community-based online platforms where HIVST kits can be ordered confidentially. In China, an online platform was used to promote HIVST. A participant reported that an official account on the WeChat application should be used to protect privacy. They expressed the concern that if community groups for HIVST services are made on social application, the privacy could be breached, whereas the MSM community prefers privacy.¹⁸

HIVST should be available at multiple places for clients. Community members have proposed that HIVST should be available at pharmacies, online, over counter, and in community-based centres to maximise HIVST uptake.

The strength of evidence was gauged using GRADE-CERQual. A summary of the findings is presented in Table III. Two findings were regarded as of low confidence; these included that HIVST could lead to mental distress and that monitoring HIVST services for MSM could be difficult.

DISCUSSION

HIV key populations face a high degree of stigma across the globe, especially in Asia.⁸ Given the highly stigmatising environment, these populations are at high risk of HIV.⁸ Moreover, these sanctions pose limitations to HIV prevention and treatment programmes for HIV key populations. HIVST is an innovative method for screening HIV without the need for in-person contact with testing providers. Globally, HIVST is implemented using various models, including digital models where online orders are placed and HIVST kits are delivered to users.²⁵ However, HIVST uptake faces significant challenges. Most of the HIVST services from middle-income countries are available in Africa, with limited research and implementation outside Africa.²⁵ Among the HIV key population, HIVST increases the uptake of HIV testing by 1.4 times among MSM and improves HIV detection by 2.10 times compared to traditional HIV testing, without increasing the risk of condomless anal intercourse.⁶

To the best of the authors’ knowledge, this is the first QES that focuses on facilitators and barriers of HIVST among MSM and TGW in Asia. Hlongwa et al. explored men’s perspectives about HIVST in Africa.¹¹ According to them, HIVST was consi- dered as a convenient and confidential method of HIV testing by African men, consistent with the findings of the present review. The same review also emphasised that HIVST should be complemented with counselling. These findings also resonate with those from Africa, where HIVST was found to be empowering in terms of allowing confidential and convenience HIV testing. However, it concluded that HIVST had the disadvantage of lacking face-to-face counselling, and cost might deter HIVST uptake.⁹ Although this finding identified concerns that HIVST may lead to mental distress, contradictory evidence was also reported, which weakens the overall strength of the findings. Wray et al. used a longitudinal cohort analysis to ascertain that HIVST leads to mental distress. The authors concluded no significant difference in distress among HIVST users.²⁶ Nevertheless, HIVST must be complemented with counselling and information on linkage to treatment.¹¹ In a recently conducted meta-analysis of observational studies and randomised control trials, 66% of all HIVST studies included a mobile health technology to provide active counselling. These services were provided through calls, messages, emails, or HIVST testing mobile or dating applications. The analysis found an increased linkage to physicians due to counselling: 96.3% for active counselling and 79.1% for passive counselling.²⁷ While HIVST is sometimes perceived to weaken linkage to treatment, a recently conducted meta- analysis concluded that HIVST is not inferior to the standard of care in linking HIV-positive individuals to treatment.²⁸ One of the barriers to HIVST uptake was the lack of a policy for implementing HIVST. According to HIVST.org, HIVST was allowed for use only in six out of forty-eight Asian countries—India, Iran, Cambodia, China, Lao, and Vietnam—and none of these countries had established policies regarding the registration or sale of HIVST kits. Furthermore, this study noted that cost remains a barrier to HIVST uptake among MSM and TG. This is particularly important given the recent global reduction in HIV funding for low- and middle-income countries, as the overall HIV response is jeopardised. Thus, countries in Asia must come forward with a policy on HIVST, including making it more affordable to leverage its ability to increase HIV detection among MSM and TG communities.²⁹

CONCLUSION

HIVST is an empowering method of HIV testing that can play its role in reaching closeted MSM and TG communities in highly stigmatising environments. However, the current evidence base is limited. Only six countries in Asia have explored the barriers and facilitators of HIVST qualitatively, and none are from Central Asia or the Middle East. Moreover, only three studies have included interviews of implementing stakeholders, making this area highly under- explored. It is recommended that further research should focus on identifying the barriers perceived by programme implementers, especially in Muslim countries, to better inform future HIVST implementation for MSM and TGW in Asia.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
SKP, UA: Conception of the study, data analysis, and draft writing.
Both authors approved the final version of the manuscript to be published.

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