User assessment of HIV self-testing (HIVST) in Brazil: an acceptable tool with great potential for reaching key populations and maximize positivity yield

BACKGROUND: Innovative strategies are paramount in a country that has a huge social disparity and an HIV epidemic concentrated in key populations (KP), who commonly experience barriers to access health services (HS). Aiming to reach the estimated 99.000 (11%) undiagnosed PLHIV, in 2018 Brazilian MoH started in 2018 a free HIVST distribution, focused on KP and young people. The aim of this study was to evaluate HIVST Brazilian users experience to guide public health policies.
METHODS: From December 2018 to January 2021, we conducted a cross-sectional study using an online self-administered structured questionnaire to assess user acceptance and experience using HIVST. The study collected socio-demographics, sexuality, risk behavior and previous testing data from HIV self-testers.
Users were encouraged to answer the post-test anonymous questionnaire by using the QR code printed in the informative folder delivered with the HIVST.
RESULTS: We obtained 813 answers. 363 (45%) of respondents were MSM and 50% were between 18 and 29 years old. 45% reported unprotected anal sex in the last 6 months and 32% of users were first time testers (46% in the 18-24 age group). Half of respondents (50%) realized the HIVST alone and 30% with a friend, partner or family member, 12% were assisted by an NGO member and 8% by a healthcare professional.
3% bought the test in pharmacies, 41% got it in a HS, 40% in outreach strategies and 13% received the test from a friend.
Regarding the testing experience, 91% of users found it easy to do, 98% would do an HIVST again and 99% would recommend it to a friend. The main advantages of HIVST pointed out were privacy (72%) and personal empowerment (51%).
Positive results were related by 28 (3.4%) people (Brazilian prevalence is 0.5%). Among the positive, 79% reported having already sought a HS to confirm the diagnosis.
CONCLUSIONS: HIVST is high acceptable, easy to perform and can maximize positivity yield. People prefer to self-test alone or with someone they trust. Most people seek confirmation after a positive result. HIVST were mostly obtained outside HS, successfully reached first time testers, young people and KP.