An exploration of men's knowledge, attitudes, and perceptions of HIV, HIV risk, and willingness to test for HIV in Yendi District, Northern Ghana

Men's utilisation of sexual and reproductive health services in low- and middle-income countries: A narrative review

Background

Men have poor access to sexual and reproductive health (SRH) services globally, particularly in low- and middle-income countries (LMICs). Nevertheless, in LMIC and high-income countries (HICs), low SRH utilisation happens on account of several factors, such as individual, health system-related, and sociocultural factors. Identifying and addressing men's SRH service underutilisation remains essential to improving their sexual health and averting higher mortality and early morbidity associated with poor health seeking behaviour (HSB) among men.

Aim

This narrative review identifies factors influencing whether men do or do not utilise SRH services in LMICs.

Setting

We report on articles published in LMICs: Africa, Asia and South America.

Method

In this narrative review, we searched for quantitative and qualitative articles published between 2004 and 2021 from international databases, including Google Scholar, ScienceDirect, EBSCOhost, Scopus, PubMed, Medline, and reference lists of retrieved published articles.

Results

A total of 2219 articles were retrieved, from which 36 met the inclusion criteria. Factors contributing to poor uptake of SRH services by men included: a lack of access and availability of SRH services, poor health-seeking behaviour among men, and SRH facilities not being perceived as 'male-friendly spaces'. Furthermore, our review reveals that decreased use of SRH services is attributed to factors such as a lack of focus on men's SRH.

Conclusion

The current underutilised state of SRH services calls for urgent implementation of evidence-based interventions. Identifying men's SRH service inhibitors and enablers will assist programme managers and policymakers in designing SRH services tailored to their sexual health needs.

Contribution

Despite numerous global interventions to motivate men, the findings provide insight into the underutilisation of SRH services. The study also reveals the inadequate comprehensive investigation of men's SRH service utilisation, especially older men, to comprehend men's problems fully. Further research needs to be conducted on SRH issues, including vasectomy, mental health, and chronic conditions related to sexual and reproductive health. The analysis can assist SRH policymakers and program managers in strengthening the policies to motivate men to engage better with SRH services.

Factors Associated with First-Time HIV Testing Among MSM via Secondary Distribution of HIV Self-test Kits in Zhuhai, China

HIV self-testing (HIVST) is an effective method to expand HIV testing coverage worldwide. We analyze the results of HIVST and sexual behaviors of first-time testers among Men who have sex with men (MSM) who participated in a secondary distribution of HIVST kits. A total of 589 participants were recruited, including 173 first-time testers and 416 non-first-time testers. The first-time testers were mainly of Han ethnicity (aOR 1.88, 95% CI 1.10, 3.24), more likely to be HIV positive (aOR 7.18, 95% CI 2.37, 21.72), and had higher income (aOR 2.01, 95% CI 1.10, 3.69). Both groups were less likely to have anal sex with male partners (χ²: 146.24, P < 0.01), (χ²: 582.72, P < 0.01) or have sex with female partners (χ²: 19.01, P < 0.01), (χ²: 35.74, P < 0.01) after HIVST. We should expand HIVST among MSM and other key populations to identify first-time testers.

Barriers and Facilitating Factors to HIV Treatment Among Men in a High-HIV-Burdened District in KwaZulu-Natal, South Africa: A Qualitative Study

Despite enormous increases in the proportion of people living with HIV accessing treatment in sub-Saharan Africa, major gender disparities persist, with men experiencing lower rates of testing, linkage to treatment, and retention in care. In this study, we investigated the barriers and facilitating factors to HIV treatment among men in uThukela, a high-HIV-burdened district in KwaZulu-Natal province, South Africa. We conducted a qualitative study including nine Black African male participants who were recruited from 18 health care facilities in uThukela District, KwaZulu-Natal province. In-depth interviews were conducted with participants who linked to care and those who did not link to care at 3-month post HIV diagnosis. We used Atlas.ti for thematic analysis. Data were coded and linked to broader themes emerging across interviews. The median age was 40 years (interquartile range [IQR]: 31-41). This study identified the following key themes which emerged as barriers to HIV treatment among men in uThukela District: lack of emotional readiness, perceived medication side effects, fear of treatment non-adherence, perceived stigma and confidentiality concerns, and poor socioeconomic factors. We identified the following enabling factors to HIV treatment among men: fear of HIV progressing, acceptance of status, disclosure, support from family and friends, positive testing experience, and accessibility of antiretroviral treatment. This study revealed barriers and enabling factors to HIV treatment among men. These factors are important to inform the design of targeted intervention strategies aimed at improving linkage and retention to HIV treatment among men.

HIV Testing among sexually active Ghanaians: an examination of the rural-urban correlates

HIV testing is critical in reducing the risk of HIV transmission. We investigated the rural-urban correlates of HIV testing amongst sexually active Ghanaians using data from the 2017/2018 Ghana Multiple Indicator Cluster Survey Six (GMICS 6). Robust Poisson models (reporting Adjusted Prevalence Ratios (APR) and 95% Confidence Intervals (CIs)) were used to achieve this aim. About 46% of the participants had ever tested for HIV. According to the results, approximately 52% and 39% of urban and rural dwellers, respectively, have undergone HIV testing. HIV knowledge, HIV stigma, gender, age, education, marital status, childbirth history, sexual history, health insurance coverage, media exposure, household wealth, and region of residence were significantly related to HIV testing with observed variations across rural-urban areas. The findings call for the expansion of advocacy efforts towards encouraging HIV testing, targeting sexually active Ghanaians particularly in rural areas.

The determinants of willingness to care for people living with HIV-AIDS: A cross-sectional study in Indonesia

Acceptance and willingness to care for people living with HIV-AIDS (PLHA) in society is still a concern. The purpose of this study is to analyse the determinants of willingness to care for PLHA in Indonesia. A cross-sectional study was conducted to process the secondary data from the Indonesian Demographic Health Survey (IDHS) conducted in 2017. A total sample of 13,731 individuals was obtained by a two-stage stratified cluster sampling technique. The variables used were socioeconomic characteristics (age, sex, education, wealth quintile, residence, employment status and earnings), knowledge about HIV-AIDS, information about HIV-AIDS and willingness to care for PLHA. Binary logistic regressions were used to analyse the data. According to the data from IDHS 2017, 71.84% of total respondents in Indonesia are willing to care for PLHA. Female respondents, individuals in all wealth quintiles and those who have more information are more likely to care for PLHA. Respondents aged 35-49 years old and currently working are less likely to care for PLHA. However, level of education, level of knowledge, residence and earnings are not related willingness to care for PLHA. The dissemination of correct and accurate information about HIV-AIDS can help the community and society understand this condition. Thus, community members can accept PLHA and become more willing to provide care. The government can determine further policies for the appropriate dissemination of information, maximally and in accordance with recommendations. Collaborations among the government, health workers and the community are needed.

HIV non-testing, perpetration of violence against women, and sexual risk-behaviour: A cross-sectional analysis of South African peri-urban township men

Despite HIV testing having improved globally, men remain disproportionately less likely to test for HIV. While violence against women (VAW) and HIV risk have a strong association among women, few studies explore men around VAW perpetration, risky-sexual behaviour, and HIV testing. Males aged 18-42 years were recruited from a peri-urban settlement near Johannesburg, South Africa. Data were from an endline of a trial. We used logistic regression to assess odds of non-HIV testing using STATA 13. At endline, 1508 men participated in the study. Of these nearly one-third (31.6%, n = 475) had not tested for HIV in the past year. HIV non-testing was significantly lower among men who were single, older, did not complete high school and were less food secure. VAW perpetration retained a significant association with HIV non-testing after controlling for socio-demographics (AOR = 0.73, 95%CI = 0.58-0.93). In multivariate models, HIV non-testing was also associated with inconsistent condom use (AOR = 0.64, 95%CI = 0.48-0.85), problem drinking (AOR = 0.72, 95%CI = 0.55-0.94) and reporting of all four risky sexual behaviours (AOR = 0.70, 95%CI = 0.49-1.01). Data suggests that one-third of men who never test for HIV in this setting may represent a high-risk group. Future campaigns could consider behaviour change around non-violence, relationship quality, and gender norms alongside HIV testing.

Costs of Providing HIV Self-Test Kits to Pregnant Women Living with HIV for Secondary Distribution to Male Partners in Uganda

Background: Secondary distribution of HIV self-testing kits (HIVST) to pregnant women attending antenatal care (ANC) clinics to give to their male partners is a promising strategy to increase testing coverage among men, but its costs are unknown. Methods: We conducted micro-costing of a trial evaluating secondary distribution of HIVST on pregnant women living with HIV (PWLHIV) in an ANC in Kampala, Uganda. Costs (2019 USD) were collected from program budgets, expenditure records, time and motion observations, and staff interviews and estimated for three scenarios: as-studied, reflecting full costs of the research intervention, Ministry of Health (MOH) implementation, reflecting the research intervention if implemented by the MOH, and MOH roll-out, the current strategy being used to roll out HIVST distribution. Results: In the as-studied scenario, cost of HIVST provision was $13.96/PWLHIV reached, and $11.89 and $10.55 per HIV-positive and HIV-negative male partner, respectively, who linked to a clinic for facility-based testing. In the MOH implementation scenario, costs were $9.45/PWLHIV, and $7.87 and $6.99, respectively, per HIV-positive and HIV-negative male partner linking to the clinic. In the MOH roll-out scenario, the cost of HIVST provision to pregnant women regardless of HIV status was $3.70/woman, and $6.65/HIV-positive male partner. Conclusion: Secondary distribution of HIVST from pregnant women can be implemented at reasonable cost to increase testing among men in Uganda and similar settings in Africa.

Barriers to HIV testing uptake among men in sub-Saharan Africa: a scoping review

Introduction: HIV testing among men remains low globally and in sub-Saharan Africa (SSA) in particular, when compared with their female counterparts. The aim of this study was to synthesise evidence on barriers to HIV testing among men in SSA using a scoping review method.Methods: A scoping review was conducted, guided by Arksey and O'Malley's framework. A search was made in PubMed, American Doctoral Dissertations via EBSCOhost, Union Catalogue of Theses and Dissertations and SA ePublications via SABINET Online and World Cat Dissertations, Theses via OCLC and Google Scholar. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) chart was used to document the review process. The PRISMA extension for scoping reviews - PRISMA-ScR: checklist and explanation - was also used. The mixed method appraisal tool version 2018 was used to determine the methodological quality of the included studies. Thematic analyses were conducted using NVivo version 11.Results: Key barriers to HIV testing among men in SSA were knowledge of HIV, fear of testing positive for HIV, stigma associated with HIV, healthcare providers' services, confidentiality, and clinic setting.Conclusion: Structural and individual factors present barriers to HIV testing uptake among men in SSA. Community and home-based initiatives have the potential to improve the uptake of HIV testing among men in SSA, considering the confidentiality concerns posed by clinic settings.

Mapping evidence of intervention strategies to improving men's uptake to HIV testing services in sub-Saharan Africa: A systematic scoping review

Background

HIV testing serves as a critical gateway for linkage and retention to care services, particularly in sub-Saharan African countries with high burden of HIV infections. However, the current progress towards addressing the first cascade of the 90–90-90 programme is largely contributed by women. This study aimed to map evidence on the intervention strategies to improve HIV uptake among men in sub-Saharan Africa.

Methods

We conducted a scoping review guided by Arksey and O’Malley’s (2005) framework and Levac et al. (2010) recommendation for methodological enhancement for scoping review studies. We searched for eligible articles from electronic databases such as PubMed/MEDLINE; American Doctoral Dissertations via EBSCO host; Union Catalogue of Theses and Dissertations (UCTD); SA ePublications via SABINET Online; World Cat Dissertations; Theses via OCLC; and Google Scholar. We included studies from January 1990 to August 2018. We used the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. The Mixed Method Appraisal Tool version 2018 was used to determine the methodological quality of the included studies. We further used NVivo version 11 to aid with content thematic analysis.

Results

This study revealed that teaching men about HIV; Community-Based HIV testing; Home-Based HIV testing; Antenatal Care HIV testing; HIV testing incentives and HIV Self-testing are important strategies to improving HIV testing among men in sub-Saharan Africa. The need for improving programmes aimed at giving more information to men about HIV that are specifically tailored for men, especially given their poor uptake of HIV testing services was also found. This study further revealed the need for implementing Universal Test and Treat among HIV positive men found through community-based testing strategies, while suggesting the importance of restructuring home-based HIV testing visits to address the gap posed by mobile populations.

Conclusion

The community HIV testing, as well as, HIV self-testing strategies showed great potential to increase HIV uptake among men in sub-Saharan Africa. However, to address poor linkage to care, ART should be initiated soon after HIV diagnosis is concluded during community testing services. We also recommend more research aimed at addressing the quality of HIV self-testing kits, as well as, improving the monitoring systems of the distributed HIV self-testing kits.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4124-y) contains supplementary material, which is available to authorized users.

Developing national strategies for reaching men with HIV testing services in Tanzania: results from the male catch-up plan

BACKGROUND

According to the 2016-2017 Tanzania HIV Impact Survey, 55% of men diagnosed with HIV during the survey self-reported that they were unaware of their HIV status. As a response, the Government of Tanzania launched a Test and Treat campaign in June 2018 with a focus on reaching men and developed the 2018-2020 Male Catch-Up plan. This article reports (1) the enablers and barriers of HIV testing services (HTS) uptake among men (2) and describes the strategies that were proposed as part of the Male Catch-Up Plan to address some of these barriers.

METHOD

Qualitative in-depth interviews were conducted with 23 men in Dar es Salaam to explore HTS enablers and barriers. To develop the Male Catch-Up Plan strategies, a desk review of published studies, and analyses of national implementers of HIV/AIDS interventions were conducted. An additional 123 interviews were also carried out with key implementers of HIV/AIDS interventions, healthcare workers, secondary school boys and members of the community in Iringa and Tanga.

RESULTS

Enablers of HTS included the desire to check one's health, high HIV risk perception, wanting to protect oneself if tested negative, and being encouraged by their sexual partners. Barriers of HTS were fear of a positive test result, and low HIV risk perception. Proposed strategies from the Male Catch-Up Plan to address these barriers included non-biomedical and biomedical approaches. Non-biomedical strategies are social and cultural approaches to promote an enabling environment to encourage health seeking behavior, safe behavior, and providing peer education programs and social marketing to promote condoms. Biomedical approaches consisted of expanding targeted HIV testing, HIV self-testing, and integrating HIV services with other health services.

CONCLUSION

A number of barriers contribute to the low uptake of HTS among men in Tanzania. National strategies have been developed to address these HTS barriers and guide the national Test and Treat campaign focusing on increasing HTS uptake among men.

"He Told Me to Check My Health": A Qualitative Exploration of Social Network Influence on Men's HIV Testing Behavior and HIV Self-Testing Willingness in Tanzania

Men continue to test for HIV at a low rate in sub-Saharan Africa. Recent quantitative evidence from sub-Saharan Africa indicates that encouragement to test for HIV from men’s network members is associated with higher previous HIV testing and HIV self-testing (HIVST) willingness. Leveraging this positive network influence to promote HIVST among men is a promising strategy that could increase HIV testing. This study investigated the reasons and strategies men used to encourage their peers to test for HIV and the outcomes in order to inform the development of a social network-based HIVST intervention for men called STEP (Self-Testing Education and Promotion). Twenty-three men from networks locally referred to as “camps” were interviewed to explore reasons for encouraging HIV testing, strategies to encourage HIV testing, and outcomes of HIV testing encouragement. Reasons men reported for encouraging their peers to test for HIV included awareness of their peers’ risky sexual behavior, knowing an HIV-positive peer, and having HIV testing experience. Strategies for encouraging testing included engaging in formal and informal conversations and accompanying friends to the clinic. Encouragement outcomes included HIV testing for some men while others remained untested due to lack of privacy in the clinic and fear of HIV stigma. Willingness to self-test for HIV and an interest to educate peers about HIVST were other outcomes of HIV testing encouragement. These findings underscore the potential of leveraging men’s existing HIV testing encouragement strategies to promote HIVST among their peers.

Community-based strategies to strengthen men's engagement in the HIV care cascade in sub-Saharan Africa

Monica Sharma and colleagues discuss evidence-based approaches to improving HIV services for men in sub-Saharan Africa.

Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa

HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.