Introduction

In 2015, an estimated 36.7 million people were living with HIV globally and nearly 40% of people living with HIV (PLWH) were unaware of their HIV status [1, 2]. In an effort to end the HIV/AIDS epidemic, the Joint United Nations Program on HIV/AIDS (UNAIDS) launched the “90-90-90” targets, with the first two goals focusing on achieving that 90% of PLWH learn their status and 90% of those diagnosed with HIV are linked to antiretroviral treatment (ART) [3]. HIV testing is crucial for achieving these targets because it is the first step in learning one’s HIV status and initiating ART for people unaware of their positive HIV status [4]. Though HIV testing services have expanded in the past decade, HIV testing uptake continues to remain lower among men compared to women [4]. The lower HIV testing uptake has resulted in fewer men than women learning their HIV-positive status for the first 90 target in Tanzania. According to the 2016–2017 Tanzania HIV Impact Survey (THIS), only 45% of men living with HIV were aware of their status compared to 56% of women [5]. Among men living with HIV who were aware of their status, 86% of them reported use of ART and 84% of those using ART were virally suppressed [5]. These data suggest that once men who are living with HIV learn their status, a high number of them initiate ART and reach viral suppression, thereby supporting the need to increase HIV testing among men in order to facilitate the achievement of the 90-90-90 targets among men and reduce HIV transmission.

As a response to the high rate of men living with HIV who are unaware of their HIV status, the Tanzania Commission for AIDS (TACAIDS) combined efforts with the National AIDS Control Programme (NACP), USAID, FHI 360 and implementing partners to launch a national Test and Treat Campaign on June 19^th, 2018 called Furaha Yangu! (My Happiness!), with a focus on engaging adult men and adolescent boys in HIV counseling, testing, and treatment [6–8]. As part of this effort, TACAIDS, UNAIDS Country Team, Benjamin Mkapa Foundation (BMF) and other partners are developing the 2018–2020 Catch-Up Plan to increase HIV services uptake among men and adolescent boys [9]. The plan will provide guidance for the nationwide campaign for men and include a set of intervention activities, including HIV self-testing (HIVST), that will be implemented in the next two years [9]. Given that HIVST will be one of the national strategies to increase HIV services uptake among men, the project described in this paper will inform the country’s efforts by identifying potential barriers and enablers of HIVST for men. HIVST, which allows a person to collect their own specimen and perform their HIV test in private, may work better for men who are not reached by facility-based testing [10–12]. In 2016, the World Health Organization (WHO) released guidelines for HIVST and recommended it as a complementary HIV testing approach to reach people (i.e. men) who are not accessing current testing services [13]. Following the WHO HIVST guidelines release, the number of countries adopting HIVST in their national policies increased from 16 to 40 [14].

As of July 2018, Tanzania’s National HIV Testing Guidelines do not allow HIVST [15]. However, there are plans to change the law by the end of 2018 to allow HIVST [16]. In addition, NACP and implementing partners began piloting HIVST projects focusing on key populations to inform the national policy and implementation of HIVST in the country [9]. Since HIVST is not yet allowed in the country there is little information about HIVST acceptability and feasibility, with the exception of two studies reporting that 66% of men in Dar es Salaam who had not tested for HIV in the past 12 months were willing to self-test and that men perceived several advantages and disadvantages to HIVST [17, 18]. Research conducted in other countries in sub-Saharan Africa suggests that HIVST is highly acceptable [19] and reached a high proportion of men in Malawi, with 90% of men aged 16–19 years old reported to have self-tested in 14 neighborhoods where trained resident volunteer-counselors offered oral HIVST kits [20]. In Kenya, secondary distribution of HIVST kits by female sex workers and women receiving antenatal and post-partum care to their male partners was also acceptable and feasible [21, 22]. While these studies have provided preliminary evidence of HIVST acceptability and different strategies to distribute HIVST among men, further research is needed to examine men’s perceptions towards HIVST and follow-up confirmatory HIV testing in case of a positive result in order to inform the successful implementation of HIVST for men.

Based on the Integrated Behavior Model (IBM), a person’s intention to perform a behavior (e.g. HIV self-testing and seeking confirmatory HIV testing), is influenced by their attitude (experiential and instrumental) toward the behavior, perceived norm (injunctive and descriptive), and personal agency (self-efficacy and perceived control) [23]. Experiential attitude is defined as the emotional response to the idea of engaging in a behavior whereas instrumental attitude refers to the beliefs about the outcomes of the behavior [23]. Injunctive norm relates to the normative beliefs about what others in the person’s social network think one should do regarding the recommended behavior and descriptive norm results from an individual’s perception of whether people in their network engage in the recommended behavior [23]. Perceived control describes to what extent a person perceives that their environment facilitates or impedes them from performing the behavior and self-efficacy is the amount of confidence a person has in their ability to perform the behavior [23]. Prior quantitative research, conducted by our team, among men in Tanzania revealed that descriptive norms were associated with previous HIV testing while willingness to self-test for HIV in the future was correlated with injunctive norms [17, 24]. Identifying how other IBM constructs (i.e. attitudes and personal agency) are related to men’s willingness to self-test for HIV and, if needed, to seek confirmatory HIV testing is important to design effective HIVST interventions for men.

For this purpose, we employed two (attitudes and personal agency) of the IBM constructs to assess qualitatively men’s attitudes and personal agency towards HIVST and confirmatory HIV testing to initiate care and treatment. In addition, we inquired about recommendations to address perceived challenges related to HIVST and seeking confirmatory HIV testing in order to inform the development of the Tanzania STEP (Self-Testing Education and Promotion) Project [25] (locally referred to as Mate Yako Afya Yako (Your Saliva Your Health).

Methods

Results

Participants characteristics

As shown in Table 1, the mean age was 27.3 years (± 6.5), ranging from 20 to 51 years old. Less than half (39%) of the men had obtained a secondary education. Nearly half of the men were single (n = 11, 48%), married or cohabiting (n = 11, 48%) as compared to having a non-cohabiting partner (n = 1, 4%). Fifteen (65%) of them were self-employed and approximately half (n = 12, 52%) had obtained an HIV test in the past 12 months. Most men (n = 18, 78%) had no prior knowledge of HIVST but willingness to self-test was relatively high (n = 15, 65%).

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Table 1. Participant demographic characteristics.

https://doi.org/10.1371/journal.pone.0202521.t001

Discussion

For the first aim of this study, men’s attitudes and personal agency towards HIVST and seeking follow-up services such as confirmatory HIV testing were assessed. Since Tanzania has not implemented HIVST, many participants were not aware of HIVST, indicating the need for HIVST awareness campaigns to increase HIVST knowledge and ensure successful implementation and scale-up. Despite the lack of HIVST awareness, most participants had favorable experiential and instrumental attitudes towards HIVST, parallel to findings from studies that included men in Zambia, Malawi and South Africa [32–35]. Similarly, men’s attitudes were positive toward confirmatory HIV testing, with many participants citing the availability of lifesaving treatment for HIV as the reason for their interest in seeking follow-up HIV services and care if their self-test results were to be positive. The availability of lifesaving treatment was also found to be an enabling factor for men to access HIV testing services in Kenya and Uganda, with men living with HIV acknowledging the importance of ART in revitalizing their physical and social lives as well as their familial roles [36, 37]. In Tanzania, the NACP provides HIV prevention, care, and treatment [38] and will publish guidelines for how self-testers can receive additional support to confirm their HIV status and start on treatment if needed. HIV treatment has been provided for free in the country since 2004 [38] and 84% of men living with HIV reported to be using ART during the recent 2016–2017 Tanzania HIV Impact Survey [5], indicating that a high proportion of men may seek care and treatment with proper guidance and support after receiving a positive self-test result.

The primary motivators (privacy, confidentiality, and saving time) men reported for desiring to self-test were consistent with other studies [33, 39, 40]. These HIVST benefits are particularly salient for men since our findings revealed that they are reluctant to test at the clinic in fear of confidentiality and privacy breach. Also, the time saving factor of HIVST was appealing to men since long work hours may prevent men from having the time to attend clinics for HIV testing [36, 37]. A study conducted in Uganda found that men spent long hours at the clinics and were sometimes turned away from clinics because of the mismatch between testing hours and work schedules [37]. Another perceived HIVST benefit is the aversion of fear, anxiety, and intimidation associated with pre-test counseling that is mandatory at health facilities prior to HIV testing. Other studies conducted in South Africa have found similar results with people preferring HIVST because they dislike face-to-face counseling and that HIVST would allow them to circumvent the repetitive, frustrating, intrusive, and time-consuming pre-test counseling offered with traditional HIV testing services [34, 41]. In a more recent study, the optional counseling nature of HIVST was also cited as an advantage among people who had tested multiple times and were subjected to the same pre-test counseling repeatedly [34].

Though HIVST was highly acceptable, some participants raised concerns about the potential psychological and physical harm a positive self-test result may lead HIVST users to experience due to the lack of post-test counseling. While these concerns mirror those reported in other formative research conducted in Kenya, Malawi, and South Africa [33, 42], no HIVST-related violence or suicides were found during a two-year community-based HIVST trial in Malawi where 14,004 residents self-tested and 524 individuals were diagnosed with HIV [20]. Similarly, a systematic review of studies conducted to inform WHO guidance found no HIVST-related harm across the trials conducted in Africa [43]. These findings indicate that although interventionists should be mindful about potential HIVST-related harms, the lack of reported HIVST-related suicides and violence suggest that proper HIVST information, pre-test counseling, and facilitated HIV care assessment [20] can prevent HIVST-related harms. Another concern was the mixed finding related to some participants reporting high self-efficacy to use the self-test properly while others had low self-testing self-efficacy, confirming similar misgivings found in other studies about accurately using the test [39, 44]. In South Africa, these concerns were validated as lack of instructions on how to interpret the self-test results contributed to a low sensitivity of the tests [45], suggesting that different strategies should be in place to ensure that potential self-testers receive additional guidance on how to accurately perform the self-test. For example, participants who received a short demonstration from a trained lay volunteer in Malawi were able to self-test with high accuracy (93.6% sensitivity, 99.9% specificity) [46]. Interventionists should consider providing additional guidance and support to participants in order to increase their self-efficacy to perform the test and thereby augmenting their trust in the result.

Our findings also revealed a low perceived willingness to seek confirmatory HIV testing and initiate treatment at the clinic among a few men due to potential stigma and discrimination. Similar concerns about stigma serving as a barrier to linkage to care among self-testers were reported in South Africa [33]. However, these concerns are not unique to self-testers as men who are diagnosed at the clinic also report stigma and threats to their masculinity and leadership role as barriers to HIV status disclosure and seeking care and treatment [47–50]. In Tanzania, masculinity norms that are associated with ideas of men being strong and dominant prevent men living with HIV from visiting the care and treatment centers [51]. Men report that going to the clinic may raise suspicion about their HIV status and potentially compromise their leadership roles [51]. In contrast, income-generating activities, and factors associated with respectable masculinity such as family and societal expectations to be a family provider and respectable role model encouraged men living with HIV to seek treatment in Uganda [49, 52]. Limited information about linkage to care for self-testing specifically among men in Sub-Saharan Africa exists [43], with one exception [53]. In Kenya, women reported that only 25% of the male partners they distributed self-test kits who had a positive self-test result sought confirmatory HIV testing and linked to care [53].

In the era of treatment as prevention, more efforts are needed to develop and implement strategies to increase linkage to care among men in sub-Saharan Africa such as the effort to develop a national campaign to address men’s fear about HIV testing and treatment in South Africa [54]. For self-testers in particular, home-based confirmatory HIV testing and treatment has been found to increase linkage to care compared to facility confirmatory HIV testing in Malawi [55]. Based on these results, future HIVST interventions in Tanzania should include a home-based confirmatory testing and treatment option to allow men to bypass seeking a confirmatory test at the clinic if they are not inclined to visit a healthcare facility. The acceptability of home-based couples counseling and testing, though different from home-based confirmatory HIV testing, has been shown to be highly acceptable in Northern Tanzania [56]. Another potential strategy to enhance linkage to care among male self-testers is the provision of food and cash assistance, which has been shown to help reduce stigma, improve livelihood, and HIV-related outcomes in Kenya [57, 58]. Similar strategies and effects of food and cash assistance were reported among men and women in Tanzania [59] and are also being evaluated in an ongoing trial [60].

The second aim of this study was to elicit recommendations directly from participants to address the negative attitudes, low perceived control and self-efficacy in the Tanzania STEP Project, a future HIVST and confirmatory HIV testing intervention targeting networks of men who socialize in camps in Tanzania. The respondents provided four suggestions and the first was to provide education about HIVST by their peers or through workshops and media in order to increase men’s knowledge about HIVST. The suggestion to first provide HIVST education is one of the reasons the English name of the study is Self-Testing Education and Promotion (STEP) [25]. Building on the peer health leadership model that our team has piloted [28] and implemented to promote HIV and gender-based violence prevention with men in Tanzania [61], a similar approach will be used in the STEP Project to recruit male camp members and train them to promote HIVST to their peers via conversation and pamphlets distribution. Since most of the participants were not familiar with HIVST, a male peer-based approach for HIVST education and promotion can improve men’s attitudes and personal agency toward HIVST and confirmatory HIV testing. In support of this approach, the Zambia Peer Educators for HIVST (ZEST) study, in which female sex worker peers were engaged to promote and distribute HIVST kits, was found to be acceptable and feasible [62, 63].

The second recommendation was to assess potential users’ readiness to respond to a positive self-test result prior to self-testing. Following this suggestion, one of the key features of the future STEP Project will be to first assess participants’ knowledge about the availability of HIV follow-up services and their willingness to follow the proper steps in case of a positive self-test result. Participants who meet this eligibility criteria will receive the modified WHO HIV testing and counseling without the risk assessment and individualized counseling. A demonstration on how to perform the self-test and interpret the different self-test result lines (negative, positive, faint negative or positive, and invalid), and information on where to seek confirmatory HIV testing and treatment will be provided to the participants. In addition, participants will be informed about the limitations of the self-test, including its inability to detect new infections during the window period [42]. Participants also recommended that mHealth strategies should be incorporated to provide post-test counseling for participants with positive self-test results. Participants mentioned that this could encourage them to seek confirmatory HIV testing and prevent HIVST-related harms. This recommendation aligns with other HIVST studies that have proposed offering participants in-person or phone-based counseling and reminders and options for linkage to care services [33, 64]. Current mHealth and virtual platforms used for online and phone-based HIVST and counseling [45, 65], facility-based HIV testing, and linkage to care and treatment [66–68] can be adapted to provide the pre-and-posttest support that self-testers will need in Tanzania. For example, a study conducted in China found that using an online video to promote HIVST with online real time instructions and pre-test/protest counseling was efficacious in increasing HIV testing in the intervention group (89.8%) compared to 50.7% in the control group [69]. In addition to providing self-testers in future HIVST interventions with mobile phone numbers for study counselors, a partnership can be formed with existing organizations such as the National AIDS Helpline organized by the Tanzania Youth Alliance Organization (TAYOA) to provide HIV counseling over the phone and information about HIV treatment services and voluntary medical male circumcision via text messages [70]. One of the goals of the STEP Project will include adding a mHealth component to provide follow-up services for self-testers.

Conclusion

HIVST was acceptable to this group of men recruited from camps, with the majority reporting positive attitude and high personal agency toward HIVST and confirmatory HIV testing. Negative attitudes towards HIVST can be addressed through peer-based programs that recruit and train peers to promote HIVST in their networks. In addition, assessing one’s knowledge in preparation of accessing HIV services, offering home-based counseling, and providing pre-and-post test support via mHealth technologies can increase the likelihood that self-testers will confirm their HIV status and initiate treatment. Delivering a package of services around HIVST (rather than thinking of it as a stand-alone technology) may increase uptake when the test becomes available and mitigate some of the anticipated social barriers.

Acknowledgments

We would like to thank the camp members who participated in the study. We appreciate the support of Dr. Kepha Mwiti from Immunolabs Medical Supplies Limited for providing the demonstration HIV self-testing kits. We are also grateful for the assistance of Paul Mihas, Dawit Alemu, and undergraduate research assistants (Johnathan Boucher, Hiwot Ekuban, Rhea Jain, Emma Kerr, Shanaya Fozdar, Allison Gray, Adesh Ranganna, Sohil Shah) with the initial coding of the data. We are also thankful for the valuable contributions of Richard S. Youngblood from NC TraCS/CTSA for his review and edits.