Background

There has been significant progress in HIV prevention efforts across Africa [1–5], however men who have sex with men (MSM) continue to bear a disproportionately heavy burden of HIV infection compared to the general adult population [6]. The risk of acquiring HIV is 27 times higher among MSM compared to other heterosexual men [7]. Surveillance data from low and middle-income countries (LMIC), shows that MSM are 19.3 times more likely to be living with HIV than the general population [8]. Kenya has the third largest population of people living with HIV in sub-Saharan Africa and the highest national HIV prevalence of any country outside of Southern Africa [9]. HIV in Kenya is characterized as a generalized epidemic among the adult population, and a concentrated epidemic among key populations [10]. The MSM population in Kenya commonly encompasses a range of sexual and gender identities, including homosexual, gay, bisexual, transgendered, and heterosexual. MSM may be married, gay, or sex workers [11]. The Kenya AIDS Strategic Framework 2014/15–2018/19 identified MSM and male sex workers (MSWs), as key populations and has prioritized these populations for HIV/AIDS prevention [12]. HIV prevalence among the MSW and MSM in Kenya is 4 to 5 times higher than in the among the general population [11]. HIV prevalence in 2010 among MSM in Kenya was an estimated 18.2% [13]. According to the Kenya HIV Prevention Response and Modes of Transmission Analysis (2008), 15.2 percent of new infections were attributed to MSM [14]. In 2007, HIV prevalence among MSM/MSWs with exclusively male partners was 41 percent in Mombasa [15]. The above findings further confirm the assertion by the Kenya AIDS Strategic Framework 2014/15–2018/19, that the MSM and MSW should be prioritized in controlling the HIV epidemic in Kenya.

More than half (53%) of the 1.6 million people living with HIV in Kenya are unaware of their HIV status [16]. The 2019 HPTN 075 study, aimed at evaluating the accuracy of self-reported HIV status among African men who have sex with men, indicated that self-report of HIV positive status at screening was less common among participants who reported sex with men and women compared to men who reported sex with men only, perhaps due to concerns about inadvertent disclosure about their same-sex behaviors [17]. In this report, approximately one third of the HIV-infected MSM who did not report a prior HIV diagnosis to study staff had ARV drugs detected and were classified as previously diagnosed [18]. It is estimated that new HIV infections could be reduced by 30% per year, if all HIV positive individuals were aware of their serological status [19].

The World Health Organization (WHO) recommends that all MSM test for HIV at least annually and those MSM who have multiple or anonymous partners or use illegal drugs should test at least every 3 or 6 months [20]. Additionally, the United Nations Programme on HIV/AIDS (UNAIDS) advocates that at least 90% of people should know their HIV status, 90% of those diagnosed linked to anti-retroviral (ARV) treatment and 90% of those on treatment achieving viral suppression [21]. Achieving “the first 90%” is a critical step in the elimination of new infections by 2030 [22]. However, more than 75% of MSM in low and middle-income countries lack access to HIV testing services [23]. There is therefore urgent need to develop and implement innovative initiatives that promote HIV testing, especially among the MSM community. HIV self-testing (HIVST) is a process where an individual conducts a HIV test on their own specimen (oral fluid or blood), and interprets the result. HIVST can be performed in a private setting, either alone or with a trusted person. Since HIV self-testing does not provide a definitive diagnosis, individuals whose tests positive for HIV are advised to seek confirmatory testing with a health provider, in line with the national HIV testing algorithm [24].

Recent research conducted in Zimbabwe, Zambia, Lesotho and Kenya revealed that HIVST is feasible, acceptable among health workers and the general population [18,22,23,25–27]. The Kenyan government introduced self-testing kits as part of “Be Self Sure campaign in May, 2017. The kits are now available to buy from pharmacies for around 8–10 United States Dollars (USD). There is potential for HIVST to enhance access to HIV testing especially within the MSM community [28], even though uptake of HIV Testing Services (HTS) among the MSM is low, compared to those in the general population due to barriers such as stigma, discrimination and poor quality of services [29].

Countries around the world are at different stages of development and implementation of HIVST guidelines. There is however no optimal approach for implementing HIVST targeting the MSM community. Very few studies have examined any aspect of HIVST among MSM in Sub-Saharan Africa [26,27]. In Kenya studies have been conducted to understand the feasibility of scaling up HIVST within the general population, including among sero-discordant couples and FSWs, yet there is little information on HIVST among MSM specifically [28,29]. Although global evidence suggests that introduction of HIVST can benefit MSM, evidence is limited on how, when, and in what contexts the delivery of HIVST to MSM could increase awareness of HIV status, and lead to early linkage to HIV treatment and prevention services in the African context [30]. Innovative interventions geared towards promoting testing among the MSM community must overcome key barriers to testing such as stigma, fear about confidentiality of venue testing, distance to testing sites and opportunity cost [31]. We conducted this research to explore acceptability and factors that would facilitate uptake of HIV self- testing among the MSM community in Nairobi.

Methods

Results

Demographics, social-economic factors

About (86.6%) of the interviewees were Kenyans. Two-thirds (64.0%) of the interviewees were aged 18–24 years of whom 86.6% were single and only 13.4% were married. A majority of the interviewees were Christians 244 (71.8%). Education attainment was high with (59.8%) reporting at least secondary education and (40.2%) tertiary level of education, however, employment status was low with (72.7%) reporting that they were unemployed. Slightly more than half (52.8%) reported earning more than 60 United States Dollars (USD), while (47.2%) earned less than 60 USD per month. More than half of all respondents (58.8%) self-identified as MSW, while the rest (41.2%) identified as MSM, (Table 1).

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Table 1. Respondent demographic & social economic information.

https://doi.org/10.1371/journal.pone.0280540.t001

Uptake of HIV self testing

Of all the participants, (55.9%) reported HIV self-testing. More older respondents aged >25 years (53.51%) reported having ever used HIV test kit, than those aged between 18–24 years (39.9%), POR 1.73 (1.09, 2.75). Some of the HIV risk behaviors for the interviewees include having multiple sexual partners and being MSW. A higher proportion of the interviewees (90.8%) affirmed that they used condoms during the last sex act. However, (57.7%) consistently used condoms. Regarding the preference in sex position, most of the interviewees were versatile, they preferred being either on top or bottom. Comparatively fewer Kenyans (42.96%) than non-Kenyans (57.78%) indicated that they had ever used HIV self-test kit. Cross-tabulation analysis of ever used HIV test kit by employment status showed that (40.43%) of the employed and (47.2%) of the unemployed had used the kit POR 1.32 (1.67, 2.60). There was a higher chance of employed respondents using the HIV test kits at (32%.) than the unemployed. The interviewees who were single were (86.61%) and married (13.39%) had statistical significance with POR 1.82 (1.96, 3.43) one use of HIV self test kit. There were more study participants who reported having used a condom during last sex and had used HIV test kit (47.21%), than those that had not used a condom during sex and had ever used an HIV test kit (29.03%) POR 2.19 (1.98, 4.90). Participants who reported condom use at last sex were nearly 2-times more likely to have had a self- HIV testing POR 2.19 (1.98, 4.90). Half the respondents (50.63%) indicated that they considered the window period in deciding when to test POR 1.47 (1.96, 2.25). The participants who reported that if they test positive on self-HIV testing were more than 2-times likely to report they would use protection or condoms with their partner POR 1.32 (1.67, 2.6). On univariate analysis, sex position, POR 1.01 (0.94, 1.08) did not influence uptake of HIV self-testing, Table 2.

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Table 2. Uptake of HIV self -testing & risk factors.

https://doi.org/10.1371/journal.pone.0280540.t002

HIV self-test acceptability, uptake & associated factors

About (77%) of the respondents were willing to self test for HIV. Among the factors influencing HIV self-testing that had a statistically significant association at Pearson Chi-Square P-value <0.05 at 95% confidence interval were frequency of HIV/AIDS test, considered the window period in deciding when to test, use protection or condoms with partner if HIV/AIDS positive, ever heard of HIV self-test, ever heard of oral HIV Self-test, heard of blood sample HIV Self-test, would prefer to use the Oral or Blood self-test kit and what do you think of the current cost, Table 3.

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Table 3. HIV self-testing acceptability, uptake & associated factors.

https://doi.org/10.1371/journal.pone.0280540.t003

Multivariate analysis for HIV self-testing among MSM

We used the measure of association (Chi-Square) and Prevalence Odds Ratio (POR) to inform the variables included in the multivariate analysis. The covariates of HIV self-testing were: respondent’s age, MSM aged 25 and above were more likely to have used HIVST than those 24 years and below; place of birth, frequency of testing for HIV/AIDS- habitual testers were more likely to have used HIVST kits than non-habitual testers; if HIV positive through HIV self-test, would go for a confirmatory test, if confirmatory test shows negative, after how long would you seek a re-test after the current negative result test. Those that would test regularly even if previous HIV test was negative, were more likely to have used the test kit, Table 4.

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Table 4. Multivariate analysis of covariates for HIV self-testing among MSM.

https://doi.org/10.1371/journal.pone.0280540.t004

Discussion

The findings of this study significantly contribute towards the generation of evidence on HIV self-testing among the MSM in Kenya as proposed by World Health Organization (WHO) 2016 guidelines [57]. This study majored on HIVST among MSM and MSW in Nairobi and the peri-urban neighboring.

The study suggests that there is a significant association between HIV self-testing and frequency of testing. MSM who used HIV self-test kits had a higher frequency of testing. Habitual HIV testers were more likely to have used the HIVST kit than the non-habitual testers and this finding is consistent with other findings that suggest that regular testing is often associated with other protective measures such as education, fewer sexual partners as well as the mindset to care for self and partners [58,59]. Our findings are also in agreement with MSM randomized to HIVST access Vs. standard clinic-based testing in Seattle, the mean number of HIV test and quarterly testing increased significantly among those in the HIVST, with no increase in risk behaviors [60]. Kenya’s National HIV testing guidelines recommends re-testing of HIV negative MSM every three months [61]. To achieve the above target, both clinic-based setting and HIV self-test options should be scaled up within the MSM community.

Our study findings show that most of the MSM preferred blood sample self-test kits as compared to oral self-test kits, most of the interviewees preferred blood sample self-test kits, since they believe the blood test will be more accurate than oral self-test. These findings are in line with a study conducted in South Africa among the MSM community that showed higher preference for fingerstick tests over oral fluid tests among the interviewees [62]. Our findings differ from study findings conducted in the US emergency department, where most of the respondents prefered oral fluid testing [63]. Given the diversity of preference for either blood sample or oral test kits and the ovewhelming support for HIVST, we would highly recommend the availability and distibution of both types of self kits to the MSM community in Kenya.

The Non-Govermental Organisations (NGO) facilities/drop in centres were the most preferred distibution points for the HIV self- test kits. Other distibution points include the private sector and the public/government facilities. Our findings differ slightly with a study conducted by Okal et al., [64], that’s showed that most of the respondents preferred public health care facilities but for the general population. The variance in the findings can be attributed to the fact that the MSM community feel stigmatized and also due to the illegal nature of homosexuality in Kenya, hence the MSM would want to stay far away from the public/Government healthcare providers. Site preference is also largely based on proximity and cost. A study conducted among general adult population showed that “easily available” as the strongest reason for which ever pick up point [65]. A study conducted in Nigeria found that MSM prefer to pick the kits from the MSM friendly drop in centers, and community health clinic (CHC) [48]. Future HIVST distribution should consider drop in centers and community pharmacies as options of distribution sites. Peer educators or Key Opinion Leaders (KOL) are still an option to be considered, though this approach would have high cost implications.

A high proportion of the respondents (80%) indicated that if they tested for HIV positive through HIV self-test, they would go for counselling and confirmatory test. Our findings are consistent with findings from a cross-sectional study done in Kenya, that showed that 74% of the respondents would seek counselling services, confirm results or seek medication after a positive HIVST [66]. Pre-test counselling should be offered before dispensing the HIV self-test. This would provide an opportunity for client to get all the information they would need before testing. The provision of information before testing would be crucial in guiding the clients on how to use the test kits, so as to reduce invalid results also the clients would know what to do depending on the results and where to seek for the healthcare services. Pre-test counseling data can also be used for monitoring the patients and for follow-ups.

A significantly high proportion of the respondents (92%) would go for confirmatory test within one month of testing. Our findings are slightly higher than a study conducted in Kenya in 2014, [66] that reported 61% of the general population sampled and 40% of MSM would go to a clinic for a confirmatory test. This demonstrates that the MSM who self-test are willing and will still link to the healthcare system. A major concern for HIVST is whether self-testers will seek care and treatment depending on the results. Being able to link to care within a week is considered optimal behavior given that linkage to care is defined as “having visited a health care provider within 30 days of being diagnosed with HIV [67]. There is therefore a challenge and a potential in enhancing uptake of HIVST among MSM. The opportunity is that, during the implementation of HIV self-test, home visits by the healthcare workers, encouraging the MSM to visit MSM friendly clinics, and calls and short message service (SMS) can potentially be utilized to ensure that the MSM that test HIV positive are not only linked to care, but are not lost in follow-up. A study conducted in Nigeria among the MSM community showed a 100% linkage to HIV and treatment [68], indicates potential viability of the suggested strategy to link and retain MSM in care. The high linkage in that study was likely due to follow-up calls after HIVST distribution, the ease of participant’s access to the opinion leaders and also the linkage to a well-trusted MSM-friendly facility that offers HIV prevention services. Studies conducted in other areas reported both fairly low [69] and high [70] linkage to HIV care and treatment after self-testing.

The use of a “test buddy” may potentially increase uptake of HIVST. A significantly high number of MSM indicated that they would prefer a testing “buddy” on the first time of self-test kit use. There was a statistically significant association between respondents who had never used a HIV self-test kit and the respondents’ need of a testing partner on first time use of HIV self-test kit. A HIVST validation study was conducted in Kenya, that reported a higher rate of invalid HIV results (37/ 239 = 15.5%) [65]. The findings are also consistent with another study done among Chinese MSM, that showed significant errors during the process of conducting HIVST that rendered almost half of the test results invalid [71]. According to that study, failure to follow the manufacturers instructions was the main cause of invalid results both for oral self test and blood sample test kits. For the finger prick users, most of the errors occurred during the stage of collecting specimen and for oral fluid users made most of the errors during the stage of testing the collected specimen. A testing partner or “buddy” would also help the MSM first time testers get accurate results.

The high cost of the test kits, lack of knowledge on correct usage of the test kits, fear, stigma and inaccessibility of HIV self-test kits were the main hindrances on the use of the kits. Most of the respondents indicated that the estimated current market cost of the self-test kit was expensive at 8–100 USD. The preferred cost of the HIVST kit was about half to one USD. Lack of appropriate knowledge on the use of HIVST kits would prevent the MSM from using the kits. This correlates to studies showing several ways in which errors would happen, this would include during sample collection using the swab, also the handling of the swab and following the procedures [65,72].

This study has some limitations. The study is based on respondent self-reports on HIVST use, and as such the veracity of such reports could not be easily determined within the design of this study. Despite the fact that the respondents, were recruited through methods designed to generate a representative sample, the sample is unlikely representative of all MSM in Kenya, since most of the respondents were young and of low and medium economic status. Demonstrating that the older and MSM with higher economic status were not represented. There is likelihood of bias in the sample as this was response driven and typically referrals through such a strategy implies that potential respondents will be drawn from friends, colleagues and known networks of the individuals making such referrals. The respondents were also drawn from Nairobi and the neighboring county, where the MSM community has been receiving considerable support from the NGOs as compared to MSM in other regions of the country. Future studies should prioritize the elder generations and also the MSM with higher income status and also from other regions of the country with few HIV prevention interventions.

Conclusions

This study has showed that age, habitual testing, self-care/partner care, as well as confirmatory testing and immediate introduction into care if found seropositive were associated with having used an HIVST kit. All the above are factors that potentially would also encourage prompt enrollment into linkage to care and treatment after self-test. Some of the key facilitating factors for HIVST uptake among the MSM community in Kenya include; awareness creation on the importance of frequent HIV testing, counselling pre and/ or post testing, emphasizing the importance of testing buddies for first- time testers and reducing the cost of the current HIV self-test kits. A potential strategy to increase the uptake of HIV-self testing would be using sexual and social networks as an entry point. This is based on the conceptual framework, the importance of testing buddies as well as the existence of sexual networks through which respondents were identified and recruited. Blood sample test kits are more preferred than Oral test kits. This study contributes to the pool of knowledge on the characteristics of MSM that would adopt and embrace HIVST, and demonstrates that the MSM are self and partner care aware and conscious. The challenge however remains on how to encourage those that are not self/partner care aware to embrace HIV testing and particularly HIVST as routine practices. Future studies may need to explore potential motivators to self-test among the young, elder MSM generations and the MSM with higher economic status.

Supporting information

Acknowledgments

We thank all participants for supporting this study.