PERSPECTIVE
published: 11 June 2021
doi: 10.3389/fpubh.2021.660256
Community-Based Interventions as
Opportunities to Increase HIV
Self-Testing and Linkage to Care
Among Men Who Have Sex With
Men – Lessons From Ghana, West
Africa
Gamji M’Rabiu Abubakari 1*, DeAnne Turner 1, Zhao Ni 2, Donaldson F. Conserve 3,
Debbie Dada 4, Amma Otchere 4, Yaw Amanfoh 5, Francis Boakye 6, Kwasi Torpey 7 and
LaRon E. Nelson 4,8,9
1Center for Interdisciplinary Research on AIDS, School of Medicine, Yale University, New Haven, CT, United States, 2 School
of Medicine, Yale University, New Haven, CT, United States, 3Milken Institute School of Public Health, George Washington
University, Washington, DC, United States, 4 School of Nursing, Yale University, Orange, CA, United States, 5 School of Social
Work at Hunter College, New York, NY, United States, 6 Priorities on Rights and Sexual Health, Accra, Ghana, 7Department of
Edited by:
Population, Family, and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana, 8 Yale Institute of
Marc Jean Struelens,
Global Health, Yale University, New Haven, CT, United States, 9MAP Center for Urban Health Solutions, Unity Health Toronto,
Université Libre de Bruxelles, Belgium
Toronto, ON, Canada
Reviewed by:
Paul S. F. Chan,
The Chinese University of Hong Kong, MSM in Ghana encounter challenges in accessing HIV services and may experience
Hong Kong barriers to HIV self-testing due to multiple forms of stigma present in health care
Michael Marks,
settings. We worked with community-based organization partners to implement three
University of London, United Kingdom
interventions that successfully engaged and retainedMSMwhich provides an opportunity
*Correspondence:
Gamji M’Rabiu Abubakari for linkage to self-testing and medical care. These interventions were (1) Many Men
mohammed-rabiu.abubakari@yale.edu Many Voices (3MV) a locally-led culturally grounded group-level HIV prevention program,
(2) Auntie’s Corner: a mobile-app based connecting MSM to health monitoring by a
Specialty section:
This article was submitted to registered nurse and (3) HIV Education, Empathy, & Empowerment (HIVE3): a mobile-app
Infectious Diseases – Surveillance, based peer support intervention for MSM living with HIV. The 3MV intervention may
Prevention and Treatment,
a section of the journal be effective in improving HIV self-testing due to its effectiveness in engaging MSM,
Frontiers in Public Health increasing HIV testing, and improving MSM understanding of the need for HIV testing.
Received: 29 January 2021 The utilization of apps like Auntie’s Corner could positively impact HIV self-testing
Accepted: 23 April 2021 among MSM because it increases contact with nurses and reporting of symptoms. In
Published: 11 June 2021
HIVE3, participants expressed appreciation of the security and privacy that protects
Citation:
Abubakari GM, Turner D, Ni Z, their identities as MSM and the peer mentors’ abilities to make referrals to the
Conserve DF, Dada D, Otchere A, nurses in Auntie’s Corners. The confidentiality component has proven key among
Amanfoh Y, Boakye F, Torpey K and
MSM and connecting MSM to self-testing through apps to report their process and
Nelson LE (2021) Community-Based
Interventions as Opportunities to receive care could increase utilization. Together, we show the efficacy of using the
Increase HIV Self-Testing and Linkage community-engaged process in reaching and engaging highly stigmatized populations
to Care Among Men Who Have Sex
With Men – Lessons From Ghana, like Ghana and sub-Saharan Africa, and its potential in increasing HIV self-testing and
West Africa. linkage to HIV care.
Front. Public Health 9:660256.
doi: 10.3389/fpubh.2021.660256 Keywords: MSM, Ghana, community-based intervention, HIV self testing, mobile health, HIV peer support
Frontiers in Public Health | www.frontiersin.org 1 June 2021 | Volume 9 | Article 660256
Abubakari et al. Opportunities for Increasing HIV Self-Testing
INTRODUCTION on Rights and Sexual Health (PORSH) to address factors that
impact HIV prevention efforts among MSM in the country.
Globally, men who have sex with men (MSM) have an∼26 times We used the ADAPT-ITT framework to modify the original
greater risk of contracting HIV than the general population (1). 3MV intervention to create a new Nyansapo manual which
Sub-Saharan Africa (SSA) remains disproportionately affected was used for the implementation. The ADAPT-ITT provides
by the global HIV epidemic– accounting for two-thirds of the a guide for needs assessment and selecting interventions and
global disease burden and 73% of HIV-related deaths (2). MSM in modifying the intervention to suit a new population. Nyansapo
SSA countries such as Ghana carry a disproportionate burden of was a retreat-style intervention where participants received
HIV compared to the general population (3, 4). Yet, HIV testing education onHIV and STI risks, HIV testing, andHIV preventive
amongMSM in SSA remains low; a large proportion (two-thirds) measures in a 3-day housed group workshop. PORSH recruited
of MSM living with HIV in South Africa, Kenya, Malawi, and for the intervention in two stages; first by contacting clients
Mozambique remain unaware of their serostatus (5). Although, with who they engaged in the past, secondly, using the snowball
some SSA countries like Ghana have increased efforts to improve technique where participants referred others to join the program.
HIV testing by increasing testing sites, MSM still face significant The recruitment yielded 57 interested persons, of which 56
accessibility barriers (6). Stigma (against MSM identity, gender participated in the program held in four sessions over 60 days.
expression, and HIV status) and misconceptions (e.g., low-risk The person dropped out because of ill-health at the time of the
perception) dissuade MSM from testing regularly (7–9). Many intervention. Details of 3MV and Nyansapo intervention stages
MSM express concerns of confidentiality, discrimination, and and results have been published earlier (12). In brief, condom
judgmental interactions with healthcare workers (6, 7, 10) and use increased by 15% for anal sex (rel. f. = 0.80–0.95), and
never tested for HIV or do not test regularly (11, 12). HIV testing by 13%, (4–17%) amongst participants (12). Also,
HIV self-testing (HIVST) technology can increase HIV irregular testers decreased by 10% (47–37%) and 100% reported
testing among MSM as it allows for testing in the privacy of understanding the need for HIV testing (12). The intervention
their homes (13). Until recently, HIVST was mainly available facilitated the preparation of a prevention menu that MSM used
in high-income countries (14, 15). The 5-year Self-Testing to identify and plan on ways to reduce HIV risk behaviors
AfRica (STAR) Initiative facilitated a widespread scale up and engaging with HIV testing. The retreat environment was
by generating evidence and developing strategic partnerships friendly, protected MSM privacy, and provided a sense of safety.
with manufacturers and regulators that informed the World As a result, they freely expressed themselves, participated in all
Health Organization’s decision to strongly recommend HIVST activities, and created social support networks among themselves.
in 2016 (13, 16, 17). Currently, up to 38 countries actively
implement HIVST policies, and SSA countries receive subsidies HIVE3 and Aunties Corner Overview
from the Gates Foundation (14–16). HIVST can dramatically Aunties Corner and HIVE3 were components of a secure bi-
increase HIV status awareness among MSM because of its directional mobile app messaging system between MSM and a
acceptability, privacy, non-stigmatization, convenience, and team of registered nurses and MSM peers designed to improve
appeal to first-time testers (18, 19). HIVST doubles HIV testing care coordination among MSM with structural or psychosocial
rates, causes no greater social harm than clinic-based testing, barriers to accessing clinic services in Ghana. Aunties Corner
and remains associated with reduced risky sexual behavior linked HIV + MSM with nurses to receive services virtually and
among MSM (17, 20). While previous HIVST studies largely documented frequency of MSM contacts with nurses and HIV
focused on high-income countries (18–20) recent evidence symptoms reports. HIVE3 was developed based on the Dennis
shows improved testing coverage within low-to-middle income Peer Support Model to connect HIV + MSM with trained peer
countries, including in SSA (20–27). WHO guidelines highlight mentors for emotional, and informational support (28). Two
the importance of engaging community members in creating CBOs, PORSH, and Center for Popular Education & Human
and delivering HIVST initiatives (17). However, we have not Rights Ghana (CEPEHRG), led the implementation of both
identified a community based HIVST project has been conducted interventions over 60 days with a convenience sample of 61
among MSM in West Africa. MSM recruited through community outreach. No dropout was
We have conducted three community-based HIV recorded. In the study, each participant was issued a smartphone
interventions with MSM in Ghana (Table 1) that can positively with a pre-installed C5 app, participants received a notification
inform the implementation of HIVST programs in West Africa. every 14 days on their C5 app reminding them of answering
These three studies include a modified version of the Many Men 20 questions about HIV symptoms and their experiences over
Many Voices – 3MV (Nyansapo) intervention, Auntie’s Corner, the past 14 days. Also, participants received a notification every
and HIV Education, Empathy, & Empowerment (HIVE3). 30 days reminding them of answering 34 questions about the
This paper demonstrates how HIVST implementation can be quality of their daily activities and functions over the past
improved with community-based interventions such as the 3MV, month. The intervention was successful in linking MSM living
HIVE3, and Auntie’s Corner. with HIV with care; 52 participants (85%) contacted a nurse,
and 59 participants (97%) reported their HIV symptoms in the
Nyansapo (Wisdom-knot) Overview Aunties Corner. For clarity, contacting a nurse include reaching
The modified 3MV – Nyansapo was designed in collaboration out for direct support, and reporting symptoms include just
with an MSM community-based organization (CBO), Priorities filling a survey about conditions on the app. The intervention
Frontiers in Public Health | www.frontiersin.org 2 June 2021 | Volume 9 | Article 660256
Abubakari et al. Opportunities for Increasing HIV Self-Testing
TABLE 1 | Field lessons for self-testing studies.
Description Applications or lesson for self-testing studies
The efficacy of modified many men, many voices 3MV (Nyansapo) for HIV prevention among men who have sex with men in Ghana
Nyansapo aimed at engaging MSM through the lead of an MSM local organization to • Nyansapo showed that MSM community-based organizations can serve
address HIV knowledge, risk, and increase positive sexual health behaviors and HIV as pathways for successful recruitment and retention of MSM in highly
testing. We used the ADAPT- ITT framework to modify the 3MV into a culturally stigmatized environments for HIV self-testing.
acceptable Ghanaian intervention named Nyansapo. The intervention comprised • Local MSM lead in the implementation of intervention can potentially
seven sessions designed to reduce HIV and STI risk among MSM in Ghana. PORSH increase utilization of self-testing as it can eliminate trust concerns and
recruited 57 MSM, 56 of which participated in the four-session retreat over 60 days. increase acceptability.
They invited a nurse with expertise in STIs to contribute to the discussion. We used • Using culturally relevant manuals can help in setting standards and
an explanatory mixed-method design to test the efficacy of the program. Where we processes for HIV self-testing interventions.
collected a survey at baseline, immediately after the intervention, and one-week • Nyansapo’s retreat participatory format when adopted for self-testing
post-intervention. We also held focus group discussion a week post-intervention to interventions, will create a conducive and private environment for learning
gauge participant experiences and suggestions. We found an increase in condom and demonstration of self-testing among MSM.
use by 15% for anal sex (rel. f. = 0.80–0.95), an increase in regular HIV testing by • Considering the need for results reporting and linkage to care, self-testing
13%, (4–17%). Overall, each participant 1-week post-intervention reported interventions could consider virtual ways of communication. Participants
understanding the need for HIV testing. Participants found the intervention helpful as can be part of a social network and communicate with each other and
it helped them to prepare a prevention menu that they use to self-reflect and to take even healthcare workers via social media or virtual platforms to
conscious efforts to reduce HIV risk behaviors and engaging with HIV testing. communicate challenges and also get access to services.
Participants also found the retreat environment as very friendly, protected their
privacy, and provided a sense of safety. As a result, they freely expressed themselves,
participated in all activities, and facilitated a process of creating and maintaining
social networks among MSM in the country. Details of the results are reported
elsewhere [Abubakari et al. (12)].
Dual-intervention: nurse-led mobile app-based symptom monitoring for HIV positive MSM in Ghana (Auntie’s corner) and HIV education,
empathy, & empowerment (HIVE3)
As a component of our dual intervention, Aunties Corner aimed to test the feasibility • Like Nyansapo, Aunties Corner, and HIVE3 showed that Partnering
and acceptability of a smartphone-based mobile application (app) for use by with organizations serving MSM stands critical to successful HIV-related
HIV-positive MSM to report HIV symptoms and quality of life to registered nurses. As programming such as HIV self-testing.
the second component of C5, HIVE3 aimed to connect MSM living with HIV with • HIV self-testing studies could connect MSM with providers virtually for
trained peer mentors. The goals of HIVE3 were to increase peer social support, support and collection of self-reported data to monitor MSM’s real-time
decrease social isolation, minimize the effects of HIV and same-gender stigmas on HIV testing results and behaviors as MSM are comfortable in using mobile
HIV self-care and healthcare-seeking behaviors. Two local MSM organizations, apps for sharing personal, and sensitive, health information is feasible, and
PORSH), and CEPEHRG led the recruitment and implementation of Aunties Corner acceptable.
and HIVE3 to 61 MSM over a 60 days period. Participants received a smartphone • Community-based strategies can support linkage to care after self-testing
with a pre-installed app, with notifications periodically to answer questions about HIV for MSM who receive a positive HIVST result.
symptoms and the quality of their daily activities. Participants also completed a Peer • HIVE3 showed that virtual peers can serve as a liaison between clients and
Support Evaluation to rate the peer support received. For Aunties, 85 initiated contact nursing staff by helping to promote and provide access to testing tools and
with a registered nurse, and 97% reported their HIV symptoms. HIVE3 was also giving peer to peer guidelines.
found to be feasible and acceptable among our sample of MSM living with HIV in • The success of the use of peers in self-testing will be enhanced if the peers
Ghana. Most participants accessed the HIVE3 app at least one time, and about half receive training to provide increase credibility.
accessed the app at least 10 times. Full results of the acceptability and feasibility • HIVE3 showed that the success of an app-based HIV-self testing
study will be published elsewhere. program will rely on ensuring anonymity between peers and clients.
was deemed feasible and acceptable among HIV + MSM for CBOs as Pathways for Successful
all indicators (supportive interactions, relationship qualities, Recruitment, Retention, and
perceived benefits, and satisfaction). Over three-quarters of the Implementation of HIVST
participants initiated at least one conversation with a peer. Nearly
Partnering with MSM focused CBOs was critical to the success
half regularly communicated with peers using the peer support
of Aunties Corner, HIVE3, and Nyansapo. The CBOs helped
app. The full results of Aunties Corner andHIVE3 studies (which
in recruiting MSM due to established connections with MSM
were approved by Institutional Review Boards of University of
and a history of providing a safe space for MSM to receive
Rochester in the United States, and Kwame Nkrumah University
services and peer support. They also received training to lead
of Science and Technology inGhana) will be published elsewhere.
the implementation. As such, the CBOs can distribute HIVST
kits and reach MSM who avoid in-person testing sites for
convenience and safety reasons (26, 29). Local CBOscan increase
DISCUSSION trust, understanding, and acceptability of the self-testing process.
Hence, HIVST will be more successful if a similar approach
Self-testing researchers can consider the following in ensuring to implementation is taken. Indeed, recruitment and HIVST
reach, engagement, retention, and success in self-testing distribution by peers in CBOs resulted in increased HIVST in
interventions among MSM in stigmatized environments. Uganda (27) and Nigeria (26).
Frontiers in Public Health | www.frontiersin.org 3 June 2021 | Volume 9 | Article 660256
Abubakari et al. Opportunities for Increasing HIV Self-Testing
Culturally Relevant Manuals Can Set community-based approaches after HIVST will enhance linkage
Standards and Processes for HIVST to care and reduction in viral loads amongMSM living with HIV.
Interventions Virtual Platforms Can Connect MSM With
An established manual, created, reviewed, and accepted in
collaboration with the CBOs can provide a standard procedure Providers and Peers for Support and
for engaging HIVST. The use of manuals helped in establishing Collection of Self-Reported Data to
a successful process during our implementation due to the Monitor Real-Time Testing Results and
structure it provided. It remains pertinent that the manual Behaviors
reflects the cultural setting and unique circumstances of the Given the stigma associated with seeking in-person care as an
particular MSM population. As seen in the modification of the MSM in Ghana or other sub-Saharan African countries (7), our
3MV to Nyansapo, the culturally relevant contents will facilitate findings suggest that mobile platforms and digital technology
acceptability, relatability, and discourse that address self-testing could be useful in ensuring a safe and private healthcare-seeking
issues relevant to the cultural setting (12). experience (7, 12). These findings align with prior research
suggesting the benefit of digital technology in connectingMSM to
A Conducive and Private Environment Will health resources and care (7). Using the C4 app, Aunties Corner
Facilitate Learning and HIVST Practice connected MSMwith nurses trained in culturally competent care
MSM face high stigma at various levels (family, friends, for MSM; this approach was found to be feasible and effective.
community) (30). Therefore, researchers engaging MSM must Studies have also found that the use of technology for access
protect their privacy, confidentiality, and security. This practice to social networks has helped with peer support, referrals, and
contributed to the success of our studies and remains significant access to services (35). These findings are similar to those in
for the success of HIVST studies among MSM. In the Nyansapo, the HIVE3 component of the C4 app. In HIVE3 we found that
by creating a secure and private retreat environment MSM providing access to peers via an online app was a feasible and
engaged freely without the threat of danger. They candidly acceptable method of peer support and could be used to refer
recounted their experiences and needs (12). In the HIVE 3 clients to medically qualified nursing staff. Although, Nyansapo
and Auntie’s Corners, the relative anonymity provided by the did not have a virtual component, participants suggested an
C5 app contributed to its high usage and retention rates. This ongoing virtual component as a way to maintain and extend peer
appeal to anonymity was echoed in a study in Thailand where support after completing the Nyansapo intervention (12). A 2014
MSM who reported privacy and confidentiality concerns chose study based in Ghana found that such online social networks
online HIVST intervention over in-person counseling and test could even extend organization research to include MSM not
administration supervision (31). A meta-analysis established already reached by the organization (35).
privacy as an essential benefit of HIVST among MSM (18, 26).
CONCLUSION
Community-Based Strategies Can Support
As HIVST continues to spread across the globe and contribute
Linkage to Care After Self-Testing for MSM immensely to increasing HIV testing acceptability among key
Who Receive a Positive HIVST Result populations, MSM within SSA countries who face extreme
We recommend that HIVST interventions should not only test stigmas at various levels such as family, friends, and even
but follow-up to connect HIV positive participants to care. from health care workers will immensely benefit from this
Although, Nyansapo was successful, it failed to follow-up to new intervention. However, we argue HIVST interventions
continue to engage participants with testing and linkage to need to take into consideration the social circumstances
care. On the other hand, Our Aunties Corner, and HIVE3 facing MSM and incorporate innovative ways to reach and
virtual community-based platforms were successful at linking encourage participation amongMSM in the sub-continent. Using
MSM to HIV care providers. By providing access to community experiences from our previous studies where we engagedMSM in
support networks, the application generated trust and provided Ghana (Table 1), we provide key lessons or suggestions to ensure
a sense of privacy and security to users, which made them feel increased acceptability and usage of HIVST among MSM in SSA.
comfortable contacting nurses on the platform. Researchers in We recommend a grassroots level work that engages MSM via
Nigeria and China highlighted the pivotal role collaborating with established MSM CBOs in order to increase reach, recruitment,
CBOs played in achieving high linkage to care in HIVST studies and retention of MSM, and using MSM peer leadership in
among MSM in their countries, attaining rates of 100 and 87% educating and providing support for MSM. Considering recent
respectively (26, 32). A community-based HIVST study among technology, we suggest the use of the internet and mobile-
men in South Africa achieved a linkage rate of 68% (33). A app technologies to engage MSM in HIVST management and
meta-analysis on studies in SSA showed that facilitated linkage support.When taken into consideration, our research lessons will
to care strategies (such as peers, community health workers, help reduce physical engagement with stigmatizing environment,
or lay counselors following-up after a positive result) increase ensure privacy, confidentiality, and security of MSM, thereby
ART initiation rates by 76% (34). As such, using innovative bolstering confidence and usage of HIVST among MSM in SSA.
Frontiers in Public Health | www.frontiersin.org 4 June 2021 | Volume 9 | Article 660256
Abubakari et al. Opportunities for Increasing HIV Self-Testing
DATA AVAILABILITY STATEMENT AUTHOR CONTRIBUTIONS
The author selected the following statement: The data analyzed in LN and GA conceptualized the paper. GA, DT,
this study is subject to the following licenses/restrictions: We did and ZN led the preparation of lessons for the 3
not conduct a full analysis for the paper, however, we included interventions under consideration with support from
abstracted information to provide context for yet publish results LN and DC. All other authors supported with the
of HIVE3 and Aunties Corner. Requests to access these datasets preparation, writing, and editing of the manuscript
should be directed to mohammed-rabiu.abubakari@yale.edu. with GA overseeing the process and compilation of the
And I did not detect any particular expressions. various contributions.
ETHICS STATEMENT FUNDING
The studies involving human participants were reviewed and This work was supported by the Yale School of Nursing
approved by Kwame Nkrumah University of Science and Independence Foundation Endowed Professorship
Technology - Ghana, and University of Rochester - United States. and the Center for Interdisciplinary Research on
The patients/participants provided their written informed AIDS (CIRA) at Yale School of Public Health (NIMH
consent to participate in this study. grant 5T32MH020031-22).
REFERENCES 12. Abubakari GM, Nelson LE, Ogunbajo A, Boakye F, Appiah P, Odhiambo
A, et al. Implementation and evaluation of a culturally grounded group-
1. UNAIDS. Global HIV & AIDS statistics - 2020 fact sheet. Available online based HIV prevention program for men who have sex with men in Ghana.
at: https://www.unaids.org/en/resources/fact-sheet. Glob Public Health. (2020) 1–18. doi: 10.1080/17441692.2020.1832555. [Epub
2. Amuche NJ, Emmanuel EI, Innocent NE. HIV/AIDS in sub-Saharan Africa: ahead of print].
current status, challenges, and prospects. Asian Pac J Trop Dis. (2017) 7:239– 13. Harichund C, Karim QA, Kunene P, Simelane S, Moshabela M.
56. doi: 10.12980/apjtd.7.2017D6-366 HIV self-testing as part of a differentiated HIV testing approach:
3. Ghana AIDS Commission. 2019 HIV Estimates and National Projections. exploring urban and rural adult experiences from KwaZulu-Natal,
(2020). Available online at: https://www.ghanaids.gov.gh/mcadmin/ South Africa using a cross-over study design. BMC Public Health. (2019)
Uploads/2019%20National%20and%20Sub-National%20Estimates%20and 19:53. doi: 10.1186/s12889-018-6366-9
%20Projections%20Dissemination%2021.07.2020.pdf. 14. Wong V, Jenkins E, Ford N, Ingold H. To thine own test be true: HIV self-
4. Ghana AIDS Commission (GAC). Ghana Men’s Study−2017. Mapping and testing and the global reach for the undiagnosed. J Int AIDS Soc. (2019)
Population Size Estimation (MPSE) and Integrated Bio-Behavioral Surveillance 22(Suppl. 1):e25256. doi: 10.1002/jia2.25256
Survey (IBBSS) Amongst Men Who have Sex with Men (MSM) in Ghana 15. Ingold H, Mwerinde O, Ross AL, Leach R, Corbett EL, Hatzold K,
(Round II), Accra, Ghana. (2017). Available online at: https://www.ghanaids. et al. The self-testing AfRica (STAR) initiative: accelerating global access
gov.gh/mcadmin/Uploads/Ghana%20Men%27s%20Study%20Report(2).pdf. and scale-up of HIV self-testing. J Int AIDS Soc. (2019) 22(Suppl.
5. UNAIDS. Reaching Out to Men and Boys: Addressing a Blind Spot in the 1):e25249. doi: 10.1002/jia2.25249
Response to HIV. Blind Spot (2017). Available online at: https://www.unaids. 16. Population Services International. HIV Self-Testing AfRica (STAR) Initiative.
org/sites/default/files/media_asset/blind_spot_en.pdf. (2020). Available online at: https://www.psi.org/project/star.
6. Ogunbajo A, Kershaw T, Kushwaha S, Boakye F, Wallace-Atiapah ND, Nelson 17. World Health Organization. WHO recommends HIV self-testing – evidence
LE. Barriers, motivators, and facilitators to engagement in HIV care among update and considerations for success. World Health Organization (2019).
HIV-infected ghanaian men who have sex with men (MSM). AIDS Behav. Available online at: https://www.who.int/publications/i/item/WHO-CDS-
(2018) 22:829–39. doi: 10.1007/s10461-017-1806-6 HIV-19.36
7. Kushwaha S, Lalani Y, Maina G, Ogunbajo A, Wilton L, Agyarko-Poku T, 18. Figueroa C, Johnson C, Verster A, Baggaley R. Attitudes and acceptability
et al. “But the moment they find out that you are MSM. . . ”: a qualitative on HIV self-testing among key populations: a literature review. AIDS Behav.
investigation of HIV prevention experiences among men who have sex with (2015) 19:1949–65. doi: 10.1007/s10461-015-1097-8
men (MSM) in Ghana’s health care system. BMC Public Health. (2017) 19. Hoyos J, Maté T, Indave B, Agustí C, Chanos S, Pichon F, et al.
17:770. doi: 10.1186/s12889-017-4799-1 Knowledge, actual and potential use of HIV self-sampling testing kits among
8. Nelson LE, McMahon J, Zhang N, Adu-Sarkodie Y, Mayer KH. Exploring HIV, MSM recruited in eight European countries. HIV Med. (2018) 19:27–
Same-Sex and Gender Non-conformity Stigmas and Delays in HIV Diagnosis, 33. doi: 10.1111/hiv.12593
Linkage, and Retention for MSM in Ghana. National Institute of Mental 20. Peck RB, Lim JM, van Rooyen H, MukomaW, Chepuka L, Bansil P, et al. what
Health (2016). should the ideal HIV self-test look like? AUsability Study of Test Prototypes in
9. Stannah J, Dale E, Elmes J, Staunton R, Beyrer C, Mitchell KM, et al. HIV Unsupervised HIV Self-Testing in Kenya, Malawi, South Africa. AIDS Behav.
testing and engagement with the HIV treatment cascade among men who (2014) 18:422–32. doi: 10.1007/s10461-014-0818-8
have sex with men in Africa: a systematic review and meta-analysis. Lancet 21. Nguyen VTT, Phan HT, Kato M, Nguyen Q, Le Ai KA, Vo SH, et al.
HIV. (2019) 6:e769–87. doi: 10.1016/S2352-3018(19)30239-5 Community-led HIV testing services including HIV self-testing and assisted
10. Gyamerah AO, Taylor KD, Atuahene K, Anarfi JK, Fletcher M, partner notification services in Vietnam: lessons from a pilot study
Raymond HF, et al. Stigma, discrimination, violence, and HIV in a concentrated epidemic setting. J Int AIDS Soc. (2019) 22(Suppl.
testing among men who have sex with men in four major cities in 3):e25301. doi: 10.1002/jia2.25301
Ghana. AIDS Care. (2020) 32:1036–44. doi: 10.1080/09540121.2020. 22. Volk JE, Lippman SA, Grinsztejn B, Lama JR, Fernandes NM, Gonzales
1757020 P, et al. Acceptability and feasibility of HIV self-testing among men who
11. Girault P, Green K, Clement NF, Rahman YA, Adams B, Wambugu S. Piloting have sex with men in Peru and Brazil. Int J STD AIDS. (2015) 27:531–
a social networks strategy to increase HIV testing and counseling among men 6. doi: 10.1177/0956462415586676
who have sex with men in greater Accra and Ashanti Region, Ghana. AIDS 23. Lippman SA, Périssé AR, Veloso VG, Sullivan PS, Buchbinder S, Sineath RC,
Behav. (2015) 19:1990–2000. doi: 10.1007/s10461-015-1069-z et al. Acceptability of self-conducted home-based HIV testing among men
Frontiers in Public Health | www.frontiersin.org 5 June 2021 | Volume 9 | Article 660256
Abubakari et al. Opportunities for Increasing HIV Self-Testing
who have sex with men in Brazil: data from an on-line survey. Cad Saude sex with men and transgender women and factors associated with service
Publica. (2014) 30:724–34. doi: 10.1590/0102-311X00008913 uptake. J Int AIDS Soc. (2018) 21:e25118. doi: 10.1002/jia2.25118
24. De Boni RB, Veloso VG, Fernandes NM, Lessa F, Corrêa RG, Lima RS, et al. 32. Zhong F, Tang W, Cheng W, Lin P, Wu Q, Cai Y, et al. Acceptability and
An internet-based HIV self-testing program to increase HIV testing uptake feasibility of a social entrepreneurship testing model to promote HIV self-
among men who have sex with men in Brazil: descriptive cross-sectional testing and linkage to care among men who have sex with men. HIV Med.
analysis. J Med Int Res. (2019) 21:e14145. doi: 10.2196/14145 (2016) 18:376–82. doi: 10.1111/hiv.12437
25. Rao A, Patil S, Aheibam S, Kshirsagar P, Hemade P, Panda S. Acceptability 33. Shapiro AE, Heerden A, Krows M, Sausi K, Sithole N, Schaafsma TT,
of HIV oral self-test among men having sex with men and transgender et al. An implementation study of oral and blood-based HIV self-testing
population: a qualitative investigation from Pune, India. Infect Dis. (2020) and linkage to care among men in rural and peri-urban KwaZulu-Natal,
13:1178633720962809. doi: 10.1177/1178633720962809 South Africa. J Int AIDS Soc. (2020) 23(Suppl. 2):e25514. doi: 10.1002/jias2.
26. TunW, Vu L, Dirisu O, Sekoni A, Shoyemi E, Njab J, et al. Uptake of HIV self- 25514
testing and linkage to treatment among men who have sex with men (MSM) 34. Sharma M, Ying R, Tarr G, Barnabas R. Systematic review and meta-analysis
in Nigeria: a pilot programme using key opinion leaders to reach MSM. J Int of community and facility-based HIV testing to address linkage to care
AIDS Soc. (2018) 21:e25124. doi: 10.1002/jia2.25124 gaps in sub-Saharan Africa. Nature. (2015) 528:S77–85. doi: 10.1038/nature
27. Okoboi S, Twimukye A, Lazarus O, Castelnuovo B, Agaba C, Immaculate 16044
M, et al. Acceptability, perceived reliability and challenges associated with 35. Green K, Girault P, Wambugu S, Clement NF, Adams B. Reaching men who
distributing HIV self-test kits to young MSM in Uganda: a qualitative study. J have sex with men in Ghana through social media: a pilot intervention. Digit
Int AIDS Soc. (2019) 22:e25269. doi: 10.1002/jia2.25269 Cult Educ. (2014) 6:209–15.
28. Dennis CL. Peer support within a health care context: a concept analysis. Int J
Nurs Stud. (2003) 40:321–32. doi: 10.1016/S0020-7489(02)00092-5 Conflict of Interest: The authors declare that the research was conducted in the
29. Yilu Q, Larry H, Andrew B, Walker JS, Liu F, Thirumurthy absence of any commercial or financial relationships that could be construed as a
H, et al. Experiences using and organizing HIV self- potential conflict of interest.
testing: a global qualitative systematic review. AIDS. (2018)
32:371. doi: 10.1097/QAD.0000000000001705 Copyright © 2021 Abubakari, Turner, Ni, Conserve, Dada, Otchere, Amanfoh,
30. Beyrer C, Baral SD, Van Griensven F, Goodreau SM, Chariyalertsak S, Wirtz Boakye, Torpey and Nelson. This is an open-access article distributed under the
AL, et al. Global epidemiology of HIV infection in men who have sex with terms of the Creative Commons Attribution License (CC BY). The use, distribution
men. Lancet. (2012) 380:367–77. doi: 10.1016/S0140-6736(12)60821-6 or reproduction in other forums is permitted, provided the original author(s) and
31. Phanuphak N, Anand T, Jantarapakde J, Nitpolprasert C, Himmad K, the copyright owner(s) are credited and that the original publication in this journal
Sungsing T, et al. What would you choose: online or offline or mixed services? is cited, in accordance with accepted academic practice. No use, distribution or
Feasibility of online HIV counselling and testing among Thai men who have reproduction is permitted which does not comply with these terms.
Frontiers in Public Health | www.frontiersin.org 6 June 2021 | Volume 9 | Article 660256