Introduction

HIV prevalence in Haiti has remained relatively stable for the last 10 years at 2.0% [1], among the highest HIV prevalence levels in the Caribbean region. Achievement of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets by 2030 hinges upon the first 95 –that 95% of all people living with HIV/AIDS (PLWH) learn their status [2]. Haiti has recorded significant progress in increasing access to HIV testing services within the last decade. HIV testing increased from 5% to 20% among men and 8% to 28% among women between 2005–17 [1]. In 2017, 60% of women reported to have ever tested compared to 41% of men [1]. The persistently high levels of the adult population who have never tested for HIV and the disparity between men and women are concerning for HIV testing and initiation of antiretroviral therapy (ART) [3]. Evidence from a nationally representative sample of heterosexual men demonstrated that condomless sex is high [4] and that HIV testing is associated with less condomless sex [5], indicating the importance of promoting HIV testing among men.

In order to increase HIV testing rates and facilitate early access to treatment, the Haitian Ministry of Health, Ministère de la Santé Publique et de la Population (MSPP), has prioritized finding novel approaches to expanding HIV testing and linkage to care, especially among men. HIV testing among women is a well-established part of antenatal care services (ANC); as of 2016 more than 90% of pregnant and post-partum women were tested for HIV as part of efforts for prevention of mother-to-child transmission of HIV (PMTCT) [6]. In 2012, the MSPP expanded access to lifelong HIV antiretroviral therapy (ART) for all pregnant and postpartum women, regardless of level of HIV disease progression, via the Option B+ program and in July 2016 the MSPP extended universal treatment for HIV to all persons living with HIV (PLWH). Retention on ART at 12 months after starting treatment is estimated at 73.1%, short of the level required for viral suppression [6], and there is evidence that women starting ART during the perinatal period are at elevated risk of loss-to-follow up [3, 7]. Lack of couples HIV testing and disclosure of HIV status between partners is a frequently cited reason for the high rates of ART attrition among Option B+ clients [8]. In this context, finding novel strategies to increase HIV testing among men and to support disclosure of status between partners is needed for progress on the 95-95-95 targets [2].

One promising strategy to reach the first 95 target [9, 10], which has been endorsed by the World Health Organization (WHO) and scaled up incrementally in Haiti since 2017, is Assisted Partner Services (APS) [11]. APS is a voluntary public health service whereby healthcare workers work with newly-diagnosed index clients to identify their sexual partners and close contacts, inform them that they may have been exposed to HIV, and link them to HIV testing services [11]. APS increases disclosure of HIV status by index clients and increases uptake of HIV testing among partners, compared to passive referral for HIV testing by index clients [12, 13]. Other strategies to reach men through their female partners include providing written invitation letters to clinic-based testing services, which are hand-delivered by women to their partners, and using community health workers (CHWs) to trace male partners in the community to invite them to attend clinic-based couple testing services. [14–16].

A second innovative strategy with potential to increase HIV testing is use of HIV self-testing (HIVST). HIVST, which allows people to test for HIV in private, has been shown to be acceptable, feasible, and effective in increasing HIV testing, including among men in Sub-Saharan Africa [17–22]. In 2016, WHO recommended HIVST as a complementary HIV testing approach to reach people (i.e. men) who are not accessing current testing services [11] and released guidelines for planning, introducing, and scaling up HIVST [23]. The benefits of HIVST include privacy, increase of access to HIV testing, earlier diagnosis of HIV and confidentiality of results, and reducing queues for facility-based HIV testing [18]. HIVST can also help bypass barriers such as stigma and discrimination that prevent people from accessing facility-based HIV testing [18]. Recent studies conducted in Tanzania found that more than half of men who had never been tested were willing to self-test [24] and that men are interested in self-testing because of the perceived benefits associated with HIVST such as privacy, confidentiality, and time saving [18, 25].

In the context of higher rates of HIV testing among women, secondary distribution of HIVST kits to men by their female partners [19, 26, 27] is recognized as a specific HIVST implementation strategy. This strategy can be applied via newly diagnosed women living with HIV (WLWH) in conjunction with APS or via HIV-negative women, such as antenatal clinic (ANC) clients [28]. Several studies from Uganda, Kenya, and Malawi have also demonstrated that women-delivered HIVST kits to male partners is acceptable, feasible, and effective in increasing HIV testing among men [26–32]. In a RCT conducted in Kenya, women were randomized to an intervention group that received two oral-fluid-based HIVST kits, instructions on how to use them, and encouragement to distribute an HIVST kit to their male partner or to use both kits for testing as a couple. The control group received invitation cards for their partner to seek facility-based HIV testing [19]. Male partner testing was reported to be higher in the intervention group (91%) than the comparison group (52%) [19]. Women in the intervention group were also more likely to report testing as a couple (75%) than those in the control group (33%) [19], indicating the potential of secondary distribution to increase couple’s HIV testing and HIV status disclosure.

Since the release of the WHO guidelines for HIVST in 2016 and the evidence from several studies, a number of implementation science studies of primary and secondary distribution of HIVST have started [23]. Most notable is the Self-Testing Africa (STAR) project, the largest HIVST project being conducted in Africa (Malawi, Zambia, Zimbabwe, Lesotho, Swaziland and South Africa) [23, 33–35]. More recently, facility-based HIVST compared to provider-initiated testing and counseling was reported to increase HIV testing in a cluster-randomized trial in Malawi [36]. While several HIVST studies, including implementation science projects, have been conducted in Africa and other countries [23], our systematic review of HIV testing interventions literature in the Caribbean [37] revealed that only two studies have focused on HIVST in the Caribbean region [38, 39]. Since the publication of this systematic review, results from a recent study in Puerto Rico revealed that the use of HIVST kits to screen sexual partners was acceptable and helped identify partners of positive HIV status among men who have sex with men (MSM) and transgender women, including sex workers, though some participants faced negative partner reactions when broaching the topic of HIVST [40–44].

While these studies have provided preliminary evidence for HIVST in the Caribbean, heterosexual individuals and PLWH were not included. In addition, little is known about the acceptability and feasibility of secondary distribution by WLWH to their male partners and there is no published literature on the perceptions of local and national stakeholders, including community health workers (CHWs), health program leaders, and clients, about the potential of implementing HIVST and secondary distribution of HIVST in the Caribbean region [37]. The perspectives of CHWs are particularly important because of their central role in community outreach for linkage to care, initiation and retention on antiretroviral therapy (ART) for patients diagnosed with HIV in Haiti [45], and because of their involvement in HIVST initiatives in other settings [35, 46]. In Haiti, the Ministry of Health has recently disseminated guidelines for HIVST to be used in community settings with assistance of CHWs, and targeted projects have focused on social network testing with HIVST targeted to MSM and female sex workers [47]; however, there have not yet been initiatives for secondary or social network distribution of HIVST with heterosexual men.

Based on the effectiveness of HIVST [20] and the interest of Haiti’s Ministry of Health to increase HIV testing among men in Haiti through APS, we conducted formative research with local and national stakeholders to assess perceptions towards integrating HIVST, including via secondary distribution by WLWH to heterosexual men, in Haiti. We also elicited their recommendations for how to implement both primary HIVST distribution and secondary distribution of HIVST for male partners of Option B+ clients in the country. This article builds on previous quantitative research assessing factors associated with HIV testing among men [48] and HIV status disclosure to sexual partners among adult men and WLWH in Haiti [49]. The findings will help to inform future implementation and scaling up of HIVST to increase HIV testing among heterosexual men in Haiti.

Method

Results

Overall, stakeholders had mixed responses about implementing HIVST as a potential HIV testing strategy in Haiti to reach men. There were different views within and across stakeholders groups. and Some of the stakeholders reported that it would be beneficial to have HIVST as an HIV testing strategy while others were not in favor of the strategy due to the lack counseling and resources to support potential self-testers. Most reported that users would prefer the oral versus the blood HIVST kit: “The oral test would be more easily acceptable and usable by everyone than blood.” Among the stakeholders who were not in favor of HIVST, they preferred testing at an institution: “I am for the person to go to test in an institution, we would avoid more damage, because he/she will be able to find professionals available for follow up.” Similarly, several stakeholders had concerns about secondary distribution of HIVST to men by WLWH due to the potential negative reactions and physical abuse by male partners in case their self-test results are positive. To address the low awareness of HIVST since it was not yet available in the country during this study, a few stakeholders recommended that campaigns should be developed to raise awareness about HIVST before piloting different strategies to determine the delivery approach that works the best for each group. Instead of women-delivered HIVST kits, stakeholders recommended that CHWs deliver the HIVST kits to male partners to provide the necessary follow-up support and prevent potential harm to the woman. Stakeholders also recommended working with the formal health sector to prevent non-disclosure of HIVST results and designating a separate section in the hospital for HIVST.

Discussion

This paper highlights the perceptions of stakeholders towards integrating HIVST, including secondary distribution of HIVST, as a strategy to increase HIV testing among men in Haiti. Stakeholders’ views on this topic are both important and timely, since the President’s Emergency Plan for AIDS Relief (PEPFAR)—a key source of external funding for Haiti’s national HIV prevention, testing, care and treatment program—has embraced HIVST as a core programmatic pillar for achieving the 95-95-95 targets [54]. To ensure on-going support from PEPFAR, Haiti and other countries were expected to make rapid progress to scale up HIVST in 2019–20. Similar to other studies [55, 56], our findings revealed that while some stakeholders had favorable views towards HIVST as a potential strategy to reach men others were skeptical. Reasons for stakeholders’ concerns about HIVST and secondary distribution were related to the lack of follow-up services for self-testers, potential harm for WLWH who may deliver HIVST kits to their male partners, non-disclosure, and linkage to care among self-testers who receive a positive self-test result. In order to address these concerns, some stakeholders recommended several strategies and cited the need to raise awareness about HIVST and conduct pilot studies of different HIVST delivery methods.

Regarding the perceived advantages of HIVST, a few stakeholders, including Option B+ clients and male partners, mentioned that HIVST would allow men to test in private, increase the number of people who learn their HIV status and initiate treatment. Our findings also revealed that Option B+ clients and male partners perceived that secondary distribution of HIVST to men by their female partners would be acceptable and preferred over testing at the clinic for different reasons, including the removal of the stress associated with facility-based testing and the ability to keep the test result private. Most importantly, this study also revealed that a few of the Option B+ patients were willing to deliver an HIVST kit to their partners. These findings are supported by a study in Malawi demonstrating that secondary distribution by WLWH to their male partners was acceptable and feasible [57]. While studies in other low-resource settings have reported similar perceived advantages towards HIVST in general [22], the acceptance of secondary distribution of HIVST by women to their male partners appeared to be higher in other studies than we found in Haiti [58, 59]. One major reason for this difference in acceptability of secondary distribution of HIVST is that our study recruited WLWH while other studies included women who were not living with HIV [58, 59]. In addition, previous trials of secondary distribution of HIVST to male partners included mostly women whose HIV status were unknown or were HIV-negative [27, 29, 60, 61]. Thus, the findings from these trials are not necessarily applicable for WLWH. Additional studies are needed globally to examine the acceptability and feasibility of secondary distribution of HIVST to men by WLWH.

Concerning the perception that HIVST can increase the number of people who test for HIV, this finding is supported by a systematic review and meta-analysis that showed that HIVST doubled the uptake of testing among men [20]. However, linkage to care among self-testers has not been examined in most studies and more data are needed to support our finding that more people will start treatment if they learn their HIV status through self-testing. One study conducted with men in Malawi found that men who self-tested were more likely to attend the clinic for linkage to care or prevention if they received a financial incentive compared to men receiving standard services without an incentive [62]. The likelihood of self-testers not linking to care in case of a positive result was raised as a perceived disadvantage in our study and is supported by evidence from other studies that have demonstrated that self-testers are less likely to link to care without additional interventions such as financial incentive or home initiation of ART [62, 63]. Future research in Haiti and elsewhere should implement strategies to objectively measure HIVST use and linkage to care among self-testers.

Other concerns raised by stakeholders about HIVST and secondary distribution of HIVST by WLWH included, but were not limited to, lack of counseling, suicidal ideation, HIV nondisclosure, the risk for a man to be verbally and physically abusive. These concerns were raised by health program managers, HCW, and Option B+ clients alike. While all the concerns about HIVST in general are consistent with the literature and with concerns raised in Sub-Saharan African settings prior to scale-up of HIVST programs [22], the evidence base on secondary distribution of HIVST by WLWH to their male partners is less robust. In our study in Haiti, all groups of stakeholders recognized that access to HIVST via secondary distribution would be a favorable option for some clients, and several Option B+ clients expressed strong enthusiasm for this option. Therefore, more research is needed to determine how best to implement such a strategy in Haiti and other settings with moderate or low overall HIV prevalence, especially for men who are unaware that their female partners are living with HIV.

In this study, stakeholders recommended several strategies to address the concerns before implementing HIVST in Haiti. These recommendations are broad and can be applied towards implementing both primary and secondary distribution of HIVST, especially for male partners of WLWH. Specifically, stakeholders recommended campaigns to raise awareness and educate people about HIVST, piloting of different strategies, and engaging the CHWs in conjunction with the formal health sector. There is potential for Haiti to broaden its model of using HIVST to increase HIV case detection. Different HIVST campaign strategies and distribution models for HIVST, including self-testing with supervision from formal health sector workers [64], have been piloted and evaluated successfully in RCTs conducted in other countries [19, 65]. Volunteer residents, community HIV care providers, women, and peer educators have been engaged to promote HIVST by distributing flyers and HIVST kits to community residents, male partners, and peers [19, 30, 46, 63, 66–68]. Fishermen living with and without HIV have been recruited and trained to promote HIVST among their peers by distributing leaflets and HIVST kits to other fishermen in their networks in Uganda [17].

In Haiti, men from formal and informal employment sectors, such as public transportation drivers, fishermen, schoolteachers, can also be trained to promote and distribute HIVST kits to their peers and younger men. CHWs already involved in providing community HIV services in Haiti [45] can also be engaged, as recommended by some stakeholders, to promote HIVST and distribute HIVST kits to community residents, including men via either primary distribution or secondary distribution. Other campaign strategies that have been used to promote HIV testing that can be translated to HIVST promote include social entrepreneurship [69, 70], crowdsourcing [71], and hosting free star-studded concerts with concurrent HIV testing and education [72]. In addition, evidence from Kenya, Uganda, and Zambia indicate that HIVST is acceptable and feasible among users of pre-exposure prophylaxis (PrEP) [73, 74]. As the MSPP begins PrEP implementation in Haiti, HIVST could be incorporated in the PrEP program to reduce the number of facility-based visits for HIV testing to confirm PrEP users are HIV-negative before receiving PrEP refills [74, 75]. In summary, stakeholders in Haiti endorsed several recommendations which have a solid base of evidence in other settings, suggesting that the MSPP can draw upon WHO guidelines for planning, introducing, and scaling up HIVST [23] while also seeking culturally and contextually-appropriate implementation strategies for these recommendations.

Conclusion

In summary, this study indicates that a few stakeholders are supportive of implementing HIVST in Haiti. However, there were several areas of important skepticism about the strategy. A prominent concern was due to the lack of follow-up services to assist self-testers to receive proper counseling and enroll on treatment in case of a positive self-test result. In addition, many stakeholders reported concerns about secondary distribution of HIVST by WLWH to their male partners who are unaware their women are living with HIV. Our findings suggest the need for more research in Haiti to determine how to address these concerns such as potential physical and social harms related to HIVST, especially for WLWH who may engage in secondary distribution of HIVST.

Supporting information