ORIGINAL RESEARCH published: 17 June 2022 doi: 10.3389/fpubh.2022.888059 Awareness and Use of HIV Self-Testing Among Men Who Have Sex With Men Remains Low in Spain 2 Years After Its Authorization Juan-Miguel Guerras 1,2 , Juan Hoyos 3*, Luis de la Fuente 1,2 , Marta Donat 2,4 , José Pulido 2,5 , Luis Sordo 2,5 , Patricia García de Olalla 2,6† and María-José Belza 2,4† on behalf of the Methysos Project Group 1 Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain, 2 CIBER Epidemiologia y Salud Pública, Madrid, Spain, 3 Independent Researcher, Madrid, Spain, 4 Departamento de epidemiología y bioestadística, Escuela Nacional de Sanidad, Instituto de Salud Carlos III, Madrid, Spain, 5 Departamento de Salud Pública y Materno-Infantil, Universidad Complutense de Madrid, Madrid, Spain, 6 Servicio de Epidemiología, Agència de Salut Pública de Barcelona, Barcelona, Spain Edited by: Objectives: HIV self-testing has been available in Spain since 2017 as a diagnostic tool Tafadzwa Dzinamarira, to promote earlier diagnosis. We aimed to assess awareness and previous use of HIV University of Rwanda, Rwanda self-testing in a sample of men who have sex with men (MSM) recruited online more than Reviewed by: Grant Murewanhema, 2 years after its legal authorization in Spain. University of Zimbabwe, Zimbabwe Methods: We analyzed 5,492 MSM recruited between May and July 2020 in gay dating Tolulope Olumide Afolaranmi, University of Jos, Nigeria apps/websites and other social networks. We estimated the proportion of participants *Correspondence: who were aware of the existence of HIV self-testing and the proportion who reported Juan Hoyos previous use. To identify factors associated with both outcomes we built two Poisson hoyosmiller@hotmail.com regression models. Among those who reported previous use we described several † These authors have contributed aspects related to their last self-test. equally to this work and share senior authorship Results: Awareness of HIV self-test was reported by 29.7% and its previous use by 5% of participants. Awareness was independently associated with recruitment in gay dating Specialty section: apps/websites, being ≥40 years old, born in Spain-other European countries, having This article was submitted to Infectious Diseases - Surveillance, higher educational level, living in medium-small municipalities and living sex life openly. Prevention and Treatment, Independent associations were also found with having received a sexually transmitted a section of the journal Frontiers in Public Health infection diagnosis (STI) or an HIV negative test in the last 12 months, and being HIV Received: 02 March 2022 positive. Use was significantly higher among participants who were paid for sex or Accepted: 16 May 2022 diagnosed with an STI in the last 12 months and who received their last HIV test in Published: 17 June 2022 the preceding year. Self-testing occurred recently, with kits acquired at pharmacies and Citation: carried out alone. Guerras J-M, Hoyos J, de la Fuente L, Donat M, Pulido J, Sordo L, García de Conclusion: Awareness and use probably have not increased sufficiently in order Olalla P and Belza M-J (2022) to make a relevant impact to the promotion of early HIV diagnosis. Additional efforts, Awareness and Use of HIV Self-Testing Among Men Who Have mainly focused on less favored MSM, should be made to take better advantage of the Sex With Men Remains Low in Spain possibilities offered by this testing option. 2 Years After Its Authorization. Front. Public Health 10:888059. Keywords: early diagnosis, HIV self-testing (HIVST), self-diagnosis, infectious disease, men who have sex with doi: 10.3389/fpubh.2022.888059 men (MSM) Frontiers in Public Health | www.frontiersin.org 1 June 2022 | Volume 10 | Article 888059 Guerras et al. HIV Self-Testing Awareness and Use INTRODUCTION never sought testing and those who already were HIV positive. Additionally, the sample was comprised almost exclusively by In 2020, 1.925 new HIV cases were reported to the Spanish participants who lived in the aforementioned major cities both of surveillance system of which 52.2% were acquired through which are more than 1.000.000 inhabitants and did not include sex between men (1). Early diagnosis is the gateway to MSM from medium-sized cities and rural areas who might have treatment which reduces morbidity (2, 3) and mortality (4) different testing needs. and drastically reduces the probability of transmission to an In this study, we analyzed an online sample of MSM recruited uninfected individual (5). Early diagnosis is in fact one of the through gay dating websites/apps and other social networks main elements of the UNAIDS 95-95-95 strategy to end the HIV more than 2 years after the authorization of HIV self-testing in epidemic. According to this strategy, by 2030, 95% of people Spain and assessed their awareness of its existence as well as the living with HIV should be diagnosed, 95% of whom should level of previous use and describe several aspects related to the be on treatment, 95% of whom should have undetectable viral self-testing process. load (6). Testing in Spain is offered confidentially and free of cost METHODS at all levels of the national health system. It is also offered in sexual health clinics which are public, free, low threshold Participants facilities oriented toward the most vulnerable population groups We performed an online based cross-sectional study between (7). Outside clinical settings, rapid testing is also offered May and July 2020. We included 5,492 participants who were free of cost in Community Based Organizations (8) and male at birth, who reported ever having had anal sex with another in community pharmacies (9). However, in Spain 16.5% of man and who were legally old enough to have sex at the moment MSM living with HIV remain undiagnosed (10) and delayed of participation. diagnosis is still common with 39.6% of newly diagnosed MSM No sample size calculation was performed. We used non- in 2020 presenting at a late stage of infection (CD4 count probabilistic convenience sampling to recruit the largest possible of <350 mm3) (1). sample of MSM. HIV self-testing is the latest incorporation to already existing testing options and aims at making HIV diagnosis more Recruitment and Data Collection accessible. In Spain, it was authorized in December 2017 (11) and Instrument can now be purchased at pharmacies at a cost of 25–30 euros. In Recruitment was mainly carried out using two dissemination this methodology, individuals need to perform their own test and methods. First, participants were invited to participate through interpret the results. Self-testing kits can be blood or saliva based personal messages and promotional banners distributed through and, if reactive, confirmatory testing is required. Clinical trials gay dating apps and websites. Invitations were only presented to have proven its capacity to increase testing frequency among participants accessing from Spain. Secondly, we also contacted MSM (12–14) and online studies conclude that self-testing is several Spanish youtubers and Instagram influencers with LGTB highly acceptable to MSM (15) who are largely in favor of it (16). oriented content who agreed to promote the study (hereafter Nevertheless, its real use is difficult to ascertain since no data Social networks other than dating apps). We provided unique is available on the number of self-testing kits sold. Additionally, links to each recruitment site to identify the recruitment site of surveillance data does not publish information on the type of each participant. Those interested in participating were directed test used in newly diagnosed individuals. Self-reported data on to an initial screen where they were informed about the aim awareness about the existence of self-testing and previous use is of the study, the funding source and the approximate length of one way of overcoming this data shortage. In Spain, a number the questionnaire (10–15 min). To avoid multiple participation, of studies assessed awareness about the existence and use of the initial screen also included a request to only complete the self-testing by MSM in online recruited samples (15, 17) and questionnaire once if invitation was received through various among attendees of a rapid testing program (18). All of them ways. Additionally, to further limit the possibility of multiple found lower levels of awareness than in other European countries responses from one individual, we used the option given by the (17, 19) whereas the level of use also sat in the lower range software of only allowing the completion of one questionnaire (17, 19). All the aforementioned studies present data collected per electronic device. After reading the initial screen, those before self-testing authorization in the studied countries. Media who decided to participate were redirected to the questionnaire attention, promotion campaigns and mouth to ear following after checking a box to confirm that they were old enough authorization probably led to higher levels of awareness but very to legally have sex in Spain (16 years old) and that they few studies have assessed this aspect post-authorization. The only wanted to participate in the study. No incentive was offered study that evaluated both outcomes after the legal authorization in exchange for participation which also limited the chances of of HIV self-testing was conducted in Spain and is in line with this multiple participation. hypothesis: level of awareness and use was substantially higher Data was collected through a self-administered questionnaire than in previous studies conducted in Spain (20). However, this that included questions assessing sociodemography, outness, sex study analyzed a sample of MSM who were seeking to be tested of lifetime sexual partners, sexual behavior in the last 12 months, for HIV in Madrid and Barcelona, the two largest cities of Spain. history of Sexually Transmitted Infections (STI), testing history Thus, by definition, it did not include participants who had and HIV serostatus. It also included a section to assess whether Frontiers in Public Health | www.frontiersin.org 2 June 2022 | Volume 10 | Article 888059 Guerras et al. HIV Self-Testing Awareness and Use participants knew about the existence of self-testing (awareness) Data Analysis and if they had already used it at the moment of survey We first performed a descriptive analysis of the main completion (use). We also included questions to asses overall characteristics of the sample. Secondly, we estimated the sexualized drug use and “Chemsex.” The latter was defined proportion of participants who reported awareness and use of as having taken mephedrone and/or methamphetamine and/or HIV-self testing by relevant independent variables. Awareness gamma hydroxybutyrate (GHB) (21) within 6 h before or during of self-testing was collapsed in a two-category variable: (1) anal sex. To assess sex of lifetime sexual partner, participants were “Yes, I knew”; (2) “No, I did not” or “I had heard something asked to choose one of the following options: (a) I have never had but was not sure.” To estimate the factors associated with sex neither with men nor with women, (b) I have had sex only awareness and with use, we used Poisson regression with with women, (c) I have had sex more often with women, but at robust variance in the framework of generalized linear models’ least once with a man, (d) I have had sex equally with men and analysis (23, 24) to calculate the crude and adjusted prevalence women, (e) I have had sex more often with men, but at least once ratios (PRs) with their 95% confidence intervals (95% CI). We with a woman and (f) I have had sex only with men. Those who initially included all the relevant variables with a significance chose answer (a) or (b) were excluded from participation. level ≤0.20 and employed the minimum Akaike information To assess economic status, we asked participants to choose criterion and the minimum Bayesian Schwartz information one of the following response options: (a) “Very comfortable,” criterion for model comparisons and to select the optimal (b) “Comfortable,” (c) “It’s tight, I have to be careful to make model. For those who reported having used it in the past, we ends meet,” (d) “I make ends meet with difficulty” (e) “I make assessed the number of times used, time since last use, where ends meet with debts.” Based on this question we built a was the last self-test acquired and who was he with the last time three category variable: options (a) and (b) were collapsded they self-tested. into the “Comfortable-very comfortable” category, (d) and (e) into the “difficult” category and option (c) conformed the “tight” category. RESULTS The questionnaire was designed in the context of a research Main Characteristics of Participants Project (the Methysos Project) which focused on MSM and had Seventy-two percent of the study participants were recruited HIV-self testing among its several areas of interest. The research through gay dating apps and websites, and 26.6% through group, developed a draft version of the questionnaire which was Social networks other than dating apps. Forty-five percent were shared with several experts on the field who critically reviewed it. ≥40 years of age, 82.8% were born in Spain and 54.7% had The suggested changes were discussed and incorporated into the finished a university degree at the moment of participation. questionnaire. Afterwards, the questionnaire was piloted to check Approximately 65% reported having a comfortable or very its internal consistency. comfortable economic situation and 31.6% lived in cities of Awareness and use comprised our main outcomes. Awareness >1.000.000 inhabitants. More than half (54.4%) lived their sex- was assessed with the following question: “Did you know that life with other men openly. Regarding sexual behaviors, 63.2% in Spain you can buy an HIV self-test at the pharmacy or reported only having had sex with other men in the past (and parapharmacy without the need of a prescription?” Participants never with women), 71.8% were involved in condomless anal had to choose between the following response options: (1) No, I sex in the last 12 months and 23.9% and 22.5% had paid did not now, (2) I had heard something but was not sure and (3) and received money in exchange for sex in the same time Yes, I knew. Use was assessed by asking: “Have you ever tested period. Almost half (46.2%) reported having been diagnosed for HIV using a self-testing kit?” In this case, participants had with an STI in the past (16.2% in the last 12 months) and to choose between Yes and No. For participants who reported 10% had been involved in Chemsex in the previous 12 months. previous use, we included a set of questions to assess the number An HIV positive serostatus was reported by 14% whereas of self-tests performed in the past, time since last use, place of 55.2% received their last negative test in the last 12 months acquisition of the last self-testing kit and the person with whom and 30.8% had never been tested or had received their last participants were with during their last self-testing episode. We negative test >12 months ago (of whom 15.3% were never created a three category variable to assess serostatus and testing testers and 15.5% had tested more than 12 months ago) history. The first category is comprised by participants who did (Table 1). not meet current recommendations for MSM of undergoing HIV testing at least every 12 months (22). Never-testers and participants who reported having tested more than 12 months Awareness of the Availability of HIV ago were included in this category. The second category was Self-Testing Kits in Pharmacies Without comprised by participants who received their last test in the the Need of a Prescription previous 12 months. The third and last category was comprised Overall, 29.7% of all MSM reported being aware of the by those who reported being HIV positive. The survey was existence of HIV self-testing (Table 2). On the multivariable anonymous and confidential and no variables enabling personal analysis, awareness was associated with recruitment in gay dating identification were collected. The study was approved by the websites/apps [Adj.PR = 1.2; (CI 95%: 1.1–1.3)] and being ≥ Research Ethics Committee of the Instituto de Salud Carlos III 40 years old [Adj.PR = 1.2; (CI 95%: 1.0–1.3)]. Compared to (CEI PI 35_2020-v3). participants born in Latin America, awareness was higher among Frontiers in Public Health | www.frontiersin.org 3 June 2022 | Volume 10 | Article 888059 Guerras et al. HIV Self-Testing Awareness and Use TABLE 1 | Main characteristics of study participants (N = 5,492). those born in Spain [Adj.PR = 1.5; (CI 95%: 1.3–1.7)] and other European countries [Adj.PR = 1.4; (CI 95%: 1.1–1.8)]. N % Compared to those who reported having up to compulsory Recruitment site secondary education, awareness was higher among those who Gay dating apps/websites 3,954 72.0 had upper secondary [Adj.PR = 1.2; (CI 95%: 1.0–1.4)] or university education [Adj.PR = 1.3; (CI 95%: 1.1–1.6)]. Living in Social networks other than dating apps 1,460 26.6 cities of under 1.000.000 inhabitants [100.000–1.000.000 Adj.PR Other* 78 1.4 = 1.2; (CI 95%: 1.1–1.4); 10.000–99.999 Adj.PR = 1.2; (CI 95%: Age at the moment of participation (years) 1.1–1.3); <10.000 Adj.PR = 1.2; (CI 95%: 1.0–1.3)] and living 1,534 27.9 <30 sex life with other men openly [Adj.PR = 1.4; (CI 95%: 1.1–1.7)] 30–39 1,489 27.1 were also associated with higher awareness. Finally, it was higher ≥40 2,469 45.0 among those reported having received an STI diagnosis in the Place of birth last 12 months [Adj.PR = 1.2; (CI 95%: 1.1–1.4)] and among Spain 4,547 82.8 those who reported having received their last HIV negative test Latin America 736 13.4 <12 months ago [Adj.PR = 1.5; (CI 95%: 1.4–1.7)] or being HIV European countries other than Spain 164 3.0 positive [Adj.PR = 1.9; (CI 95%: 1.6–2.2)]. Other countries 45 0.8 University education 3,003 54.7 Previous Use of HIV Self-Testing Kits Five percent reported having already used an HIV self-test before Economic situation the day of survey completion. On the multivariable analysis, Comfortable-very comfortable 3,547 64.7 previous use was higher among participants who reported having Tight 1,488 27.1 been paid for sex in the last 12 months [Adj.PR = 1.4; (CI 95%: Difficult 448 8.2 1.1–1.8)], in those who reported having been diagnosed with an Inhabitants of place of residency STI in the last 12 months [Adj.PR = 1.4; (CI 95%: 1.0–1.8)] and More than 1,000,000 inhabitants 1,731 31.6 among those who reported having been tested for HIV in the 100,000–1,000,000 1,812 33.1 previous 12 months [Adj.PR = 4.7 (CI 95%: 3.1–7.1)] (Table 3). 10,000–99,999 1,283 23.4 Among participants who reported previous use of a self-test, over <10,000 646 11.8 half (52.2%) reported having used it only once, 65.9% used their Lives sex life with other men... last self-test in the previous 12 months, 62.4% acquired it over the Openly 2,984 54.4 counter at a pharmacy and 71.6% used it alone (Table 4). Discreetly 2,009 36.6 Hidden/In total secrecy 497 9.1 DISCUSSION Has had sex only with men 3,472 63.2 Awareness and previous use in this online sample of MSM Number of male sexual partners with whom he had condomless recruited more than 2 years after its legal authorization in Spain anal sex (last 12 months) remains low. Awareness was found to be higher in participants None 1,546 28.2 recruited in gay dating websites/apps, older and European One 1,550 28.2 individuals, with educational levels above compulsory secondary 2–4 1,228 22.4 education, who lived in medium to small sized municipalities 5–9 417 7.6 and who lived their sex life with other men in an open manner. 10 or more 749 13.6 Awareness was also higher among those who reported having Has paid for sex in the last 12 months 1,307 23.9 been diagnosed with an STI in the last 12 months and among Has been paid for sex in the last 12 months 1,234 22.5 HIV positive individuals. Use was higher in those who reported History of STI** having been paid for sex or diagnosed with an STI in the last 12 Never diagnosed with an STI 2,924 53.8 months and among participants who received their last negative Diagnosed in the last 12 months 878 16.2 HIV test in the last 12 months. Diagnosed more than 12 months ago 1,634 30.1 We recruited a large and varied online sample of MSM using gay dating apps-websites and other social networks. Thus, we Has been involved in chemsex (last 12 months)*** 520 10.0 were able to include relevant subgroups such as MSM living HIV testing history/serostatus in medium and small sized municipalities as well as never Never tested & last tested >12 months ago 1,690 30.8 tested and HIV positive individuals. The overall awareness rate Last tested <12 months ago 3,029 55.2 was notably higher than in previous studies conducted before HIV positive 768 14.0 its legal authorization in Spain (15, 17) and other European % estimated over cases with valid data. *Public health agency and NGOs. **STI, countries such as Denmark, Greece, Portugal, Romania or Sexually transmitted infections. ***Mephedrone and/or methamphetamine and/or gamma Slovenia and very similar to that found in Germany, Belgium hydroxybutyrate (GHB) within 6 h before or during anal sex. (17) and France (19). The higher level of awareness found in Frontiers in Public Health | www.frontiersin.org 4 June 2022 | Volume 10 | Article 888059 Guerras et al. HIV Self-Testing Awareness and Use TABLE 2 | Proportion of participants who were aware of the existence of HIV self-testing and associated factors (N = 5,492). N % cPR 95% CI aPR 95% CI Total 1,632 29.7 Recruitment site Social networks other than dating apps and others* 359 23.3 1.0 1.0 Gay dating apps/websites 1,273 32.2 1.4 1.2–1.6 1.2 1.1–1.3 Age at the moment of participation (years) <30 372 24.3 1.0 1.0 30–39 441 29.6 1.2 1.1–1.4 1.1 0.9–1.2 ≥40 819 33.2 1.4 1.2–1.5 1.2 1.0–1.3 Place of birth Latin America 156 21.2 1.0 1.0 Spain 1,413 31.1 1.5 1.2–1.7 1.5 1.3–1.7 Other European countries 52 31.7 1.5 1.1–2.0 1.4 1.1–1.8 Other countries 11 24.4 1.2 0.6–2.1 1.2 0.7–1.9 Education Up to compulsory secondary education 131 24.5 1.0 1.0 Upper secondary education 541 27.7 1.1 0.9–1.4 1.2 1.0–1.4 University education 959 31.9 1.3 1.1–1.6 1.3 1.1–1.6 Economic situation Difficult 113 25.2 1.0 Tight 401 26.9 1.1 0.9–1.3 Comfortable-very comfortable 1,118 31.5 1.2 1.0–1.5 Inhabitants of place of residency More than 1,000,000 inhabitants 476 27.5 1.0 1.0 100,000–1,000,000 587 32.4 1.2 1.0–1.3 1.2 1.1–1.4 10,000–99,999 381 29.7 1.1 0.9–1.2 1.2 1.1–1.3 <10,000 183 28.3 1.0 0.9–1.2 1.2 1.0–1.3 Lives sex life with other men... Hidden/In total secrecy 109 21.9 1.0 1.0 Discreetly 533 26.5 1.2 1.0–1.5 1.1 0.9–1.3 Openly 988 33.1 1.5 1.2–1.8 1.4 1.1–1.7 Number of male sexual partners with whom he had condomless anal sex (last 12 months) None 463 29.9 1.0 1.0 One 386 24.9 0.8 0.7–1.0 0.8 0.8–1.0 2–4 362 29.5 1.0 0.9–1.1 0.9 0.8–1.0 5–9 132 31.7 1.1 0.9–1.3 0.9 0.8–1.1 10 or more 287 38.3 1.3 1.1–1.5 0.9 0.8–1.1 Has been paid for sex in the last 12 months No 1,227 28.9 1.0 Yes 401 32.5 1.1 1.0–1.3 History of STI** Never diagnosed with an STI 735 25.1 1.0 1.0 Diagnosed more than 12 months ago 537 32.9 1.3 1.2–1.5 1.1 1.0–1.2 Diagnosed in the last 12 months 343 39.1 1.6 1.4–1.8 1.2 1.1–1.4 Has been involved in chemsex*** (last 12 months) No 1,364 29.2 1.0 Yes 187 36.0 1.2 1.1–1.4 HIV testing history/serostatus Never tested & last tested >12 months ago 326 19.3 1.0 1.0 Last tested <12 months ago 974 32.2 1.7 1.5–1.9 1.5 1.4–1.7 HIV positive 328 42.7 2.2 1.9–2.6 1.9 1.6–2.2 % estimated over cases with valid data. cPR, Crude Prevalence Ratio; aPR, Adjusted Prevalence Ratio; CI, Confidence Interval. *Others includes, Public health agency and NGOs. **STI, Sexually transmitted infections. ***Mephedrone and/or methamphetamine and/or gamma hydroxybutyrate (GHB) within 6 h before or during anal sex. Frontiers in Public Health | www.frontiersin.org 5 June 2022 | Volume 10 | Article 888059 Guerras et al. HIV Self-Testing Awareness and Use TABLE 3 | Proportion of participants who had used a self-testing kit in the past and associated factors (N = 5,488). N % cPR 95%CI aPR 95%CI Total 275 5.0 Recruitmen site Social networks other than dating apps and others* 66 4.3 1.0 Gay dating apps/websites 209 5.3 1.2 0.9–1.6 Age at the moment of participation (years) <30 80 5.2 1.2 0.9–1.6 30–39 89 6.0 1.4 1.1–1.8 ≥40 106 4.3 1.0 Place of birth Latin America 31 4.2 1.0 Spain 226 5.0 1.2 0.8–1.7 European countries other than Spain 14 8.5 2.0 1.1–3.8 Other countries 4 8.9 2.1 0.7–6.0 Education Up to compulsory secondary education 17 3.2 1.0 Upper secondary education 88 4.5 1.4 0.8–2.4 University education 169 5.6 1.8 1.1–2.9 Lives sex life with other men... Hidden/In total secrecy 14 2.8 1.0 Discreetly 85 4.2 1.5 0.9–2.6 Openly 175 5.9 2.1 1.2–3.6 Number of male sexual partners with whom he had condomless anal sex (last 12 months) None 66 4.3 1.0 One 63 4.1 1.0 0.7–1.3 2–4 58 4.7 1.1 0.8–1.6 5–9 29 7.0 1.6 1.1–2.5 10 or more 59 7.9 1.8 1.3–2.6 Has paid for sex in the last 12 months No 198 4.8 1.0 Yes 77 5.9 1.2 1.0–1.6 Has been paid for sex in the last 12 months No 193 4.5 1.0 Yes 80 6.5 1.4 1.1–1.9 1.4 1.1–1.8 Unprotected intercourse with women (last 12 months) No 255 4.9 1.0 Yes 20 6.6 1.3 0.8–2.1 History of STI** Never diagnosed with an STI 129 4.4 1.0 1.0 Diagnosed more than 12 months ago 74 4.5 1.0 0.8–1.4 1.0 0.7–1.3 Diagnosed in the last 12 months 68 7.8 1.8 1.3–2.4 1.4 1.0–1.8 HIV testing history/serostatus Never tested & last tested >12 months ago 25 1.5 1.0 1.0 Last tested <12 months ago 230 7.6 5.1 3.4–7.8 4.7 3.1–7.1 HIV positive 20 2.6 1.8 1.0–3.2 1.4 0.7–2.6 % estimated over cases with valid data. cPR, Crude Prevalence Ratio; aPR, Adjusted Prevalence Ratio (adjusted by age); CI, Confidence Interval. *Others includes, Public health agency and NGOs. **STI, Sexually transmitted infections. our study—when compared to pre-approval studies conducted Madrid and Barcelona (20) was very similar to what has been in Spain—is probably explained by the media attention and found in the present study. However, in spite of its growth, promotion that followed its approval. In fact, in the only awareness is still very low and additional efforts need to be study conducted post-approval, awareness among attendees of made to improve it in MSM. In this sense, the popularization of sexual health clinics and community-based testing programs in COVID 19 self-testing devices could have increased the readiness Frontiers in Public Health | www.frontiersin.org 6 June 2022 | Volume 10 | Article 888059 Guerras et al. HIV Self-Testing Awareness and Use TABLE 4 | Number of self tets performed, times since last self-testing episode, The higher level of awareness found in residents of medium place of acquisition and company during last episode among participants who and small size cities and towns is an encouraging finding since reported having used a self-test in the past (N = 275). MSM from less populated municipalities could have lower access N % to HIV testing than MSM residing in larger cities. Home-based testing has been highlighted as a preferential testing option by Number of self-testing kits used* rural MSM in studies (26–28) conducted in the US. This finding One 143 52.2 needs to be confirmed in the European context but the higher Two 51 18.6 levels of awareness found in our study could be an expression Three or more 80 29.2 of the need of increased access to HIV testing in this subgroup Time since last self-test* of MSM. Awareness was also higher among MSM who lived ≤12 months 180 65.9 their sex life with other men in an open manner which is >12–24 49 17.9 in line with previous studies (20) and highlights the need of >24 months to 5 years 34 12.5 increasing it among less open MSM. In fact, the latter could be >5 years ago 10 3.7 facing stigma and discrimination related barriers and the privacy Where was the last self-test acquired* and anonymity offered by self-testing could facilitate access to At a pharmacy (over the counter) 171 62.4 testing (29). At an online pharmacy 36 13.1 The higher awareness found among those diagnosed with an Vending machine 0 0.0 STI in the last 12 months could reflect a “worried well” situation At a country (other than Spain) where it is legally sold 19 6.9 since higher rates of STI are generally associated with increased Purchased it on the internet without having certainty 7 2.6 risk of condomless sex. However, in our sample, we did not about its legality find associations between higher rates of condomless anal sex Others 41 15.0 and awareness. With whom did he self-test last time The association was especially intense among HIV positive Alone 197 71.6 MSM. This is the first time that awareness is assessed in already Stable partner 25 9.1 diagnosed individuals who comprise a non-negligible subgroup Occasional partner 8 2.9 of the MSM population. Although, they cannot directly benefit Friend 27 9.8 from this testing methodology HIV positive individuals could Family member 5 1.8 recommend it to peers, friends and sexual partners and could CBO/NGO staff 6 2.2 help to increase awareness among MSM. On the other hand, Health profesional 3 1.1 it is important to underline the low levels of awareness found Others** 4 1.5 among undertested MSM. This is a relevant finding as data from modeling studies highlight the importance of specifically % estimated over cases with valid data. *Due to missing values, the total does not add up targeting never testers as the most efficient way of averting new to 275. **Others include: pharmacist, psychologist and “I do not remember”. infections through HIV self-testing strategies (30). Similar to awareness, the proportion of participants who reported previous use was higher than in online studies of both the general and MSM populations for self-diagnostic conducted among MSM before its authorization in Spain (15, technologies and offers an opportunity to roll-out effective self- 17) and other European countries (17) and very similar to a testing promotion campaigns. study conducted in Spain after its approval (20). Nevertheless, Awareness is relevant because it is a necessary condition to previous use still remains very low. The increase of use of HIV access self-testing. Our multivariable analysis revealed that it self-testing could lead to a rise of testing frequency in MSM is higher in participants recruited through gay dating websites and, if accompanied of prompt linkage to care, could contribute suggesting the need of promoting this methodology in other to curbing the epidemic in this population group. There are online settings serving MSM with a different profile such as several possible strategies to increase the low use found in our YouTube, Instagram and other social networks. Concerning study. First, use will not increase before MSM are made aware sociodemography, increased awareness was found among of the existence of this testing option and, as noted before, participants who were over 40 years of age, born in European awareness in Spain is still low. If promotion of HIV self-testing countries and with higher educational level. These findings is left to mouth to ear, use will probably increase very slowly. highlight the need of raising awareness among less favored Promotion campaigns focusing on those MSM groups who do groups such as Latin-American migrants and those with lower not know about the existence of self-testing, should be conducted educational level to reduce testing access inequities. Although to raise the number of MSM who use a self-testing kit to check the variable assessing economic situation was not retained in their serostatus. In this sense, the new Spanish plan for the the final model, when considering the promotion of self-testing prevention and control of HIV and STIs (2021–2030) includes among less favored subpopulations it is important to note, that the visibilization of self-testing (31) as one of its activities. regardless of the level of awareness, the current price of 25–30 Second, to overcome the aforementioned price barrier, partly euros could be an important barrier as has been suggested in or fully publicly funded distribution of HIV self-testing could previous studies (25). increase its use (14) especially in less favored individuals and Frontiers in Public Health | www.frontiersin.org 7 June 2022 | Volume 10 | Article 888059 Guerras et al. HIV Self-Testing Awareness and Use in MSM with ongoing sexual behaviors for whom a test each 3 distribution and sale of self-testing through different ways could months is recommended. Third, diversification of distribution also contribute to increase its use. strategies could also increase self-testing. In our sample, most MSM acquired their last self-test over the counter at a pharmacy DATA AVAILABILITY STATEMENT but online marketing and distribution could help improve access to self-testing as suggested by a number of studies (12). This The original contributions presented in the study are included is especially important for MSM living in rural areas who can in the article/supplementary material, further inquiries can be have limited access to pharmacy offices. Satisfaction with the self- directed to the corresponding author/s. testing experience will not affect overall use but will influence the decision on whether to use a self-test again. In our study we did METHYSOS PROJECT GROUP not assess user satisfaction but almost half of the participants who had used a self-test reported having used it more than one time. María del Carmen Burgos, César Pérez Romero, Lidia Herrero The use of self-testing was higher in certain subgroups. (Instituto de Salud Carlos III, Madrid); José Antonio San Thus, we found a higher use in two high risk groups such Juan Bueno (Asociación Pink Peace, Madrid); David Palma as those who had been paid for sex and among MSM Díaz, Francisca Roman Urrestaruzo, Jesus E Ospina, Miguel who received an STI diagnosis in the last 12 months. For Alarcón Gutiérrez (Agència de Salut Pública de Barcelona, sex workers, HIV self-testing could offer the possibility Barcelona); Jorge del Romero, Oskar Ayerdi, Carmen Rodríguez, of checking their (and their clients) serostatus before Sonsoles del Corral Del Campo, Natividad Jerez Zamora, Marta engaging in sexual encounters. However, this practice is Ruiz Fernández, Montserrat González Polo (Centro Sanitario risky due to longer window periods and reduced accuracy Sandoval, Madrid); María Jesús Barbera Gracia, Jorge-Néstor of self-testing during acute infection (32) that can lead García-Pérez, Luis López Pérez, Claudia Broto Cortes, Julio to false-negative results in a highly infectious stage (33). Morais Martin (Unitat d’Infeccions de Transmissió Sexual Similar to knowledge, use was substantially higher among Drassanes, Hospital de la Vall d’Hebron, Barcelona). those who received their self-test in the last 12 months suggesting the need of promoting self-testing especially among AUTHOR CONTRIBUTIONS undertested individuals as a way of increasing the fulfillment of testing recommendations. LF, PG, and M-JB conceived, designed, and supervised the study. Results are not without limitations. Although we made J-MG and PG organized the recruitment of participants. J-MG, an effort to recruit MSM from a varied range of sites, this MD, JP, and LS contributed to the recruitment of subject and is a convenience sample and extrapolating conclusions from data collection. J-MG, JH, MD, LS, and JP performed the main this study to other MSM populations should be made with analyses. J-MG, JH, PG, and M-JB wrote the manuscript. JH, extreme caution. We did not ask participants about their LF, and M-JB were responsible for drafting and critical revisions sexual orientation since our approach to sexuality was strictly of the manuscript. J-MG, JH, LF, MD, JP, LS, PG, M-JB, and behavioral. We could not ascertain if any of the HIV positive the additional members of the Methysos Project Group made participants were diagnosed as a consequence of using a self- substantive contributions to the current article. All authors read test since the site where diagnosis occurred and the type of and approved the final manuscript. All authors contributed to the test used were not assessed. Self-testing presents challenges to article and approved the submitted version. document to what extent reactive results are being confirmed and linked to care and to quantify what is their contribution to the FUNDING overall number of newly diagnosed individuals. However, unless surveillance units publish data on setting and type of test used for This work received funding from the National Drugs Plan newly diagnosed individuals, it seems as a natural step that needs (Ministry of Health, Government of Spain, 2019I017). to be taken in future studies on HIV self-testing. Awareness and use of HIV self-testing among MSM recruited ACKNOWLEDGMENTS online in Spain, has increased when compared to studies conducted before its legal authorization but remains low. In order We would like to thank following websites, companies and to reach its full potential, the use of self-tests needs to be increased institutions who collaborated in the recruitment: Pink Peace, by improving awareness especially among less favored MSM such Wapo, Bakala, MachoBB, Scruff, Xtudr, GROWLr, Grindr, as Latin-American migrants, with lower education levels, who are Chem-Safe. We would also like to thank Gabriel José Martin undertested and less open about their sexuality. Additionally, the (youtube) @frewaskachannel and @tigrilloig (Instagram). REFERENCES Nacional Sobre El Sida - D.G. De Salud Pública, Calidad E Innovación/Centro Nacional De Epidemiología - ISCIII. (2021). Available online at: 1. Unidad De Vigilancia De VIH Y Comportamientos De Riesgo. 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