MSM and TGW welcomed the idea of introducing HIVST, especially blood-based diagnostic kits, accessed via reputable outlets. They liked the convenience and confidentiality of HIVST in a stigmatised context. Key informants shared enthusiasm for HIVST but also raised concerns regarding antecedents within the health, regulatory and legal system that were at odds with the beneficiaries’ desire for convenience and confidential HIV testing in a stigmatised context. In addition key informants held different views on priorities to address this urgent HIV epidemic.
HIVST: Big Benefits and High Demand from Target Users and Key Informants
HIVST availability was considered by all participants as being a beneficial addition to the HIV testing strategy in the Philippines, particularly in reaching high-risk groups such as young MSM. All key informants stated a major benefit for HIVST would be increased access to testing.
“it [HIVST] will increase access to HIV testing and other populations that are not reached through our routine testing…..because of the stigma, discrimination that is still experienced in this country” Laboratory participant
A majority of MSM and TGW showed enthusiasm and willingness to perform HIVST in the future after watching a video of the testing procedure.
The appealing factors for HIVST in both groups included awareness of HIV status in a confidential, private and convenient manner in comparison to current facility testing, an opinion shared by most key informants.
“For me, it’s just for myself whether I’m HIV positive or not, nobody else will know if you’re positive” MSM FGD high socio-economic status
“People don’t want to go to clinics, it is stigmatising. They don’t want to be seen in those clinics, they may know someone in the facility, or in the area of the facility. They don’t want to get judged” Male Service provider
MSM and TGW highlighted that self-testing would be empowering, and allow individuals to take responsibility of their own health.
“It [HIVST] would be easier, you can do it anywhere, anytime, you're at home, in your room, in the toilet, you won't be hassled to go to the clinic, and wait there” TGW FGD 1
MSM and TGW showed interest in partner testing, and felt HIVST could lead to a shift in relationship dynamics, with increased decision-making regarding sexual intercourse. TGW believed HIVST could make their relationships stronger by increasing mutual trust.
Key informants felt that HIVST could reach new and previous testers. Yet most key informants felt currently HIVST would mostly benefit those with good knowledge and previous testing experience. Doctors and service providers viewed educating the public on HIV as an essential pre-requisite to create demand for a HIVST program and thus reaching new testers. However this would be challenging within the religious and conservative culture present in the Philippines.
“The most beneficial [group are those] who have their test before, because they have been orientated with HIV 101, they will know the consequences of the test if they ever are positive” Male Doctor
“To sustain the use of a HIV self-test, and sustain its market ability, people should understand what the benefits are of using this and this is just not done through marketing, but really making people aware of what HIV is” Female NGO representative
Concerns were expressed regarding the current knowledge of HIV amongst the public. This was reflected in the varying knowledge of HIV amongst FGD participants as some MSM from urban poor areas showed poor knowledge, requiring misconceptions to be corrected.
“There are no medicines for HIV, right?” MSM FGD 1 urban poor area
Desirable characteristics of HIVST kits and access
Over half of MSM and TGW participants preferred blood-based to oral fluid HIVST kits as they felt it would be more accurate.
“Blood is better, because you'll know if you have HIV, because it's blood-to-blood” TGW FGD 1
They felt the kit should have instructions in Tagalog, access to a video demonstration and telephone hotline to aid those with literary difficulties.
All key informants, MSM and TGW felt that a high price would restrict access of HIVST, but this was especially so among participants from poor urban areas. MSM participants from low socio-economic groups were willing to pay up to 200 pesos. Whilst MSM from middle to high economic groups and TGW suggested paying between 50-875 pesos and 300 pesos respectively.
Distribution and linkage to care
A range of options for distribution were mentioned by key informants, MSM and TGW regarding the most suitable avenue for acquiring HIVST kits. Popular options amongst all participants included clinics, community sites and pharmacies. These sites were favoured by MSM and TGW as they were considered trustworthy. Online purchase was favoured by 1 MSM and 1 TGW due to the convenience of buying the product and its delivery, which would eliminate the stigma. However key informants and most MSM and TGW disagreed, and were concerned about fake kits being sold or being discovered by family members. Two program implementers argued for multiple avenues for distribution such as vending machines.
“Self-testing should be real self-testing, there should be no human-human interaction to get that kit” Male program implementer
Linkage to HIV services following a reactive result was a frequent concern raised by all participants. All groups emphasised the need for clear information to be included with HIVST kits regarding the processes a tester can expect after a reactive test result. This included the requirement for a confirmatory test, accuracy of test kits, and the location of HIV services.
“So self-testing is ok, but if I turn out reactive, where do I ask for help?” MSM FGD 1 urban poor area
“My predicament about the support, you really cannot separate testing and follow-up, treatment because it does not end from testing yourself. That's why I wanted to make sure that if you're doing it, you have an available support” MSM high socio-economic status.
“They should be familiar with what they should do, once the results are positive, because you cannot stop at just testing, and not knowing what to do afterwards” Male Doctor
“There is a problem of that linkage to care, to me is also very important, because you don’t want them to test and then nothing happens” Female program Implementer
Regulation, Readiness and Priority
Key informants recognised addressing the urgency of the epidemic and were enthusiastic about HIVST, however they felt regulatory, policy and the current health system required changes prior to its implementation (figure 1).
All key informants stated that HIVST should be regulated, and identified the FDA as the organisation to oversee this. Regulation was considered essential to ensure accurate test kits were available to the public. The National Laboratory was also identified to be responsible for conducting a performance assessment of HIVST kits. Those which pass the accepted in-country threshold for sensitivity and specificity would be recommended to the FDA.
“The accuracy of performing the test, and then how they interpret it because the quality of testing is very important because getting a false positive or false negative result might have a tremendous implication for the patients, so it’s very important to get an accurate test” Male Doctor.
Knowledge regarding the use of HIVST in other contexts was evident amongst all key informants. Most key informants were also aware of HIVST kits being available via the internet. Two MSM participants had prior knowledge of HIVST, and its availability via the internet and also stores within the city.
“The prevention of abuse of sales of unregistered kits, that is my concern and that is my reservation for HIV self-testing” Participant from HIV reference laboratory
Key informants found there to be no current policy which supported HIVST in the Philippines. They identified two sections of the Republic Act No.8504 (HIV/AIDS Prevention and Control Act of 1998) which would be a challenge for implementing self-testing, namely pre and post-test counselling by an accredited counsellor, as well as the requirement that HIV testing can only be conducted by a medical technologist. They were however optimistic that the promotion of HIVST as a screening program as opposed to testing, could lift these restrictions. In the Philippines, the testing guidelines from 2017 draw a distinction between screening and testing. While testing is only performed by trained medical technologist, screening is seen as an additional procedure prior to testing that can be performed by lay trained provider, midwives, nurses and physician using rapid diagnostic tests.
Both key informants, MSM and TGW highlighted counselling as important, especially for first-time testers. They recognised that counselling could take several modalities including remote counselling. Peer counsellors and telephone services were popular choices.
“If you get this test result and then you are not properly counselled, you don’t know where to go, what does it actually mean, then you can end up with a lot of people depressed, angry at the world, so it can cause more harm than good, without the proper set of interventions that go with the introduction of self-testing” Male NGO representative
Although all key informants were supportive of HIVST, views differed as to the priority for implementation in the Philippines. Some service providers stated this as a high priority program, to provide new tools to fight the growing HIV epidemic. Whilst a few participants stressed strengthening the current health system in terms of HIV testing, linkage to care, increasing ART coverage and reducing loss to follow-up.
“I think in the Philippines there are more systemic testing issues, and the testing system, that if they were changed and addressed, they would make much more of a change in terms of testing coverage, rather than, more than the introduction of self-testing” Female program implementer.