The results indicate that almost half of the MSM accepted the HIVST, but this is lower among who never been tested for HIV and are in a less vulnerable social context (i.e. who had a high level of education and socio-economic status, who had high HIV/AIDS knowledge and more access to medical appointment). The planning actions and information about HIVST directed to MSM must be focus on more vulnerable people.
Figueroa et al. , in a review of the literature regarding attitudes and HIVST acceptability, demonstrated that, of the 14 studies analyzed, eight indicated high acceptability (≥ 67%), five moderate (between 34–66%), and one low (≤ 33%). The moderate acceptability found in our study may be because since at the time of the RDS investigation (2016), HIVST kits were not yet available in Brazil, neither commercially nor through the public health system. The commercialization of this product in Brazil took place in November 2015, when the National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária: ANVISA) approved the sale of HIVST in pharmacies. In 2017, the first HIVST registration took place. The product has been commercially available since then, in both physical and online pharmacies and drugstores in all Brazilian states, at a cost of BRL 70.00 (21.90 US$) to BRL 80.00 (25.00 US$) per kit (7–8% of the minimum wage). We note that, even among those disposed to use the HIVST, its high cost may act as an access barrier and compromise the potential impact of this strategy, particularly in low-income contexts, thereby justifying their free distribution to key and priority populations .
Brazil has a long track record in successfully implementing a public HIV prevention and treatment interventions through of Brazilian Health Care System (SUS) [32–34]. In 2019, Brazil began offering free HIVST in select 14 cities and now is expanding to other cities. The strategies initially adopted was the distribution of HIVST in sociable places to key-population, to sexual partnerships PLWH and people in high vulnerability to HIV infection . The implementation of HIVST to free distribution and as a public health policy may promote the increase of testing frequency among high-risk MSM . Moreover, it has been considering as a technology with good cost-effectiveness [37, 38].
The HIVST has been put forward as a strategy to extend HIV diagnoses that may contribute to the reduction of transmission by enabling early diagnosis, access to care and treatment, and reduced viral load [20, 39, 40]. Our results suggest that the acceptability of HIVST is higher precisely among those who have already tested for HIV, and thus justify ample promotion of HIVST, particularly to MSM who are not used to routine testing.
We also found greater acceptability related to increased knowledge about HIV/AIDS, participation in LGBT NGOs and recent medical appointments. This highlights the fact that HIVST in itself is not enough to increase prevention opportunities (e.g. accessing information, increasing knowledge, being recommended by health services, NGOs). HIVST should be jointly available with reinforced HIV/AIDS prevention activities that promote HIVST within a combined prevention strategy, including strengthening and extending health services, targeted health education campaigns and support for community-based organizations and NGOs .
Of that MSM we interviewed who had never taken an HIV test, self-reported discrimination was one of the factors that increased the likelihood of HIVST acceptability. As pointed out in the literature, stigma, and concerns about confidentiality and privacy are among the barriers to testing confronted by MSM [4, 41–43]. Those who have not yet been tested, or were tested a long time ago, may resort to HIVST as a strategy to avoid potential discrimination or confidentiality fears in health services.
On the other rand, among MSM who had taken an HIV, those who reported a recent condomless receptive anal sex were much likely to accept HIVST. A study conducted in Spain documented that MSM with high-risk infection behaviors had high intentions to do a future HIV testing . Furthermore, this phenomenon in our research may be due to the high-risk perception found among this subgroup (data not showed). A study among the population, in general, had shown that higher perceived risk of HIV was associated with higher HIV testing , while a study among MSM showed just the opposite .
“Fear” is given as the main reason for not taking the HIVST. However, “fear” is not limited to HIVST technology, given that fear is also seen as a barrier to conventional testing conducted in health services . This is about the fear of the stigma of taking the test since it might imply both homosexuality and the fact that discover that is a PWLH [4, 48, 49].
Further, although our data do not allow us to examine in-depth the meaning of fear as a reason for not taking the test, we could argue that such fear is related to more general aspects referred to in other studies. Specifically, in the case of HIVST, the literature refers to the fear of a positive result without being properly linked to a health service [42, 48, 50]. As Flowers et al.  suggest, in research conducted with MSM in the United Kingdom, HIVST has the potential to reduce certain barriers related to traditional testing but may promote other complicating factors, such as a reduction in commitment to health services and professionals to follow up test results and access services, and fewer opportunities for health prevention and education regarding risk behaviors.
Our analysis is not without limitations, including the potential selectivity of the recruited network, the potential non-representativeness of the MSM population in the cities or a set of 12 cities. But the participants are those MSM in a social network and can be reached by prevention activities. The questionnaires had not constructed to only measure the HIVST theme and we did not have deep questions about previous knowledge, uptake and usability. Further, this is a cross-sectional study with evident limitations for producing causal inferences and generalizations.