Globally, HIV testing rates and linkage to HIV care among HIV-positive individuals remain much lower among men than women [1]. It is for this reason that a 2017 UNAIDS report referred to men and boys as the ‘blind spot’ in the HIV prevention response [2]. Citing survey and program reports from 25 sub-Saharan African countries, the report indicated that in countries such as Burundi, Côte d’Ivoire, Liberia, Mozambique, Niger, Nigeria, Togo and Uganda, men living with HIV were about a third less likely to know their HIV status, and in Congo, the Gambia, Ghana and Sierra Leone, knowledge of HIV status among men living with HIV was about half the rate found among women [2]. While HIV testing among men has improved [3, 4, 5], their uptake of HIV testing services remain generally below the 90% threshold [6]. Hegemonic masculinity norms [7], coupled with continuing high levels of stigma and discrimination [8], continue to keep men away from getting tested for HIV, coming to terms with their HIV-positive status, taking instructions from nurses and engaging in health enabling behaviours. These dynamics contribute to poorer HIV testing uptake and treatment outcomes for men compared to women in high prevalence settings, calling for innovative approaches to reach men with HIV testing and linkage to HIV care services.
Evidence from sub-Saharan Africa has demonstrated that HIV self-testing can increase uptake of testing services and facilitate linkages to care, especially among persons who are at high risk of HIV infection [9, 10, 11]. Several approaches have been used to reach men with HIV self-testing services, including during household visits by community HIV care providers [12], female-delivered HIV self-testing approaches [4, 13, 14, 15], delivery through existing social networks [16], and distribution through the internet; particularly among men who have sex with men [17, 18, 19]. Using a social network strategy to distribute HIV self-test kits to African American and Latino men who have sex with men, Lightfoot et al. [17] found that individuals reached through a peer-based HIV self-testing strategy were significantly more likely to have never tested for HIV than men who have sex with men reached through community-based HIV testing programs. Similarly, Lippman et al. [18] found that network distribution of HIV self-test kits not only reached first-time men who have sex with men testers but also increased the frequency of HIV testing from 37.8% before to 84.5% after introduction of HIV self-test kits. MacGowan et al. [20] reported 34 infections were found among social network members who received HIV self-test kits from study participants. Tun et al. [19] reported 100% linkage to HIV care among HIV-positive men who have sex with men who were identified through an intervention that involved HIV self-testing through key opinion leaders.
Collectively, these studies suggest that men are willing to use HIV self-test kits to test for HIV [9, 11, 21], with additional evidence suggesting that men are willing to self-test for HIV if they receive HIV self-test kits from their friends or sexual partners [16, 22]. Fleming and other scholars have argued that use of gender-transformative approaches in which men are engaged to reach fellow men with HIV prevention interventions can create safety nets within which men can discuss issues that affect their own health, including HIV testing [6, 23]. Studies among existing social networks of heterosexual men from the general population in Tanzania have found that men already engage in HIV testing conversations with friends in their social networks [21, 24] and that discussing HIV testing with a sexual partner and having been encouraged to test for HIV by a close friend were associated with higher odds of being willing to self-test among men [9, 21]. While these studies have provided preliminary evidence for the potential to leverage men’s social networks to deliver HIV self-test kits, no research has been conducted to examine heterosexual men’s willingness to distribute HIV self-test kits to fellow men or receive HIV self-test kits from fellow men in Tanzania, where 51% of men living with HIV were not aware of their HIV status in 2017 [25].
In 2018, there were 72,000 new cases of HIV infection among adults aged 15 years and older in in Tanzania [25]. Women are disproportionately affected by HIV in Tanzania, with a 6.3% prevalence in 2018 compared with a 3.4% prevalence among men [25]. Other populations in Tanzania who are significantly affected by HIV include people who inject drugs, mobile populations, young people, and men who have sex with men [26]. Mobile male populations, including truck drivers, plantation workers, and fishermen have also been found to be at increased risk of HIV infection [24]. However, men are less likely than women to test for HIV. In response, the government of Tanzania developed national strategies, including HIV self-testing, [27] and launched a national Test and Treat campaign focused on increasing HIV testing among men [28]. At the time of the campaign launch, however, the Tanzanian government had not yet approved a policy to support HIV self-test implementation. Thus, there is limited evidence in Tanzania and elsewhere of how best to reach heterosexual men with HIV self-testing through male peer-delivered approaches. The majority of male peer-delivered HIV self-testing studies that have been conducted were among men who have sex with men [18, 29, 30, 31] or in small, isolated populations living in the fishing communities instead of the general population [16].
In an effort to effort to address the HIV self-testing research gap in Tanzania for heterosexual men, the Tanzania Self-Testing Education and Promotion (Tanzania STEP) project for men was launched in 2018 [32]. Since then, the Government of Tanzania also started a national HIV self-testing demonstration project focused on men who have sex with men and female sex workers (FSWs) as part of Sauti (meaning “voice of the people”), a five-year implementation science community-based HIV prevention program funded by the U.S. President’s Emergency Plan for AIDS Relief and U.S. Agency for International Development (PEPFAR/USAID) [33, 34]. The overall aim of the Tanzania STEP and national HIV self-testing demonstration projects was to generate country-specific data on the implementation models, uptake, feasibility and acceptability HIV self-testing in order to inform policy development and future implementation and scale-up of HIV self-testing in Tanzania. Based on the evidence from these projects and other countries, a policy to support HIV self-testing implementation in Tanzania was approved in November 2019 [2]. In this study, we use baseline data from the Tanzania STEP project to investigate factors associated with men’s comfort to distribute or receive HIV self-test kits from close male friends among heterosexual men who socialize in networks locally referred to as "camps" in Dar es Salaam, Tanzania in order to inform implementation of social network-based HIV self-test kits distribution among heterosexual men. This paper also describes the design, sampling methods, male peer educators selection and training, and data collection for the Tanzania STEP Project locally known as Mate Yako Afya Yako (Your Saliva Your Health) [32].