Although the HIV epidemic is in decline, Thailand has one of the highest levels of HIV prevalence in Asia and the Pacific (1). Owing to Thailand’s successful HIV testing programs, however, 94% of people living with HIV were aware of their status as of 2018 (1). Although testing services are readily available in Thailand, among high-risk populations such as men who have sex with men (MSM) and female sex workers (FSW), many (71% and 42%, respectively) have not used testing services within the past year (2).
HIV testing serves as the gateway to HIV treatment and care, as well as the entry point to measuring progress to the UNAIDS 90-90-90 targets. Previous studies have identified many barriers to HIV testing at the patient, health care provider, and institutional levels. These barriers include perception of HIV risk, fear and stigma related to HIV, accessibility to HIV services, and human and financial resources for delivering HIV services (3–9).
To combat the fear of stigmatization and increase testing privacy, in 2016, the World Health Organization (WHO) recommended HIV self-testing (HIVST) as an important approach that should be offered in addition to traditional HIV testing (10). According to WHO, HIVST is a technique that allows people to conduct an HIV test on themselves in a private setting, including collecting their own fluid or blood specimen, testing the specimen for HIV antibodies, and interpreting the result (10). Like most other HIV tests conducted in a laboratory or clinic, the self-testing kit does not provide an HIV diagnosis; rather, it screens for HIV antibodies that may indicate an infection (11). Also included in the WHO report was the first HIVST global guidelines. Several countries have responded to these guidelines, with 28 implementing HIVST, 59 executing HIVST policies, and 53 countries in the process of developing policies (12).
In some countries, HIV self-testing has shown promising results as a gateway to prevention and care; however, barriers to full implementation and access remain (11). One potential barrier to HIVST access is the cost of the test. Research has indicated that people in Kenya and China would be willing to pay a higher cost for HIVST, while research in the U.S. has shown that people would be willing to purchase HIVST only if the cost is low (13, 14). Other potential barriers include lack of awareness of the availability of self-testing and negative attitudes toward the test (14, 15). Researchers summarizing the arguments for and against HIVST reported empowerment of test users and the normalizing of testing as positive factors, and the high cost, possibility of false-negative results, need for counseling and referrals, and potential for coercion among partners as negative factors (14).
In order for HIVST to fulfill its potential as a tool for reducing HIV transmission, members of the general population must be aware of the test. According to the literature, roughly half of participants in multiple studies had heard of the test, with awareness higher among those with higher education or who were themselves at elevated risk of HIV. Across three studies, 55–77% of at-risk populations were aware of HIVST, with the greatest awareness among MSM, gay, highly educated, and previously tested individuals (16, 17). A study in North Carolina among young, black MSM reported a significant relationship between HIVST awareness and higher income (16). The literature also identified a gap in HIVST awareness among those of different age groups. Given the recent introduction of HIVST to Thailand, it is important to identify population groups that may have lower awareness of the availability of self-testing so they can be prioritized in future interventions and educational campaigns.
Attitudes toward HIVST vary across different demographic characteristics and can impact individual’s willingness to utilize self-testing services (13). Across various studies, positive attitudes towards HIVST have been most prevalent among men having sex with men and among those who were female, married, of rural backgrounds, of higher education or income, and who had previously been tested for HIV (13, 18). Findings about the level of acceptance of HIVST among different age groups has varied, with some research reporting a greater relative acceptance among older, and other research reporting greater acceptance among younger, age groups (18, 19). Given that awareness and attitudes vary across risk and demographic groups, it is important to understand existing attitudes and possible barriers to HIVST among local Thai populations to develop the most effective public health programs promoting the adoption of HIVST in Thailand.
Research has shown that one’s attitudes toward HIV testing may be impacted by one’s own stigmatizing attitude toward people living with HIV (PLHIV). For example, a study of individuals in Cape Town found that those with stigmatizing attitude toward PLHIV had higher negative attitudes towards HIV testing than those without indicated stigma (15). In parallel, another study conducted in Ghana reported an indirect relationship between stigmatizing attitude and overall uptake of testing (20). In simpler terms, those with more stigmatizing attitudes toward PLHIV were less likely to use testing services. A study in Nigeria reported that women from rural areas with lower education levels held beliefs about HIV that were more negative than the beliefs of women from other areas. These more negative beliefs were associated with higher levels of stigma and a decreased likelihood of testing (21). Given these associations, it is essential to examine the role of HIV stigma and its relationship with HVST awareness and attitudes to better understand how people may react to the availability of HIVST.
The current study explores HIVST awareness and attitudes in a rural region of Thailand. Given the recent implementation of HIVST in Thailand, the purpose of this study was to: (1) examine awareness and attitudes toward HIVST among residents of Northern Thailand, and (2) understand how these constructs, along with other covariates are related in this community. This investigation contributes to existing literature on HIVST and to our knowledge, is the first study of HIVST awareness and attitudes in Northern Thailand. In Thailand, although the FDA approved selling HIVST kits in Thai pharmacies in April 2019, little research has been conducted to date, and awareness and attitudes related to HIVST among members of the Thai general public remain unknown (22). Understanding perceived barriers to HIVST, including lack of awareness, negative attitudes toward HIVST, and HIV stigma may be helpful in developing effective health education programs promoting HIVST in Thailand. Thus, developing greater understanding of how Thai people may respond to the availability of HIVST is essential.