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Gaps in the HIV self-testing cascade among people with HIV in Taiwan: Usage patterns, barriers, and public health
Chun-Yuan Lee1, Yi-Pei Lin2, Bih-O Lee3
1Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC; M.Sc. Program in Tropical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Center for Tropical Medicine and Infectious Disease Research, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC.
Background:
Information on the usage patterns of human immunodeficiency virus (HIV) self-tests (HIV-STs), the factors influencing these patterns, and reasons for delays between positive HIV-ST results and confirmatory testing in people with HIV in Taiwan is lacking.
Methods:
We conducted a multicenter, cross-sectional survey in Taiwan over the period from February 2023 to December 2024 to examine the use of HIV-STs among individuals who received a diagnosis of HIV from 2017 to 2024. We employed exploratory factor and multivariable analyses to identify the barriers hindering and the factors influencing HIV-ST use.
Results:
We recruited 458 participants who had received a diagnosis of HIV, predominantly men who had sex with men (92.79 %), aged ≤ 30 years at HIV presentation (51.75 %). We analyzed their prediagnosis HIV-ST use along a five-tier cascade: (1) being diagnosed as HIV, (2) being aware of HIV-ST, (3) considering HIV-ST use, (4) having used an HIV-ST previously, and (5) using HIV-STs annually. Exploratory factor analysis categorized 16 barriers into four domains: indifference to HIV risk, fear of negative consequences (including discrimination and stigmatization after a positive result), and structural barriers to accessing HIV-ST services. From 2017-2024, awareness, willingness, and use of HIV-STs increased, yet significant drop-offs occurred between stages-most notably, a 51.31 % reduction from Tier 1 to Tier 2. Participants aged 30-50 were less likely to use HIV-STs than their younger counterparts, and usage was significantly higher in 2021 versus 2017. Notably, 33.33 % of individuals delayed confirmatory testing for more than two weeks after a positive HIV-ST, primarily due to fear of negative consequences, which was also the leading barrier to progression along the HIV-ST cascade.
Conclusions:
High attrition in the HIV-ST cascade, due to low awareness, and delays in confirmatory testing, driven by fear of negative consequences, undermine its public health impact. Optimizing its utility requires dual strategies: targeted campaigns to increase awareness and supportive systems to facilitate linkage-to-care by mitigating stigma.
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