Using individual stated-preferences to optimize HIV self-testing service delivery among men who have sex with men (MSM) in Malaysia: results from a conjoint-based analysis

Shrestha et al. BMC Public Health (2020) 20:1777 https://doi.org/10.1186/s12889-020-09832-w RESEARCH ARTICLE Open Access Using individual stated-preferences to optimize HIV self-testing service delivery among men who have sex with men (MSM) in Malaysia: results from a conjoint-based analysis Roman Shrestha1,2* , Haridah Alias2,3, Li P. Wong2,3, Frederick L. Altice1,2 and Sin H. Lim2,3 Abstract Background: HIV self-testing (HIVST) has the potential to improve HIV testing uptake and frequency for key populations like MSM who experience multiple barriers accessing clinic-based HIV testing. In the absence of HIVST in Malaysia, there is no guidance to inform HIVST delivery. This study investigated the acceptability of HIVST and preferences about the HIVST service delivery approaches using a standardized stated preference method. Methods: A cross-sectional online survey conducted between January and April 2019 assessed the interest in HIVST in 544 MSM in Malaysia. Participants ranked eight hypothetical HIVST service delivery program elements with varied combinations of six, two-level HIVST service delivery program attributes (cost, privacy, accuracy, kit collection site, kit type, and testing support). SPSS conjoint procedure was used to estimate the relative importance of each attribute and preference across eight possible HIVST service delivery programs. Results: Overall, 70.4% had previously tested for HIV, and of those, 64.0% had done so in the past 6 months (45.0% of all participants). Of all the participants, 25.2% reported having used HIVST previously. The acceptability for HIVST service delivery models ranged from 44.9 to 77.1%, with mean acceptability of 56.2% across the eight hypothetical HIVST distribution scenarios. The HIVST service delivery scenario with the highest acceptability had the following attributes: no cost (free), anonymity (name not required), 99–100% accuracy, home-delivered, fingerstick, and testing support using telephone hotline or texting. HIVST cost was the most important attribute (relative importance score: RIS = 19.30) associated with acceptability, followed by anonymity (RIS = 18.41), accuracy (RIS = 17.33), kit delivery (RIS = 16.99), fingerstick kit (RIS = 15.86), and support (RIS = 12.08). (Continued on next page) * Correspondence: 1 Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, 135 College Street, Suite 323, New Haven, CT 06510, USA 2 Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Shrestha et al. BMC Public Health (2020) 20:1777 Page 2 of 11 (Continued from previous page) Conclusions: Acceptability for HIVST in Malaysian MSM was high but differed markedly by a number of HIVST delivery scenarios and attributes. These findings could be relevant as the Malaysian Ministry of Health is in the process of developing a regulatory framework for ensuring the quality of kits, as well as policies supporting safe use while broader implementation under national AIDS programs. Keywords: HIV, HIV self-testing, Men who have sex with men, Implementation science, Conjoint analysis, Malaysia Background HIV testing is the first step towards achieving UNAID’s 95–95-95 targets [1] as well as for bridging the HIV prevention gap to scale-up pre-exposure prophylaxis (PrEP) in key populations [2]. For key population groups like men who have sex with men (MSM), however, HIV testing uptake is often low due to multilevel factors like fear, stigma and discrimination, criminalization, and disclosure of sexual/gender identity, lack of anonymity, and concerns about confidentiality [3–8]. In Malaysia, a middle-income country with a Muslim majority, same-sex behaviors are criminalized in both secular and Sharia laws, resulting in high levels of stigma and de facto discrimination. Consequently, MSM in Malaysia inadequately test, which has thwarted scale-up of effective HIV testing, prevention, and treatment programs for the lesbian, gay, bisexual, and transgender (LGBT) community. Sexual health programs have mainly focused on mandatory HIV testing among Muslim couples planning to marry. Consequently, HIV prevention and treatment programs are inadequately designed for MSM, who now account for most new HIV infections in Malaysia [9]. With only 61.6% of Malaysian MSM having ever tested for HIV and less than half (44.5%) tested in the past 12 months [10], innovations in HIV testing are needed. In an effort to address gaps in delivering HIV testing services, to achieve national and global testing targets, the World Health Organization (WHO) recommends and guides HIV self-testing (HIVST) to supplement traditional facility and community outreach testing [11]. HIVST offers an alternative to other testing strategies, including reaching new MSM and increase testing frequency to facilitate early HIV detection and treatment and prevent new infections [12, 13]. HIVST increases convenience, privacy, and confidentiality, but its uptake may be limited by cost for some MSM, particularly in Malaysia, concerned with legal constraints and face high rates of stigma and discrimination. While HIVST research has increased globally, no empirical studies have been conducted in Malaysia. HIVST is currently not licensed in Malaysia, and the country does not have any formal regulation of HIVST kits yet. However, unregulated HIVST kits are available for purchase at several pharmacies nationwide and are also widely available through the internet (RM20 = ~ USD5). As the Malaysian Ministry of Health develops its national HIVST policy to expand HIV testing in key populations, empirical evidence to guide nation-wide HIVST strategy is critical. Specifically, MSM are heterogeneous in terms of their preferences about HIV testing, and as HIVST becomes (...truncated)