Muwanguzi et al. BMC Health Services Research
https://doi.org/10.1186/s12913-021-07259-6
(2021) 21:1217
RESEARCH
Open Access
Venues and methods to improve
professional men’s access to HIV selftesting and linkage to HIV prevention or
treatment: a qualitative study
Patience A. Muwanguzi1*, Esther M. Nasuuna2, Florence Namimbi2, Charles Peter Osingada1 and
Tom Denis Ngabirano1
Abstract
Background: HIV testing among men in sub-Saharan Africa is sub-optimal. Despite several strategies to improve
access to underserved populations, evidence regarding engaging men in professional and formal occupations in
HIV testing is limited. This study explored employed professional men’s preferences for uptake of HIV self-testing,
and linkage to HIV care, or prevention services.
Methods: This was an explorative-descriptive qualitative study where a sample of 33 men from six Ugandan urban
centres. Participants were purposively selected guided by the International Standard Classification of Occupations to
participate in in-depth interviews. The data were collected using an interview guide and the sample size was
determined by data saturation. Eligibility criteria included fulltime formal employment for over a year at that
organization. The data were analyzed manually using thematic content analysis.
Results: Three categories emerged: uptake of HIV self-tests, process of HIV self-testing and linkage to post-test
services. The different modes of distribution of HIV self-test kits included secondary distribution, self-tests at typically
male dominated spaces, delivery to workplaces and technology-based delivery. The process of HIV self-testing may
be optimized by providing collection bins, and mHealth or mobile phone applications. Linkage to further care or
prevention services may be enhanced using medical insurance providers, giving incentives and tele counselling.
Conclusion: We recommend utilization of several channels for the uptake of HIV self-tests. These include
distribution of test kits both to offices and men’s leisure and recreation ‘hot spots’, Additionally, female partners,
peers and established men’s group including social media groups can play a role in improving the uptake of HIV
self-testing. Mobile phones and digital technology can be applied in innovative ways for the return of test results
and to strengthen linkage to care or prevention services. Partnership with medical insurers may be critical in
engaging men in professional employment in HIV services.
Keywords: Workplace HIV testing, HIV self-testing, Men, Urban, Sub-Saharan Africa
* Correspondence: pamuwanguzi@gmail.com
1
School of Health Sciences, College of Health Sciences, Makerere University,
Kampala, Uganda
Full list of author information is available at the end of the article
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Muwanguzi et al. BMC Health Services Research
(2021) 21:1217
Background
HIV testing uptake among men in sub-Saharan Africa
remains sub-optimal, however, linkage to care represents
the one of the greatest challenges to achieving the Joint
United Nations Programme on HIV/AIDS (UNAIDS)
targets [1]. In 2020, knowledge of HIV status was lower
among men (79%) than women (87%) across subSaharan Africa, but the largest gap was among men aged
35–49 years, with an estimated 701,000 remaining undiagnosed [2]. In 2019, 12% of the new infections and
28% were among men aged 15–24 and 25–49 respectively in East and Southern Africa [1]. In Uganda, approximately 62% of men living with HIV, knew their
HIV status in 2019 [3], while the estimated incidence
among adults aged 15–64 years in urban areas was
0.44% compared to 0.39% in rural areas, with the annual
incidence peaking among men aged 35–49 years (0.47%)
[4]. This is the typical peak age of employment. Therefore, reaching working men with HIV testing and treatment coverage could be critical to reducing HIV
incidence among women in sub-Saharan Africa, and by
extension, reducing mother-to-child transmission [2].
Men in sub-Saharan Africa report that they face
stigma when they go to take an HIV test at a health facility, thus the preference for community-based HTS [5].
Stigma exists when “elements of labeling, stereotyping,
separation, status loss, and discrimination occur together
in a power situation that allows them” [6]. In this case,
this stigma may arise from individuals, community
members and health workers negative beliefs, attitudes,
and fears [7]. Therefore, strategies for improving men’s
uptake of HIV testing service, have focused not only on
clinical-based
populations
but also
emphasize
community-based services [8, 9] such as home-based
testing, workplace-based testing, and partner testing.
Findings from men in rural Zambia suggest that
community-based testing reduces the cost and inconvenience associated with travelling to health facilities
[10]. Although community-based HIV testing may reduce stigma, it still does not overcome some of the barriers such as long waiting lines when men go to health
facilities to initiate antiretroviral therapy (ART) [5].
Therefore, the provision of treatment at non-facility testing sites through differentiated service delivery may help
in addressing some of these challenges [11]. A study on
community influences on married men’s uptake of HIV
testing in Chad, Ghana, Malawi, Nigeria, Tanzania,
Uganda, Zambia, and Zimbabwe recommended flexible
hours, expanding mobile clinics, and private access to
care are also recommended [12, 13]. Campaigns to increase the uptake of HIV testing using cash and nonmonetary incentives have reported varying levels of success [14]. In south Africa, a mobile clinic that combined
testing and incentives reported a positivity yield (15%),
Page 2 of 12
however, this was among youth in informal dwellings
with high unemployment rates which may raise ethical
concerns such as potential for coercion [15].
HIV self-testing (HIVST) is another strategy that has
shown success in reaching high-risk men and first-time
testers [16]. According to the World Health
Organization (WHO), this strategy reduces men’s interaction with the healthcare system for testing, overcomes
several masculinity issues and can be distributed in various creative ways [17]. Despite the high uptake of HIV
self-testing in non-facility-based testing, linkage to HIV
confirmatory testing, ART initiation and prevention services remained a challenge in Malawi and Zambia and
other sub-Saharan countries [18–22]. WHO recommends self-testing at the workplace as a potential strategy to reach men, since studies report one of the key
reasons for their lack of HIV testing and care as their
busy work schedule [23]. The International Labour
Organization (ILO) classifies occupations into ten major
groups, Managers, Professionals, Technicians and associate professionals, Clerical support workers, Service and
sales workers, Skilled agricultural, forestry and fishery
workers, Craft and related trades workers, Plant and machine operators, and assemblers, Elementary occupations
and Armed forces occupations [24]. A few studies assessing HIVST in workplaces in sub-Saharan Africa have
been conducted at mining and farming industries
(Malawi, Zambia, and Zimbabwe) [16], at truck yards
(Kenya) [25], farms, agricultural industries, factories,
construction sites and taxi ranks (South Africa) [26].
These studies have largely been conducted among men
in informal types of employment. We did not find published literature regarding HIV testing and linkage practices targeting men employed in professional and formal
occupations, Managers, Professionals, Technicians and
associate professionals, Clerical support workers, and
Service and sales workers. The men in these types of occupations typically work regular hours which are normally the same as clinic opening hours and may
therefore not engage in HIV services due to their work
schedules. They are also at higher socio-economic status;
higher education level and national HIV policy makers
may assume that they have adequate knowledge regarding HIV, and thus may not be prioritised while designing
national HIV testing plans. This may omit an unidentified transmission source of the HIV infection, since
some of these men may be living with HIV but unaware
of their status. Furthermore, there is limited information
generally regarding what works for reaching men, and
there is need to reach ‘older men’ over 35 years old for
HIV services [27]. Given that there is a paucity of literature regarding this population, we set out to explore
professional men’s preferences for uptake of HIV selftesting and linkage to post-test services in Uganda.
Muwanguzi et al. BMC Health Services Research
Page 3 of 12
(2021) 21:1217
The study was conducted during the COVID-19 pandemic in Uganda, and data were collected between September and November 2020.
Methods
Research team and reflexivity
The research team members are all health professionals.
PAM, EMN, TDN and CPO have received extensive
training in qualitative research methodology, while
EMN, and FN work in the field of infectious diseases,
specifically HIV. The research assistants have all undergone training in qualitative research methods and retrained at the start of this project. PAM kept a daily selfreflective journal before and during the study period.
This journal included the researcher’s assumptions, beliefs, opinions, and an analysis of how these might affect
the study process and study outcomes.
assumption that each man’s perceptions may also be influenced by their different professions or occupations.
The selection of occupations was guided by the International Standard Classification of Occupations (ISCO)
[24]. Using this approach, 122 men received an email
with details of the study and as part of their consent,
were requested to provide a phone number, Skype® address or receive a Zoom® meeting link depending on
their preferred mode of contact. Of the 122 men who
were approached, 57 declined to participate. Therefore,
65 consented and were enrolled. Data collection stopped
when no new information emerged from the interviews,
indicating that the study had gained maximum information about the phenomenon after 33 interviews.
Data collection
This was an explorative-descriptive qualitative (EDQ)
study among men in six urban Ugandan towns and cities.
The EDQ design was chosen because of its suitability for
studies aiming to explore preferences, concerns, attitudes,
and perception [28]. The study was conducted in the following urban sites: Kampala, Gulu, Hoima, Wakiso, Mbale
and Mbarara. A list of urban centres from the Uganda
Bureau of Statistics (UBOS) [29], was categorized by region. We then selected the six (6) centres from each region using simple random sampling. The men were
purposively selected to participate in in-depth interviews.
The eligibility criteria included: Working at a professional/
formal job, regular hours, > one year, and holding a fulltime position. We selected the cut-off of one year, with
the assumption that after one year in the role, one may be
comfortable enough to make suggestions regarding their
welfare at the workplace.
Due to the COVID-19 restrictions and country research
guidelines, we conducted one-time phone, Zoom®, or
Skype® in-depth interviews (IDI). The interviews were
conducted by PAM and two research assistants from 1st
September to 26th November 2020, and each lasted 45
min to one hour.
Data collection employed an interview guide. The
guide was developed by the research team and pilot
tested among a similar population in another district.
The interview guide included questions about the men’s
perception of HIV testing at the workplace, HIV selftesting, ways to improve uptake of testing at the workplace and their preferences for linkage to care or prevention services following a positive or negative self-test
result, respectively. The researchers listened to each
interview recording daily to identify further areas for
probing questions. The probing questions included
modes of delivery of the HIV self-test kits and follow-up
after a self-test. All the interviews were audio recorded
with the participants’ permission.
Selection of participants
Data analysis
In the first instance, we contacted the office of the chief
administrative officer in each town to identify the
medium and large-sized workplaces. We sought administrative clearance from each individual workplace and
email addresses for potential participants from the human resource officer at each work setting. We
approached workplaces that had over 50 male professional employees. Participants were purposively sampled
to include men from all employment levels ranging from
senior management, middle management, lower-level
management, supervisors, and employees. Additionally,
we selected men from diverse professions, occupations,
and roles, and from both public and private sectors. We
identified men in different professional roles and selected one person per professional role or category. The
aim was to elicit heterogeneous responses with the
The data were manually analyzed using thematic content
analysis [30]. As this was an EDQ study, we used the
thematic content approach because there was no prior
research or theoretical definition on this phenomenon to
offer guidance on the themes [31]. The first author
(PAM) transcribed the recordings and together with another author (TDN), immersed themselves in reading
the transcripts. Then the transcripts were read again and
each of the analysts noted preliminary interpretations of
the text while performing open coding. Another member
of the team reviewed the codes from both coders to
achieve consensus. That additional team members arbitrated between the coders where there was no consensus. All the initial codes highlighted with similar colours
were then clustered together into categories and subcategories which captured the essence of the
Study design and participants
Muwanguzi et al. BMC Health Services Research
participants’ descriptions. These observations are reported under the four categories in the results section.
Results
Participant’s characteristics
Thirty-three men participated in-depth interviews (IDI).
The ages of the participants ranged from 25 to 55 years.
They had all attained tertiary/post-secondary level of
education and 5/33 (15.2%) had taken an HIV test in the
last two years. Table 1 presents the characteristics of the
men.
Men’s preferences for HIV self-testing and posttest
services
We report the findings generated from our study in
three categories: uptake of HIV self-testing, process of
HIV self-testing and linkage to post-test services. The
coding tree of the categories and sub-categories is presented in Fig. 1.
Table 1 Partcipants characteristics
Enrolment, N
33
Age (years)
Mean (SD)
41.6 (8.42)
Median (IQR)
42 (35–47)
Categorical, n (%)
18–25
1 (3.0)
26–35
8 (24.2)
36–45
12 (36.4)
46–55
12 (36.4)
Occupation (ISCO)a
Managers
7 (21.2)
Professionals
16 (48.5)
Technicians and associate professionals
6 (18.2)
Clerical office workers
4 (12.1)
Highest education level
Diploma
4 (12.1)
Bachelor’s degree
6 (18.2)
Post graduate diploma
7 (21.2)
Professional certification
6 (18.2)
Master’s degree
8 (24.2)
PhD
2 (6.1)
Took HIV test < two years ago
Yes
5 (15.2)
No
28 (84.8)
Willing to take HIVST at work
a
Yes
24 (72.7)
No
9 (27.3)
ISCO International Standard Classification of Occupations
Page 4 of 12
(2021) 21:1217
Uptake of HIV self-testing
We asked the participants the best way to distribute
HIVST kits to them. Four sub-categories emerged for
the distribution channels of HIV self-test kits including
secondary distribution, testing at typically ‘male spaces’,
workplace delivery and technology-based delivery. The
categories and sub-categories are presented in Fig. 2.
Secondary distribution
Female-delivered HIVST
This involves giving the test kits to men’s female work
colleagues to share with their partners. The participants
presumed that men who work in professional jobs, probably had partners of similar social and economic standing, and therefore had the same characteristics such as
difficulty accessing HIV testing or limited time to go to
the health facility for HIV testing services. Another proposed way was to identify female groups such as church
groups and through their leaders, send test kits to their
partners. Therefore, they suggested the use of their female colleagues to reach other men.
Give our female colleagues the testing kits to reach
their partners at other workplaces. When they test
here, they can receive a test kit for their partner and
give you the partner’s phone number that way, you
can reach out to the partner after maybe a week to
follow-up. (IDI, 04)
Peer distribution
Several participants suggested that one of the ways to
get anyone involved is using peers, a particularly useful
group to influence and encourage positive behavior. One
participant explained:
Men can be influenced by friends, role models and
like-minded people. So, the kits can be delivered by
work colleagues or champions. If this person takes up
HIV self-testing, then other people are likely to take
it up as well. Identify community and workplace
champions, who can either create awareness or who
can lead by example. (IDI, 17)
Established men’s groups
Participants suggested that men have established groups
such alumni groups, savings groups, and social media
networking groups among others and that these groups
are usually consistent with their income level or their socioeconomic status. They recommended secondary distribution of HIV self-test kits using these networks.
I think men have groups where they belong, these
maybe physical of virtual groups. For example, savings groups and alumni associations. They will
Muwanguzi et al. BMC Health Services Research
(2021) 21:1217
Fig. 1 Coding tree for reaching men in formal employment for HIV self-testing and posttest services
Fig. 2 Preferences for the uptake of HIVST among men in formal employment
Page 5 of 12
Muwanguzi et al. BMC Health Services Research
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(2021) 21:1217
typically meet regularly or have some annual meetings depending on why the groups were formed. The
test kits can be distributed through the organizers or
they can provide an avenue for reaching these men.
Some of these schools like from all-boys schools have
thousands of members. (IDI, 14)
Another member proposed groups at churches:
You can even distribute the test kits through the different men’s church groups or even the women’s
groups to distribute to their partners. (IDI, 06)
Testing at ‘male spaces’
The participants highlighted the existence of ‘male
spaces’, which are places dominated by men of a certain
status or places where men typically meet after hours or
at the weekend. The recommended venues include fitness centres and health clubs, places of worship, pubs
and bars, car washing bays, golf clubs and corporate
sporting events.
Corporate sporting events
Most participants mentioned sports events such as the
corporate league or the annual marathons, although currently this might be difficult with the COVID-19 restrictions. One shared:
Corporate men usually patronize corporate sports
events because these are the ways in which they can
market their company products, meet with other
people and network. If you talk to the organizers,
you could set up your tent or send the information
beforehand that there will be HIV self-testing. (IDI,
08)
Fitness centres and health clubs
More than a few participants suggested that men who
work in offices could be targeted at high-end fitness centres, saunas, and gymnasiums (gyms). One participant
expounded:
Many men who work in offices, spend the greatest
part of the day at their desks. Therefore, they usually
like to go to the gym for a workout either in the evening or early in the morning, or at the weekend. I suggest that you go to gyms that have relationships and
packages with corporate companies, high-end ones,
gyms in residential areas and those at 3- and 4-star
hotels. (IDI, 07)
Places of worship
Some men who work in offices go to places of worship
on Friday, Saturday or Sunday depending on their
religion. Some participants suggested this as a potential
way for reaching men.
You can speak to the religious leaders because some
of these men really trust them. The leaders can use
their platforms to raise awareness for HIV testing
and then on a particular day of worship, you can
distribute the test kits. (IDI, 12)
Pubs and bars
Participants recommended pubs and bars as potential
places to get men to take an HIV test. They however
expressed concern about taking the test while they are
inebriated and the possibility of personal or social harm
if they received a positive test result.
There are certain types of pubs and bars that are
typically frequented by corporate men, where they go
to relax and unwind after a long day or week. I see
it as a potential place where one can reach men with
the services. However, it might be complicated with
someone taking the test under the influence of alcohol, you never know what they may do when they
find an unexpected result. (IDI, 24).
Car washing bays
Many individuals take their cars for a wash either on
Saturday evening or on Sunday evening in Ugandan
towns. These bays have now expanded to provide drinks
and barbecue services, and become a place where friends
meet, more so in the COVID-19 era. Some participants
proposed that this would be a good place to reach men
for HIV testing.
The washing bay would be a good place; you can
usually find men there in small groups. Therefore,
if one member of the group takes the HIV test kit,
then it is likely that the others will at least consider taking one as well. Therefore, if you look for
up-market car washing bays with proper seating
especially close to residential areas, you will find
men. (IDI, 02)
Golf clubs
Some participants proposed the golf clubs as potential
places to reach men of middle and higher incomes for
HIV testing.
The men that go to a golf club are those people with
big salaries like CEOs. Talk to the chairperson of the
golf association or just meet the management and
then you can provide testing services when they have
tournaments or during the weekend when most
people play. (IDI, 30)
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Workplace-based testing
Staff clinic
and someone can either call me back or just work on
the order. (IDI, 20)
Some places of work have a staff clinic for their employees and the participants proposed this clinic as a
venue for HIV self-testing.
Another participant suggested using existing transportation phone applications. He proposed:
I think if you go to the staff clinic where we go for
our treatment like malaria, you can work with the
health workers there and men can pick the kits. It
will also help when I have any questions, I can talk
to the health workers. However, I will not give them
my results, those ones I will take to the hospital.
(IDI, 09)
These days, I use the SafeBoda® app to get items delivered fast and securely since they use motorcycles. I
think if you worked with them, you could add a feature where men just placed an order for a self-test
kit on the SafeBoda® app, and get it delivered to the
client anywhere within their operational radius.
(IDI, 04)
HIVST kit dispensers
HIVST digital vending machines
A few participants suggested that the same way they receive condoms in the washrooms, a separate dispenser
could be put for the HIV self-test kit. One man shared:
Some of the men proposed accessing the test kits from a
specially designed digital vending machine. One participant expounded as follows:
A few years ago, one of the HIV projects installed
condom dispensers in the male washrooms. Why
can’t you also put that for the test kits because it is
private? I can pick the kit and take the test from the
washroom and dispose of the kit immediately. (IDI,
18).
You can make a vending machine that contains several sexual and reproductive health commodities like
condoms, lubricants, and the self-testing kits. One
can enter a phone number to access the kit, then
check the records later to see which phone number
picked up a kit. (IDI, 03)
Office health and wellness events
Online shopping platforms
Almost every participant reported that they have annual
or regular office health and wellness events. They proposed this as a quick way to reach men for HIV selftesting. One shared:
Due to the COVID-19 pandemic and global progress,
many individuals including those in Low- and MiddleIncome Countries are shopping online. Some of the men
proposed that HIV self-testing could leverage on such
platforms to distribute the kits to men who work in offices. This is an excerpt from an interview:
Every year, we have these wellness events. They usually have tests for eyes, dental services, blood pressure and talk to us about circumcision and prostate
cancer screening. There is also HIV testing and blood
transfusion services, however, people rarely go to the
tent for HIV testing. I think the self-testing is a good
way because you pick up your kit and test in private,
in addition to the other health services.
(IDI, 18)
Technology-based HIVST kit delivery
Smart phone applications
Several participants suggested providing a special number to use for social media communication, and to place
orders for their test-kit delivery. However, they needed
to be reassured about the confidentiality of their information. One professional shared:
If you provide a number which has Facebook® and
WhatsApp® and such similar platforms, when I'm
ready I can then send a message to place my order,
The kit can be included on the platform as one of
the items for sell, and the people who are doing the
HIV self-testing can be the sellers. For example, an
online shopping platform like Jumia with a large
market share in Uganda is a good place to start.
Jumia offers door-to-door delivery services, so that
way the kits reach the user and will be delivered all
you have to do is call the client for follow-up. (IDI,
27)
HIVST process
HIVST collection bins
One participant suggested that we can provide a bin or a
locked storage container in the washroom, where participants can put their used test kits after reading the test
result. He suggested the installation of locked collection
sanitary bins in the washrooms such that men could
place the test kits there immediately after a test, and
these would be picked up regularly to confirm the results. This meant that each participant’s test kit would
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be clearly linked to either a phone number or a participant identifier number. This would then allow those that
have not deposited their kits to be identified and
followed up by a phone call. He shared:
I think you can put a locked bin in the washrooms
and people can place their test kits there after testing. Someone can check regularly and empty the bin
and then see our results. I am not sure for how long
the results remain valid though. (IDI, 10)
Linkage to confirmatory testing, ART initiation and
prevention services
Tele counselling
The men proposed that they could receive telephone
counselling to answer questions and for the health
workers to follow up for further testing. Furthermore, the
participants suggested that the person who will conduct
virtual posttest follow-up should meet the men before
they take the test, this will establish rapport and instil confidence when the men must divulge their test results.
One shared:
Telephone follow up
Participants proposed telephone follow-up as one of the
easiest ways to get people to return the test results. They
recommend that this should be discussed beforehand so
that a participant is given the choice for how they would
like the test results to be returned. One participant
elucidated:
All men in office jobs have mobile phones and they
go everywhere with them. If you discussed beforehand that someone should be called after a certain
period to return the test results, when you call, he
will respond. Do not underestimate the power of telephone calls because that way the patient or health
worker can also ask any follow-up questions that
they have. (IDI, 27)
Mhealth phone applications
The men put forward that smart phone applications
such as Facebook or WhatsApp could be a potential
channel for the testers to return their results. They also
proposed the development of specific apps to encourage
HIV testing. One participant expressed as follows:
I think for me the easiest way would be send a real
time picture of the test result and then dispose of the
kit immediately. Almost all of us use WhatsApp or
Facebook or even email, if you promise that my results will not be shared anywhere. A new application
for this kind of thing could also be developed, where
for example the phone can read and upload test results (IDI, 17)
Another participant proposed below:
… smart phones can be an extremely useful tool, for
the sake of confidentiality, we can just send a text
message with a code that either says “yes or no” of “1
or 2” such that whoever reads that message will not
know what we are talking about. However, the code
should be sufficient for the message recipient to know
whether the sender has tested positive or negative.
(IDI, 23).
I think the phone can be used for follow-up and support after getting one’s test results. In this era of
COVID and with our busy schedules it's very hard
for me to keep going to the facility, but if I have
somebody to continually offer guidance and information, I think it makes it easier. (IDI, 18)
Medical insurance providers
Several of the men recommended liaising with their
medical insurance service providers because they have
databases of all the beneficiaries receiving medical coverage. They advised that these databases could be used for
contacting the men for the initial uptake of HIVST, and
further engagement after the test. One participant
shared:
We all receive health insurance, therefore, if you get
in touch with our insurance providers and you discussed at that level, in conjunction with the human
resource officer then you can get information about
the men. You can access phone numbers you or
email addresses and contact them regarding the testing. It is also important that you connect with the
health facilities providing care such that if one tests
positive, it becomes quite easy to get treatment as
part of the medical insurance plan. (IDI, 25).
Non-monetary incentives
Several of the participants reported that they needed
some form of motivation or incentive to take this test.
They suggested that the incentives should be non- monetary and gave several examples of incentives that would
motivate them to take the test. One participant shared:
Why would I want to take an HIV test? There must
be a reason why, especially if you want me to take it
at the office. But if you put a test and said those
who take the test and go for treatment will be given
something, then I would be willing to participate.
(IDI, 11)
Another participant expounded:
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No, I do not want money but maybe mobile data, or
a gym membership discount, supermarket vouchers
or maybe discounts for my monthly TV subscription.
(IDI, 29).
Several participants suggested that the incentives could
also be used to enhance linkage to further services.
You could even motivate them that you will give
them a reward when they bring back the results or
when they go for other services. For example, circumcision or when they start on treatment if they test
positive. (IDI, 33).
Discussion
The results of this explorative-descriptive qualitative
study provide insights into professional men’s preferences for accessing HIV self-testing (HIVST) services in
Uganda. We focused on men working in professional
and formal occupations, who were employed in full-time
positions and had worked for a year at the same
organization. Although these men are highly educated
with 100% attaining a post-secondary qualification, only
15.2% had taken an HIV test in the last two years.
Three categories emerged from the interviews: uptake
of HIVST, Process of HIVST and linkage to post-test
services. The men proposed different modes of distribution of kits such as secondary distribution of test kits,
self-testing at typically male dominated spaces, delivery
to workplaces and technology based the delivery of the
self-test kit. They suggested that test results could be
returned using collection bins and giving incentives and
tele counselling to enhance linkage to further care and
services. This agrees with findings from a study by Parish and colleagues among dental professionals in USA
where they recommended greater support from national
dental organizations, and dental insurance companies to
enhance uptake of HIV testing in dental settings [32].
Our findings indicate that men are amenable to
female-delivered HIV self-test kits and they propose
various ways. Female partner delivered HIVST has been
used successfully among pregnant women in during
antenatal care [33–35] and female sex workers [36, 37].
Some studies have reported challenges with this method
including lack of immediate counselling, concerns
around trust, and intimate partner violence (IPV) or verbal abuse depending on how the woman presented the
matter or if the man was taken unawares [38]. A study
in Uganda did not report any serious adverse events
among individuals that self-tested for HIV following
female-delivered HIVST, while women in Malawi reported verbal or physical abuse and economic hardship
[39]. Another difficulty with this method is that it relies
on the solidity of the couple’s relationship. It can be
Page 9 of 12
affected by the gendered power dynamics and control
over decision-making in the household, for instance if
the woman does not usually have a lot of say in the
home [40]. On the other hand, this strategy encourages
HIV-status disclosure and adherence to HIV treatment
in future if they test positive, because they will test together as a couple. Matovu et al. suggest some strategies
to optimize the female delivered HIVST approach including maintaining open communication throughout
the process, placing kits in conspicuous locations in the
house, and seeking support from health workers [41].
Increasing the number of distribution channels of HIV
self-test kits in key ‘hot spots’ of men is vital to reaching
them for HIV testing [42]. One recurrent discovery in
this study was finding the men where they are. This
aligns well with the Ugandan MoH guidelines which recommend novel methods to engage men in HTS including testing at workplaces, and key populations hotspots
[43]. Some studies have been conducted around finding
men at such settings including venues for televised football matches in Uganda [44], workplaces [16, 25], community centres, at male-dominated workplaces and at
venues including sporting events, tuckshops, bottle
shops and other public gatherings in South Africa [26].
We therefore propose the identification of ‘male spaces’
in communities and working with community leaders
and champions to provide creative dissemination strategies for HIV self-testing that are user friendly and
convenient.
Technology based delivery was another important distribution method for the study participants. This includes the use of interventions that have been reported
with some success such as smart phone applications [45,
46], HIVST electronic vending machines [47, 48] and
online shopping platforms [49], although there are challenges with such unsupervised and unregulated distribution models. The World Health Organization (WHO)
recommends that appropriate instructions, information
and support, as well as contact details should be provided with the kit when HIVST kits are distributed directly to the user [50].
The participants recommended the use of collection
bins for returning test kits. This method reduces the
likelihood of accidental disclosure and solves the challenge of where to safely dispose the used test kit [51].
Although this method may be feasible as part of a research study, it may not be easy to scale up due to the
number of workplaces nationwide but could be considered for places with a large workforce. Additionally, it
may place health workers at additional risk as they
would be required to sift through medical waste.
Telephone follow up and tele counselling emerged repeatedly from our findings as the men’s preferred
method to support their linkage to confirmatory testing,
Muwanguzi et al. BMC Health Services Research
(2021) 21:1217
ART initiation and prevention services. All the study
participants possessed mobile phones, which is not
surprising in a country with about 25 million estimated cellular phone subscribers [52]. Mobile phones
could be used to send reminders and health education information. It should be noted that they requested a discussion prior to HIVST as they were
worried that somebody else would access their phone
and cause unintentional disclosure. Furthermore, the
men expressed the need for confidentiality and as
such proposed the use of platforms that have a facility for video or face-to-face calls. Telehealth approaches of delivering HIV testing and care are
currently being trialled in some settings [53, 54],
while telephone follow-up has been successful in several studies [26, 55–57]. However, some of the challenges included some men giving wrong numbers,
others refusing to pick their calls, while other phones
went to voicemail. We therefore recommend the use
of telehealth models to improve men’s engagement at
different points of the HIV care continuum.
One strategic finding that arose was the recommendation to liaise with medical insurance providers. Several
studies on HIV self-testing have listed the cost as one of
the barriers to the uptake of testing. Estem et al. suggest
that offering HIV self-tests through medical insurance
programs may be an effective approach and overcome
the challenge of the cost, as this would be covered as
part of the insurance scheme [42]. The insurance providers would also play a pivotal role in the initial
sensitization and creation of awareness about testing and
follow up after testing.
Strengths and limitations
The strength of this study is that it is the first to exclusively document the preferences for HIV self-testing
among professional men. The findings provide insight
into how this underserved population can be reached to
participate in these initiatives and importantly this
knowledge lays the foundation for strategies to for linkage to treatment and care in the event of reactive selftest results. As this was a qualitative study, participants
were purposively selected from different work settings.
By design qualitative studies do not result in
generalizable findings but rather our results may be
transferable to similar settings. To improve transferability, we endeavoured to select participants from different
ranks, professions, and sectors. Additionally, we involved
participants from six Ugandan districts.
On the other hand, the interviews that were conducted
by phone made it impossible to observe for non-verbal
cues, therefore, in places with good internet connectivity,
we prioritized the use of Skype® and Zoom® video calls.
Page 10 of 12
Conclusions
This study explored the professional men’s preferences
for access to HIV self-testing, and linkage to care, or
prevention services and revealed that some men were
not aware of their HIV status. This study suggests several strategies to optimize the uptake of HIV self-testing
among men in formal employment, however further
quantitative and experimental research is needed to
evaluate the effectiveness of these strategies in Uganda
and in other sub-Saharan African contexts. Additionally,
linkage to care remains a challenge and further research
to determine the strategy with the highest proportion of
men linked to HIV treatment and care following positive
self-test results is warranted.
We make the following recommendations based on
our study findings. First, we suggest the utilization of
various channels to distribution HIV self-test kits including workplace-based testing, testing at men’s leisure and
recreation ‘hot spots’, and secondary distribution
through female partners, peers and established men’s
groups including social media groups. Second, make the
most of mobile phones to provide HIVST education and
innovative ways for returning test results and to encourage linkage to post-test services and technology such as
online shopping platforms and vending machines. Third,
we recommend strengthening partnerships with medical
insurers since they have access to both the employees
and the health facilities. Finally, we recommend working
with key stakeholders including community leaders, religious leaders, employers, leaders of established men’s
groups and health professionals as champions to increase the uptake of HIV testing and enhance linkage to
post-test services.
Acknowledgements
The authors would like to express their gratitude to the research assistants
and all the participants for their engagement in this study.
Authors’ contributions
Conceptualization: [Patience A. Muwanguzi, Tom Denis Ngabirano, Esther
Michelle Nasuuna, Florence Namimbi], Methodology: [Patience A.
Muwanguzi,]; Formal analysis and investigation: [Patience A. Muwanguzi,
Tom Denis Ngabirano]; Writing - original draft preparation: [Patience A.
Muwanguzi, Tom Denis Ngabirano]; Writing - review and editing: [Esther
Michelle Nasuuna, Florence Namimbi, Charles Peter Osingada]; Funding
acquisition: [Patience A. Muwanguzi]; Resources: [Esther Michelle Nasuuna,
Florence Namimbi]; Supervision: [Charles Peter Osingada]. The author(s) read
and approved the final manuscript.
Funding
This project was made possible by a NURTURE fellowship award funded
under Grant Number D43TW010132 (PI: Nelson K. Sewankambo) from the
Fogarty International Center of the National Institutes of Health. The authors
report no conflict of interest. The funders had no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript.
The contents are solely the responsibility of the authors and do not
represent the official views of the supporting institutions.
Availability of data and materials
All relevant data have been presented in this paper and the raw data is
available from the authors upon reasonable request.
Muwanguzi et al. BMC Health Services Research
(2021) 21:1217
Declarations
Ethics approval and consent to participate
The study was approved by the Makerere University School of Health
Sciences Research Ethics Committee (Ref. Number: 2018–054) and the
Uganda National Council of Science and Technology (Ref Number: HS 2672).
Additionally, administrative clearance was obtained from each study district.
Written informed consent was sought from each participant prior to
participation via email. All methods were carried out in accordance with
relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
School of Health Sciences, College of Health Sciences, Makerere University,
Kampala, Uganda. 2Infectious Diseases Institute, College of Health Sciences,
Makerere University, Kampala, Uganda.
Received: 23 May 2021 Accepted: 2 November 2021
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