This is the first study to have been undertaken with health workers from SCS in northeastern Brazil about their knowledge, acceptability, and willingness to offer HIVST. Although most of the participants enrolled for the study reported knowing about HIVST (79.8%), the levels of acceptability (55.2%) and willingness to offer it (47.1%) were moderate.
In a systematic review among key populations, eight of the fourteen studies found high acceptability (≥ 67%), five found moderate acceptability (34–66%), and one found low acceptability (≤ 33%) of HIVST [17]. In our study, we found the acceptability of HIVST among the health workers to be moderate, which differs from the reports of high acceptability found in systematic reviews of specific populations and age groups in different parts of the world [17, 21, 27]. Also in Brazil, a study carried out in 2016 with MSM in 12 cities found a similar level of acceptability of HIVST (47.3%), which was even lower among the MSM who had never done an HIV test (42.7%) [28]. Although this study did not involve health workers, the coincidence of the levels may be indicative of the incipient nature of self-testing in the country.
In our study, assisted testing at the health facility was the preferred means of administering HIVST, which could indicate the health workers interviewed could still be operating from the traditional perspective of voluntary counselling and testing (VCT), which assumes users voluntarily seek out services. This approach is different from provider-initiated counselling and testing (PITC), which is marked by the routine proactive offer of testing by health providers at all consultations. Both assume a particular posture on the part of the health worker in presenting the user the opportunity to get an HIV test [29, 30]. Considering the Brazilian MoH current proposal to expand HIV testing using HIVST and promote user autonomy, the traditional approach of VCT could constitute an obstacle to the test kit’s distribution, while approaches more akin to PITC could help generate demand for testing.
In this study, fewer than half of the health workers demonstrated willingness to offer HIVST. The main reasons for this relate to potentially negative mental health outcomes, such as suicide risk, self-harm, and harm to others in response to a positive test result. Studies with key populations such as MSM, transgender people, and sex workers in different countries have found similar misgivings about HIVST use, but to date there is no evidence in the literature that HIV self-testing is associated with such outcomes [31, 32].
As for the practice of counselling, the traditional format still seems to prevail among health workers, since the absence of post-test counselling for negative test results was also considered a reason for not offering HIVST. In a systematic review of qualitative data collected between 1998 and 2018, Njau et al. [32] found a similar concern among health workers and administrators in five African countries. A qualitative study conducted in a STI/AIDS counselling and testing center in Maceió, Brazil, in 2017 found that some health workers felt HIVST could diminish their professional role and could threaten their work, potentially hampering the continuity of care dispensed to users [33]. The data about the lack of availability of counselling suggests both a concern on the part of health workers unwilling to offer HIVST about users’ care, while also reinforcing the space of power occupied by these health workers in the user-professional relationship, leaving little space for lay subjects to express their autonomy.
The denial of HIVST because of lack of counselling could also reduce the capacity to diagnose HIV infection among stigmatized key populations who face multiple barriers to accessing care. Previous experience shows that unconventional testing and counselling formats, such as approaches using online technologies, are related to enhanced HIVST acceptability or an enhanced experience of self-testing by users [34–36]. In a study in 2015–2016 in the Brazilian city of Curitiba, Boni et al. [37] demonstrated the feasibility of internet-based strategies for the free, anonymous provision of HIVST and information on its use. The repeated use of HIVST without the presence of a health worker but with the doors of health services open to users is deemed advantageous for users, because it gives them greater autonomy in choosing what testing method to use, increases confidentiality and privacy, and reduces the chance of their suffering some form of HIV-related stigma or discrimination [38–41].
However, HIVST use should not be turned into a free-for-all. It should be used according to the latest scientific evidence and the legal provisions of SUS, which include access to online post-testing guidance, a toll-free 24-hour telephone hotline for any HIVST registered in Brazil [42], and explicit user support guidelines provided by the MoH, such as confirmation of diagnosis and assurance of linkage to health services [14].
It is important to be aware that social changes should be taken into account and novel ways of providing information and counselling could be needed, which are still a challenge to the widespread introduction of self-testing [32, 43, 44]. Quicker approaches mediated by easy-to-access digital technologies, or options that may not even require real-time user-professional interaction are potential routes forward, provided user access is enabled in such a way as to prevent the risk of excluding precisely those key populations among whom the epidemic is disproportionately high [40, 45].
Prior knowledge of HIVST on the part of health workers was not associated to increased willingness to offer it, which could suggest that such willingness may be influenced by other concerns vis-a-vis this testing option. Conversely, indicators that suggest greater familiarity with HIVST, such as working at a service where HIVST is already on offer, having received training in HIVST, and knowing about its distribution by SUS seem to be important in increasing the willingness to offer it, indicating the need for a broader repertoire of awareness-raising options.
Our study also found that willingness to offer HIVST was strongly associated with acceptability of HIVST. In a systematic review, Sekhon et al. [46] propose a definition of acceptability that involves a subjective evaluation of a health intervention by both the individual who delivers the intervention and the individual who experiences it. These aspects are based not only on prior knowledge, but also on prior practical experience of the intervention. As such, the level of specific training in a new health technology could be a critical factor influencing its uptake [47, 48]. It is therefore important for continuing education and training to be provided on HIVST at SCS.
In our study, the health workers who reported they would use HIVST themselves were four times more likely to offer it than those who said they would not use it. This could be a good indicator of confidence in the test and its use. Multi-center studies in Kenya in 2009 and 2010 [49] and in Ethiopia in 2012 [50] with health workers found HIVST training and experience using HIVST, respectively, to be associated with willingness to offer it.
Willingness to offer HIVST was also higher among those who felt very or quite confident about offering HIVST than those who did not feel confident about doing so. Around 68% of the health workers reported the potential failure of users to use the test or read the result correctly as a reason for not offering HIVST, which shows their concern at having laypersons perform a medical test. The same concerns have also been reported elsewhere [24, 51, 52]. Although errors in conducting the finger-prick test are among the concerns relating to HIVST [53], recent tests indicate that users and health workers may have the same performance when doing this kind of HIVST [54], and that the finger-prick test is more precise than a saliva test, insofar as it involves analyzing a blood sample [45].
Being confident about HIVST could be impacted not just by the capacity of the test to give a reliable result, but also by concerns about the healthcare service being able to provide support for users who have a positive test result. For example, in a systematic review of factors that help and hamper the diffusion of HIVST, Musheke et al.[55] identified studies showing that lack of trust in health systems could be a barrier to HIV testing and treatment.
Additionally, our study results indicate that willingness to offer HIVST is higher among health workers who agree that the general public should be eligible to receive the test. This indicates that although the vulnerability of certain social groups and the importance of their having access to HIVST is recognized, the test could be well accepted among professionals for large-scale distribution in a comprehensive health system like the Brazilian one. However, the MoH [15] guidelines have focused on the provision of HIVST through strategies geared towards people using PrEP, people whose sexual partner is living with HIV, and key and priority populations for the HIV epidemic in Brazil [14].
The limitations of this study include its sampling process, which was not completely probabilistic, and the fact that willingness to offer HIVST was analyzed by health workers from SCS that both dispensed and did not dispense HIVST. As the outcome variable has to do with future willingness, those professionals who worked at services where HIVST was dispensed could have a higher proportion for this outcome. To overcome these limitations, the municipalities with SCS were put in a draw, considering the nine health districts in the state of Bahia, and just one of the centers at which HIVST was on offer was included in the study.