Syphilis self-testing to expand test uptake among men who have sex with men: a theoretically informed mixed methods study in Zimbabwe

Abstract

Objectives: Self-testing for STIs such as HIV and syphilis may empower sexual minorities and expand uptake of STI testing. While much is known about HIV self-testing (HIVST), less is known about syphilis self-testing, particularly in low-income settings. The objective of this study is to determine context-specific facilitators and barriers for self-testing and to assess the usability of syphilis self-testing in Zimbabwe among men who have sex with men (MSM). Methods: This mixed methods study was conducted in Harare as part of a larger syphilis self-testing trial. The study included in-depth interviews (phase one) followed by usability testing and a second interview (phase two). In-depth interviews were conducted with MSM and key informants prior to syphilis self-testing. The same MSM then used the syphilis self-test, quantitatively assessed its usability and participated in a second in-depth interview. Phase one data was analysed using a thematic approach, guided by an adapted Social Ecological Model conceptual framework. Phase two interviews were analysed using Rapid Assessment Procedure qualitative methodology, and usability was assessed using a pre-established index, adapted from existing HIVST evaluation scales. Results: Twenty MSM and 10 key informants were recruited for phase one in-depth interviews and 16 of these MSM participated in phase two by completing a syphilis self-test kit. Facilitating factors for self-testing included the potential for increased privacy, convenience, autonomy and avoidance of social and healthcare provider stigma. Barriers included the fear to test and uncertainty about linkage to care and treatment. Data from the usability index suggested high usability (89.6% on a 0-100 scale) among the men who received the self-test. Conclusions: MSM in Zimbabwe were willing to use syphilis self-test kits and many of the barriers and facilitators were similar to those observed for HIVST. Syphilis self-testing may increase syphilis test uptake among sexual minorities in Zimbabwe and other low- and middle-income countries.

Prioritizing syphilis control: Now is the time for action

“…Self-testing involves a person conducting and interpreting their own test result. Clinic closures and travel restrictions during COVID-19 have accelerated syphilis self-testing uptake ( 20 , 21 ) and expanded self-sampling pilots ( 22 ). Expanding these opportunities for syphilis testing in diverse settings could help to catalyze more syphilis control programs, policies, and research.…”

Limited syphilis testing for key populations in Zimbabwe: A silent public health threat

“…A study conducted in Zimbabwe to assess the usability of syphilis self-testing in MSM reported high self-test usability and found that self-testing provided increased privacy, convenience and autonomy in comparison to hospital/clinic-based testing. 24 In China, syphilis self-testing increased testing rates amongst MSM who had never tested for syphilis in the hospital (adjusted odds ratio [aOR]: 2.96; 95% confidence interval [CI]: 1.86–4.72). 18 The similarities between HIV self-testing and syphilis testing may increase the acceptability of syphilis self-testing amongst KPs in Zimbabwe because some of the patients may be familiar with HIV self-test kits on the market, for example, the HIV OraQuick.…”

“… 18 The similarities between HIV self-testing and syphilis testing may increase the acceptability of syphilis self-testing amongst KPs in Zimbabwe because some of the patients may be familiar with HIV self-test kits on the market, for example, the HIV OraQuick. 24 It is important, however, to ensure the availability of facility-based confirmatory testing for patients who have reactive screening tests. To successfully implement this approach, there is a need to craft guidelines and education material specific for KPs on the correct use of devices and consider any concerns that might be barriers to the implementation of syphilis self-testing.…”