In JAMA Network Open, Garofalo et al1 share exciting results from their study promoting HIV testing and linkage to care among men who have sex with men (MSM) in West Africa. Men who have sex with men in Nigeria and globally experience high levels of social stigma and criminalization, and as a result many have not had adequate access to HIV testing and care. In this study, Garofalo et al1 found that an intervention that combined use of publicly available social media apps (Grindr, Facebook, and WhatsApp) and peer navigation was associated with increased HIV testing uptake and identification of MSM living with HIV, and linkage to care was high at 31 of 36 participants (86.1%) with positive HIV test results. There were no concerns about safety or confidentiality reported during the study and no adverse events.
The positive results of this study could have a significant impact on achieving the ambitious UNAIDS 95-95-95 goals (95% of people living with HIV aware of their status, 95% of those aware of their status on treatment, and 95% of those on treatment virally suppressed) in Nigeria and other parts of sub-Saharan Africa (SSA). As the authors point out, “Men who have sex with men have the highest HIV prevalence in Nigeria (23%) and are the only group in whom prevalence continues to rise.”1 This observation supports the need for innovative approaches, because the current approaches are clearly not working. However, few studies in SSA have specifically investigated the provision of services for MSM, and systematic reviews on the topic have confirmed that most studies have been conducted outside the African continent.2 This is highly problematic because Nigeria is not unique among African countries: As the HIV epidemic is better contained in the general population, incidence is becoming more concentrated in key populations across SSA. Therefore, it is critical to conduct research to identify new strategies for HIV testing, prevention, and treatment among MSM, persons who inject drugs, female sex workers, and other historically marginalized populations.
One of the novel features of the intervention in this study is the way it pairs publicly available social media apps with peer navigation, neither of which has been widely used among MSM in SSA. The combination of community-based testing approaches and facilitated linkage has been shown to be highly effective in identifying new HIV cases and achieving linkage to HIV care in the general population in SSA.3 Few studies among MSM were available for inclusion in the meta-analysis by Sharma et al,3 highlighting both the challenges and importance of HIV testing studies such as that of Garofalo et al1 that focus on key populations. Interventions that incorporate HIV self-testing (HIVST) options into community-based testing approaches are especially important to evaluate among MSM. Although HIVST was not part of the iCARE Nigeria (Intensive Combination Approach to Roll Back the Epidemic in Nigerian Adolescents) intervention, one could imagine that offering HIVST would further increase uptake of testing by providing another layer of privacy and confidentiality for MSM experiencing high levels of stigma, criminalization, and unmet need.
Using existing social media platforms that are widely and publicly available is another innovative aspect and one that is central to the intervention’s success. Developing a unique app and marketing it would require substantial time and money and may or may not achieve widespread acceptance and use. Despite leveraging established platforms, the intervention required considerable expertise and technical support, both of which the research group had. However, not all ministries of health, facilitators, and research groups interested in implementing a similar intervention will have access to that level of technical support. Understanding more about the specific technological requirements would allow for informed decision-making. There is no question that the widespread availability and use of these apps by the general public are extremely appealing features. Whether such an intervention can be broadly scaled up will be answered as others try to replicate this study in other programs and research studies.
The innovative nature of the intervention also raises questions about feasibility and sustainability, an important component of which is cost. It is unclear how many people and what recurring expenses were required to manage the social media platforms. There are also additional human resources and costs associated with offering the preferred options for testing. Most participants (336 of 339 [99.1%]) underwent HIV testing in the home or in community settings rather than the less costly facility settings, most likely due to stigma associated with being identified as MSM. Reducing social stigma in public facilities in SSA and making them more welcoming to MSM and other high-incidence populations will take time, but it will be essential to containing HIV as the epidemic evolves and an increasing proportion of new cases occur among key populations.
In many parts of SSA, it is not just MSM but all men who have been difficult to reach with facility-based HIV testing strategies and are less likely to know their HIV status. Could a social media outreach intervention coupled with facilitated linkage also be used for men who have sex with women (MSW)? Although globally we are close to reaching the UNAIDS 95-95-95 target for women, only 82% of men living with HIV know their HIV status.4 Approaches to increasing testing for men include assisted partner services, mobile testing, couple testing, and workplace and community-based testing; social media and peer mobilization or navigation have not played a substantial role in strategies for reaching men in the general population, although such approaches could be reconsidered. Although MSW are generally not part of social networks in the same way that MSM are, and population-specific apps such as Grindr do not exist for MSW, these are important concepts to explore.
This leads to our final consideration on how this intervention fits into current World Health Organization guidance on improving uptake of HIV testing and linkage to care among men. In 2021, a policy brief was released that promoted social networking to increase HIV testing among key populations, including MSM.5 This guidance encourages programs confronting epidemics among key populations to use social network–based approaches, such as working with peers of key populations to recruit men in their social, sexual, and drug-injecting networks for HIV testing. Also included is the secondary distribution of HIVST kits to partners and social contacts and the use of digital tools and innovative technologies (eg, social media, messaging, and online platforms) to reach social networks. This study fills an important gap and provides solid data in support of 2 of these specific approaches in reaching young MSM: peer navigation and social media. It also emphasizes the need for more evidence on implementation of social networking strategies, including their affordability, sustainability, and ethical and legal barriers that need to be addressed to scale up these innovations.
Published: February 22, 2022. doi:10.1001/jamanetworkopen.2022.0155
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Farquhar C et al. JAMA Network Open.
Corresponding Author: Carey Farquhar, MD, MPH, Department of Global Health, University of Washington, 3980 15th Ave NE, Seattle, WA 98105 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Farquhar C, Masyuko S, Mugo P. Social Network–Based Strategies to Improve Uptake of HIV Testing and Linkage to Care Among Men Who Have Sex With Men in Sub-Saharan Africa. JAMA Netw Open. 2022;5(2):e220155. doi:10.1001/jamanetworkopen.2022.0155
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