HIV Self-testing for Men Who Have Sex With Men (MSM) in England and Wales: A multi-method study of self-testing intervention development and evaluation

Background: Undiagnosed HIV among men who have sex with men (MSM) remains a significant public health challenge in the UK. Higher rates of recent and repeat HIV testing are necessary to ensure recent falls in HIV incidence among MSM in parts of England and Wales are fully reproduced nationally. HIV self-testing (HIVST) is the latest in a long line of HIV testing interventions, which has been developed to reduce barriers to testing for those at risk of acquiring the virus. An HIV Self-testing Public Health Intervention (SELPHI) is the first randomised controlled trial (RCT) delivering free HIVST kits to MSM in Europe. SELPHI has two interventions and aims to assess whether HIVST can increase diagnosis of prevalent HIV infections (intervention A) and reduce the time between infection and diagnosis for those at on-going risk of new HIV infections (intervention B). Social sciences have been at the heart of SELPHI, contributing to formative, implementation and evaluation research. This thesis seeks to develop an understanding of the potential contribution of HIVST to the wellbeing of MSM in England & Wales. It contributes significantly to the academy by developing a comprehensive evidence base enabling policy makers and service providers to optimise HIVST service delivery. Methods: This work is conceptually grounded in implementation science and uses the Behaviour Change Wheel (BCW), which includes the COM-B model of behaviour change to provide a framework for intervention development and to understand participant outcomes. A pragmatic, multi-method approach has been taken whereby the optimal data collection methods have been carefully selected based on their suitability to answer the research questions. Results: This thesis includes three studies presented over five published papers. The first is a formative study (contributing to papers 1 and 2) of qualitative focus group discussions with MSM which produces new understandings of the diversity of their values and preferences with regard to HIVST. This study also interrogates narrative understandings of the potential use of the technology, demonstrating HIVST use may be limited to when MSM do not perceive significant risk, except in the context of significant barriers to service access. The second study (contributing to paper 3) is a mixed methods interrogation of the implementation pilot, demonstrating high feasibility and acceptability of an HIVST intervention delivered to MSM through the SELPHI study. The final study (contributing to papers 4 and 5) is an evaluative analysis of qualitative in-depth interviews with individuals who have undergone HIVST, showing high acceptability and varying intervention performance across groups. The utility of COM-B as a model for understanding behaviour change in relation to HIVST is examined in paper 5. Conclusions: Online delivery of HIVST to MSM is feasible and acceptable; contexts of use and intervention performance will vary across groups. A number of intervention adaptations can be made to increase acceptability and the potential reach of HIVST interventions. The absence of a robust concept of need in COM-B means that this model may be sub-optimal in designing HIVST interventions, and perhaps interventions which meet needs generated by social norms.