Stigma, privacy concerns, sexual behaviors, and testing history shape willingness to use HIV self-testing among African refugee men engaged in sex work in Italy – a mixed method study—BGSH-023

BACKGROUND: African refugee men engaged in sex work in Italy experience multiple barriers to facility-based HIV testing, including stigma, privacy concerns, and structural constraints within healthcare systems. HIV self-testing (HIVST), particularly oral fluid–based HIVST, may help address these barriers, yet evidence on willingness to use HIVST in this population remains limited. METHODS: We employed a mixed-methods sequential exploratory design in partnership with a community-based organization. Quantitative survey data were collected from 150 African refugee men engaged in sex work, alongside qualitative data from 20 in-depth interviews and two focus group discussions. Descriptive analyses summarized willingness, perceived facilitators, and barriers. Multivariable logistic regression was used to identify factors independently associated with willingness to use HIVST, reporting adjusted odds ratios (aORs) and 95% confidence intervals (CIs). Qualitative data were analyzed using summative content analysis to contextualize quantitative findings. RESULTS: Among participants eligible for HIVST analysis (n = 115), 44.4% reported willingness to use HIVST. Commonly reported facilitators included convenience and privacy (47.1%), avoidance of stigma in healthcare settings (23.5%), and ease of use, while key barriers included concerns about test accuracy (27.0%), fear of receiving a positive result without support (20.9%), and limited access to HIVST kits (32.2%). In adjusted analyses, willingness to use HIVST was independently associated with belonging to a religion (aOR = 5.27, 95% CI: 3.77–15.83), having health insurance (aOR = 4.56, 95% CI: 2.78–9.92), experiencing immigration-related challenges in healthcare access (aOR = 1.93, 95% CI: 1.22–4.25), more frequent HIV testing (> once per year; aOR = 2.27, 95% CI: 1.98–5.21), awareness of HIVST (aOR = 3.24, 95% CI: 1.36–6.29), and prior HIVST use (aOR = 2.12, 95% CI: 1.80–8.21). Qualitative findings highlighted occupational relevance, autonomy in health decision-making, and persistent fears of stigma if seen with HIVST kits. CONCLUSIONS: Willingness to use HIVST among African refugee men engaged in sex work in Italy was moderate and shaped by prior testing engagement, healthcare access, and structural vulnerabilities. Expanding HIVST education, reducing cost barriers, and integrating peer-led, stigma-sensitive support mechanisms may improve HIV testing uptake and strengthen HIV prevention efforts in this population.