A Cross-Sectional Assessment of HIV Self-Testing Preferences and Uptake Among Key Populations in Phnom Penh, Cambodia

Michael M. Cassell; Philippe Girault; Sopha Nith; Chandary Rang; Sereyvisith Sokhan; Sovannary Tuot; Vichet Kem; Pagna Dork; Aphyra Chheav; Mary Sos; Chanry Im; Sotheary Meach; Kimrun Mao; Penh Sun Ly; Vohith Khol; Sovannarith Samreth; Bora Ngauv; Vichea Ouk; Sopheap Seng; F. Stephen Wignall

doi:10.9745/GHSP-D-21-00412

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A woman performing HIV self-testing as part of a community worker's (not pictured) outreach efforts in Cambodia. Credit: © 2021 Sor Voleakhena/Cambodian Women for Peace and Development.
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An example of HIV self-testing promotional materials that are currently used by national HIV program partners in Cambodia. Credit: © 2021 Courtesy of the Cambodia National Center for HIV/AIDS, Dermatology, and Sexually Transmitted Diseases
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FIGURE
Summary of Recruitment and Enrollment Results, HIV Self-Testing Study, Phnom Penh, Cambodia
Abbreviations: MSM, men who have sex with men; EW, female entertainment workers.

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TABLE 1

Recruitment Channels and Key Sociodemographic Characteristics of Participants in Key Population Groups, HIV Self-Testing Study, Phnom Penh, Cambodia

	Men Who HaveSex With Men		TransgenderWomen		EntertainmentWorkers		Total
	No. (%)(N=455)	P Value	No. (%)(N=325)	P Value	No. (%)(N=430)	P Value	No. (%)(N=1,210)	P Value
Mode of recruitment		<.001		<.001		<.001		<.001
Outreach worker face-to-face	290 (63.7)		315 (96.9)		429 (99.8)		1,034 (85.5)
Outreach worker online	160 (35.2)		8 (2.5)		1 (0.2)		169 (14.0)
Online advertising	5 (1.1)		2 (0.6)		0		7 (0.6)
Age group		<.001		<.001		<.001		<.001
<18 years	0		0		2 (0.5)		2 (0.2)
18–24 years	132 (29.0)		124 (38.2)		207 (48.1)		463 (38.3)
25–29 years	189 (41.5)		112 (34.5)		118 (27.4)		419 (34.6)
30–34 years	93 (20.4)		61 (18.8)		64 (14.9)		218 (18.0)
35+ years	41 (9.0)		28 (8.6)		39 (9.1)		108 (8.9)
Level of education completed		<.001		<.001		<.001		<.001
No schooling	6 (1.3)		7 (2.2)		143 (33.3)		156 (12.9)
Primary	44 (9.7)		61 (18.8)		205 (47.7)		310 (25.6)
Secondary	130 (28.6)		114 (35.1)		77 (17.9)		321 (26.5)
High school	189 (41.5)		98 (30.2)		5 (1.2)		292 (24.1)
At least 1 university degree	75 (16.5)		42 (12.9)		0		117 (9.7)
No answer	11 (2.4)		3 (0.9)		0		14 (1.2)
Current occupation		<.001		<.001		<.001		<.001
Unemployed	33 (7.3)		20 (6.2)		0		53 (4.4)
Student	56 (12.3)		12 (3.7)		0		68 (5.6)
Civil servant	15 (3.3)		8 (2.5)		0		23 (1.9)
Self employed/freelance	165 (36.3)		81 (24.9)		2 (0.4)		248 (20.5)
Employee outside government	95 (20.9)		52 (16.0)		0		147 (12.1)
Hotspot worker^{^a}	66 (14.5)		134 (41.2)		423 (98.4)		623 (51.5)
Other	13 (2.8)		13 (4.0)		5 (1.2)		31 (2.6)
No answer	12 (2.6)		5 (1.5)		0		17 (1.4)
Current marital status		<.001		<.001		<.001		<.001
Married to a man	11 (2.4)		20 (6.2)		235 (54.7)		266 (22.0)
Married to a woman	14 (3.1)		1 (0.3)		1 (0.2)		16 (1.3)
Divorced/separated	3 (0.7)		0		34 (7.9)		37 (3.1)
Widowed	2 (0.4)		1 (0.3)		5 (1.2)		8 (0.7)
Single	423 (93.0)		303 (93.2)		155 (36.0)		881 (72.8)
No answer	2 (0.4)		0		0		2 (0.2)

↵a Derived by combining the categories “massager,” “beer promoter,” “escort girl,” “hotspot manager,” and “salon worker” to mitigate risks of inadvertent disclosure of participant identity given that some cells only contained 1 or 2 individuals.

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TABLE 2.

Key Behavioral Characteristics of Participants in Key Population Groups, HIV Self-Testing Study, Phnom Penh, Cambodia

	Men Who HaveSex With Men		TransgenderWomen		EntertainmentWorkers		Total
	No. (%)(N=455)	P Value	No. (%)(N=325)	P Value	No. (%)(N=325)	P Value	No. (%)(N=1,210)	P Value
Condom use at last sex with casual male partner^{^a}		<.001		.739		<.001		<.001
No	294 (64.6)		165 (50.8)		28 (6.5)		487 (40.2)
Yes	159 (34.9)		159 (48.9)		401 (93.3)		719 (59.4)
No sex in the past 3 months	0		0		1 (0.2)		1 (0.1)
No answer	2 (0.4)		1 (0.3)		0		3 (0.2)
Total	455 (100)		325 (100)		430 (100)		1,210 (100)
Frequency of condom use during the past 3 months^{^a}		<.001		<.001		<.001		<.001
Never	127 (27.9)		75 (23.1)		19 (4.4)		221 (18.3)
Sometimes	243 (53.4)		183 (56.3)		319 (74.2)		745 (61.6)
Most of the time	77 (16.9)		46 (14.2)		90 (20.9)		213 (17.6)
Always	8 (1.8)		20 (6.2)		2 (0.5)		30 (2.5)
No answer	0		1 (0.3)		0		1 (0.1)
Total	455 (100)		325 (100)		430 (100)		1,210 (100)
Role during anal sex in the past three months		<.001		<.001		NA		<.001
Always insertive	214 (47.0)		6 (1.8)		NA		220 (28.2)
Always receptive	68 (14.9)		266 (81.8)		NA		334 (42.8)
Both receptive and insertive	168 (36.9)		50 (15.4)		NA		218 (27.9)
No anal sex in the past 3 months	0		1 (0.3)		NA		1 (0.1)
No answer	5 (1.1)		2 (0.6)		NA		7 (0.9)
Total	455 (100)		325 (100)		NA		780 (100)
Received money or goods for sex from a male or TG partner^{^b}		<.001		<.001		<.001		<.001
No	347 (76.3)		175 (53.8)		5 (1.2)		527 (43.6)
Yes	102 (22.4)		149 (45.8)		425 (98.8)		676 (55.9)
No answer	6 (1.3)		1 (0.3)		0		7 (0.6)
Total	455 (100)		325 (100)		430 (100)		1,210 (100)
Gave money or goods for sex to a male or TG partner^{^a}		<.001		<.001		NA		<.001
No	317 (69.7)		257 (79.1)		NA		574 (73.6)
Yes	128 (28.1)		66 (20.3)		NA		194 (24.9)
No answer	10 (2.2)		2 (0.6)		NA		12 (1.5)
Total	455 (100)		325 (100)		NA		780 (100)

Abbreviations: NA, not asked; TG, transgender.
↵a Last anal sex for men who have sex with men and TG and last vaginal sex for entertainment workers.
↵b In the past 3 months.

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TABLE 3.

Participant History of HIV Testing and Exposure to Interventions, HIV Self-Testing Study, Phnom Penh, Cambodia

	Men Who HaveSex With Men		TransgenderWomen		EntertainmentWorkers		Total
	No. (%)(N=455)	P Value	No. (%)(N=325)	P Value	No. (%)(N=430)	P Value	No. (%)(N=1,210)	P Value
Last HIV test done		<.001		<.001		<.001		<.001
Never tested	325 (71.4)		186 (57.2)		360 (83.7)		871 (72.0)
In past 3 months	0		0		1 (0.2)		1 (0.1)
Between 3 and 6 months	3 (0.7)		3 (0.9)		8 (1.9)		14 (1.2)
Between 6 and 12 months	33 (7.3)		32 (9.8)		47 (10.9)		112 (9.3)
More than 12 months	86 (18.9)		102 (31.4)		13 (3.0)		201 (16.6)
No answer	8 (1.8)		2 (0.6)		1 (0.2)		11 (0.9)
First-time tester		<.001		.007		<.001		<.001
Yes	322 (70.8)		185 (56.9)		360 (83.7)		867 (71.7)
No	125 (27.5)		137 (42.2)		69 (16.0)		331 (27.4)
No answer	8 (1.8)		3 (0.9)		1 (0.2)		12 (1.0)
Exposure to tailored HIV interventions in the past 12 months		<.001		<.001		<.001		<.001
Yes	58 (12.7)		79 (24.3)		13 (3.0)		150 (12.4)
No	381 (83.7)		242 (74.5)		417 (97.0)		1,040 (86.0)
No answer	16 (3.5)		4 (1.2)		0		20 (1.7)

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TABLE 4.

Participant Uptake of HIV Self-Testing by Key Population Group, Phnom Penh, Cambodia

	Men Who HaveSex With Men		TransgenderWomen		EntertainmentWorkers		Total
	No. (%)(N=455)	P Value	No. (%)(N=325)	P Value	No. (%)(N=430)	P Value	No. (%)(N=1,210)	P Value
Selected HIV testing options		<.001		<.001		<.001		<.001
Assisted HIVST using oral fluid	356 (78.2)		281 (86.5)		413 (96.0)		1,050 (86.8)
Assisted HIVST using finger prick	89 (19.6)		40 (12.3)		7 (1.6)		136 (11.2)
Unassisted HIVST using oral fluid	8 (1.8)		4 (1.2)		10 (2.3)		22 (1.8)
Unassisted HIVST using finger prick	2 (0.4)		0		0		2 (0.2)
Type of HIVST kit selected		<.001		<.001		<.001		<.001
Oral fluid	364 (80.0)		285 (87.7)		423 (98.4)		1,072 (88.6)
Finger prick	91 (20.0)		40 (12.3)		7 (1.6)		138 (11.4)
HIV modalities		<.001		<.001		<.001		<.001
Assisted	445 (97.8)		321 (98.8)		420 (97.7)		1,186 (98.0)
Unassisted	10 (2.2)		4 (1.2)		10 (2.3)		24 (2.0)
HIVST kit delivery preference		<.001		<.001		—		<.001
Outreach workers in the community	81 (17.8)		96 (29.5)		430 (100)		607 (50.2
Community-based organization facility	364 (80.0)		226 (69.5)		0		590 (48.8)
Courier service	10 (2.2)		3 (0.9)		0		13 (1.1)

Abbreviation: HIVST, HIV self-testing.

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TABLE 5.

Participant Choice of Test Type by Key Population, Mode of Recruitment, and Prior Testing Experience, Phnom Penh, Cambodia

		Men WhoHave SexWith Men				TransgenderWomen				EntertainmentWorkers				Total
		Oral-fluid	Finger-prick			Oral-fluid	Finger-prick			Oral-fluid	Finger-prick			Oral-fluid	Finger-prick
	N	No. (%)	No. (%)	P Value	N	No. (%)	No. (%)	P Value	N	No. (%)	No. (%)	P Value	N	No. (%)	No. (%)	P Value
Total participants	455	364 (80.0)	91 (20.0)	<.001	325	285 (87.7)	40 (12.0)	<.001	430	423 (98.4)	7 (1.6)	<.001	1,210	1,072 (88.6)	138 (11.4)	<.001
Mode of recruitment				<.001^{^a}				=1^{^a}				=.016^{^a}				<.001
Outreach workerface-to-face	290	263 (90.7)	27 (9.3)		315	276 (87.6)	39 (12.4)		429	423 (98.6)	6 (1.4)		1,034	962 (93.0)	72 (7.0)
Outreach workeronline	160	96 (60.0)	64 (40.0)		8	7 (87.5)	1 (12.5)		1	0	1 (100)		169	103 (60.9)	66 (39.1)
Online advertising	5	5 (100)	0		2	2 (100)	0		0	0	0		7	7 (100)	0
First-time tester^{^b}				<.001				<.001				=.604^{^a}				<.001
Yes	322	240 (74.5)	82 (25.5)		185	150 (81.1)	35 (18.9)		360	353 (98.1)	7(1.9)		867	743 (85.7)	124 (14.3)
No	125	116 (92.8)	9 (7.2)		137	132 (96.4)	5 (3.6)		69	69 (100)	0		331	317 (95.8)	14 (4.2)

↵a Fisher's exact test.
↵b Excluding a total of 12 observations with "No answer" to the question on HIV testing history: 8 observations for men who have sex with men; 3 for transgender; 1 for entertainment workers.

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TABLE 6.

Participant Test Result by Key Population, Mode of Recruitment, Choice of Testing Option, and Previous Testing History, Phnom Penh, Cambodia

		Men Who HaveSex With Men				TransgenderWomen				EntertainmentWorkers				Total		P Value
	N	Reactive No. (%)	Non-reactive No. (%)	P Value	N	Reactive No. (%)	Non-reactive No. (%)	P Value	N	Reactive No. (%)	Non-reactive No. (%)	P Value	N	Reactive No. (%)	Non-reactive No. (%)	P Value
Total participants	455	37 (8.1)	418 (91.9)	<.001	325	36 (11.1)	289 (88.9)	<.001	430	11 (2.6)	419 (97.4)	<.001	1,210	84 (6.9)	1,126 (93.1)	<.001
Mode of recruitment				=.105^{^a}				=.248^{^a}				=.974^{^a}				=.050^{^a}
Outreach worker face-to-face	290	28 (9.7)	262 (90.3)		315	35 (11.1)	280 (88.9)		429	11 (2.6)	418 (97.4)		1,034	74 (7.2)	960 (92.8)
Outreach worker online	160	8 (5.0)	152 (95.0)		8	0	8 (100)		1	0	1 (100)		169	8 (4.7)	161 (95.3)
Online advertising	5	1 (20.0)	4 (80.0)		2	1 (50.0)	1 (50.0)		0	0	0		7	2 (28.6)	5 (71.4)
Outreach vs. website enrollment				=.347^{^a}				=.210^{^a}				-				=.080^{^a}
Outreach	450	36 (8.0)	414 (92.0)		323	35 (10.8)	288 (89.2)		430	11 (2.6)	419 (97.4)		1,203	82 (6.8)	1,121 (93.2)
Online advertising	5	1 (20.0)	4 (80.0)		2	1 (50.0)	1 (50.0)		0	0	0		7	2 (28.6)	5 (71.4)
Choice of HIVST option				=.576^{^a}				=.062^{^a}				=1.0^{^a}				=.229^{^a}
Assisted	445	36 (8.1)	409 (91.9)		321	34 (10.6)	287 (89.4)		420	11 (2.6)	409 (97.4)		1,186	81 (6.8)	1,105 (93.2)
Unassisted	10	1 (10.0)	9 (90.0)		4	2 (50.0)	2 (50.0)		10	0	10 (100)		24	3 (12.5)	21 (87.5)
Choice of HIVST kit type				=.548				=1.0^{^a}				=1.0^{^a}				=.881
Oral fluid	364	31 (8.5)	333 (91.5)		285	32 (11.2)	253 (88.8)		423	11 (2.6)	412 (97.4)		1,072	74 (6.9)	998 (93.1)
Finger prick	91	6 (6.6)	85 (93.4)		40	4 (10.0)	36 (90.0)		7	0	7 (100)		138	10 (7.2)	128 (92.8)
First-time tester^{^b}				=.208				=.445				=.225^{^a}				=.050
Yes	322	22 (6.8)	300 (93.2)		185	18 (9.7)	167 (90.3)		360	11 (3.1)	349 (96.9)		867	51 (5.9)	816 (94.1)
No	125	13 (10.4)	112 (89.6)		137	17 (12.4)	120 (87.6)		69	0	69 (100)		331	30 (9.1)	301 (90.9)

Abbreviation: HIVST, HIV self-testing.
↵a Fisher's exact test.
↵b Excluding a total of 12 observations with "No answer" to the question on HIV testing history: 8 observations for men who have sex with men; 3 for transgender; 1 for entertainment workers.