HIV self-testing awareness among African refugee male sex workers in Italy: A mixed-methods study

HIV disproportionately affects African refugee male sex workers (ARMSWs) in Italy, who face individual, structural and systemic barriers to HIV prevention and care services. HIV self-testing (HIVST) offers a promising strategy to improve testing access, yet awareness remains understudied in this population. This study examines HIVST awareness and associated factors among ARMSWs to inform targeted interventions. A mixed-methods sequential exploratory design was employed, combining quantitative surveys (n = 150) with qualitative interviews (20 in-depth interviews, 2 focus group discussions) among ARMSWs in Italy. Participants were recruited through venue-based and snowball sampling in partnership with a community organization. Quantitative data on HIVST awareness and correlates, including sociodemographic, healthcare access, and sex work characteristics, were analyzed using chi-square tests and logistic regression. Qualitative data from audio-recorded interviews underwent summative content analysis to explore awareness pathways and perceptions. Key findings revealed only 45% of participants were aware of HIVST, with just 47.8% of these having ever used a self-test. Higher education (aOR=1.92, p = 0.022) and prior STI testing (aOR=2.32, p = 0.015) significantly predicted awareness of HIVST. Qualitative data showed two awareness pathways: first-time exposure through the study and prior encounters via clients or community programs. Participants highlighted HIVST's privacy and convenience as key benefits. Community-based, peer-led approaches, combined with healthcare provider engagement, are essential for increasing HIVST awareness and uptake among ARMSWs. These findings have broader implications for improving HIV testing strategies among hard-to-reach migrant populations across Europe.