Substance Use is Linked to Less Facility-Based but Greater Self-HIV Testing Willingness Among African Refugee Male Sex Workers in Italy: A Cross-Sectional Study

ABSTRACT: Substance use can shape engagement with HIV prevention services among migrant sex workers, yet little is known about its influence on HIV testing behaviors in European contexts. Our study examined how alcohol and drug use relate to HIV testing frequency and HIV self-testing (HIVST) willingness among African refugee male sex workers (ARMSWs) in Italy. We conducted a cross-sectional survey among 150 ARMSWs residing in Northern Italy. Participants, recruited through peer networks and community organizations, completed structured questionnaires assessing substance use patterns, and HIV testing behaviors. Chi-square tests, and Kruskal-Wallis tests were used to explore associations between substance use and two outcomes: frequency of HIV testing and willingness to use HIVST.Participants (N = 150) had a mean age of 30.6 years, most identified as men (96.7%) and were 25 years or older (86.0%). Alcohol use in the past 12 months was reported by 60.0%, and 69.3% used illicit drugs, predominantly noninjectable substances (78.8%). Half (50.5%) of participants tested for HIV less than once per year or never, despite 65.4% reporting awareness of testing sites. Alcohol and drug use were significantly associated with irregular HIV testing frequency. Being drunk or high while working and increased substance use after entering sex work were linked to less frequent HIV testing. Awareness of HIVST was moderate (44.7%), and willingness to use HIVST was expressed by 40.7% of participants. Increased alcohol use after entering sex work (p = .049) and being high while working (p = .046) were both positively associated with HIVST willingness. Substance use meaningfully shapes HIV testing engagement among ARMSWs in Italy. Substance use appears to influence HIV testing engagement among ARMSWs in Northern Italy. Although increased alcohol use and being high while working were linked to greater openness to HIVST, both were associated with less frequent facility-based testing. Integrated harm-reduction and HIV prevention strategies that address substance use while expanding access to community-led HIVST distribution may enhance testing uptake and continuity of care among this marginalized population.