"Yes, I Saw It at a Client’s House": Factors Associated with Oral HIV Self-Testing Awareness Among African Refugee Male Sex Workers in Italy—A Mixed-Methods Study- BGSH-022

"Yes, I Saw It at a Client’s House": Factors Associated with Oral HIV Self-Testing Awareness Among African Refugee Male Sex Workers in Italy—A Mixed-Methods Study- BGSH-022 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article "Yes, I Saw It at a Client’s House": Factors Associated with Oral HIV Self-Testing Awareness Among African Refugee Male Sex Workers in Italy—A Mixed-Methods Study- BGSH-022 Henry Delali Dakpui, Gamji Rabiu Abu-Ba’are, Mubarik Sena Saaka, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6383201/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract 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. Sociology Sexual & Reproductive Medicine Infectious Diseases HIV Self-testing sex workers awareness INTRODUCTION The HIV epidemic continues to be a major global public health challenge, disproportionately affecting marginalized groups such as migrants, sex workers, and racial and sexual minorities (Santoso et al., 2022 ; Segala et al., 2024 ; UNAIDS, 2023 ). In Europe, African migrants face multiple structural and social barriers that limit their access to HIV prevention, testing, and treatment services (Ndumbi et al., 2018 ; UNAIDS, 2024 ). Among this group, African refugees experience distinct and compounded challenges that further restrict their healthcare access (Jakab et al., 2015 ; Kanengoni-Nyatara et al., 2024 ). Despite the long history of men engaging in sex work (Kaye, 2014 ), HIV research and interventions in globally and Europe have largely focused on female sex workers (Giomi et al., 2022 ; Platt et al., 2013 ; Trani et al., 2006 ), leaving a critical gap in understanding the experiences of African refugee male sex workers (ARMSWs). In this context, limited research suggests that economic instability forces many into precarious working conditions, limiting their ability to negotiate safe sex practices (Bacio, 2023 ; Rinaldi, 2021 ; Scott et al., 2021 ). Legal and administrative barriers, including restrictive immigration policies and fear of deportation, discourage healthcare engagement, particularly among those who are undocumented (Galanis et al., 2022 ; Ndumbi et al., 2018 ). Language and cultural barriers further hinder access to health services, as many struggle to navigate healthcare systems that lack culturally competent providers(Lagi et al., 2023 ). Societal and internalized stigma, coupled with fears of disclosure, deters many sex workers in Europe from routine HIV testing, increasing the likelihood of undiagnosed infections and continued transmission (Adeyinka et al., 2023 ; Macioti et al., 2021 ; Rinaldi, 2021 ). Moreover, many refugees endure traumatic migration experiences, including violence, overcrowded detention centers, and extreme social isolation, leading to significant psychological distress that further inhibits healthcare engagement (Altin & Sanò, 2017 ; Perreira & Ornelas, 2013 ; Theisen-Womersley & Theisen-Womersley, 2021 ; Vukčević Marković et al., 2023 ). HIV testing services (HTS) play a crucial role in addressing the HIV epidemic in Italy (Galli et al., 2020 ). These services are primarily delivered through client-initiated testing and counseling (CITC), where individuals voluntarily seek testing at healthcare facilities, community-based centers, or through outreach programs (WHO, 2012 ). Additionally, provider-initiated testing and counseling (PITC) are integrated within clinical settings; here, healthcare providers routinely recommend HIV testing to patients, especially those accessing services for sexually transmitted infections (STIs) or other conditions associated with higher HIV risk (Galli et al., 2025 ). National guidelines in Italy emphasize the importance of regular HIV testing, particularly for key populations at higher vulnerability (M. Galli et al., 2020 ). Nevertheless, significant barriers to HTS persist. Stigma, fear of discrimination, concerns regarding confidentiality, and limited service accessibility, especially among undocumented migrants and marginalized groups, continue to impede optimal testing rates. Data indicate that many individuals within these groups, especially migrants and sex workers, remain unaware of their HIV status (Alvarez-del Arco et al., 2014 ; Lagi et al., 2023 ). Studies have further demonstrated that low awareness of testing options, the fear of a positive diagnosis, and concerns over confidentiality all contribute to a reluctance to seek testing (Deblonde et al., 2010 ; den Daas et al., 2016 ; Mirandola et al., 2017 ). The persistent failure of traditional healthcare systems to effectively address these issues underscores the need for innovative and alternative testing strategies. In this context, HIV self-testing (HIVST) has emerged as a promising tool to increase testing coverage, particularly among populations that face entrenched healthcare disparities. HIVST enables individuals to test in the privacy of their own homes, a feature that is particularly important for those confronting discrimination and legal uncertainties, such as migrant MSWs (Dakpui et al., 2024 ; Figueroa et al., 2018a , 2018b ; Jamil et al., 2017 ; Johnson et al., 2017 ; Z. Wang et al., 2018a , 2018b ; World Health Organization, 2016a , 2019 ). The World Health Organization strongly recommends HIV self-testing as an essential strategy to expand access to HIV services (World Health Organization, 2016b ) In support of this recommendation, Italy approved the use of HIVST in 2016, marking a significant step in enhancing early diagnosis and intervention for HIV among its most vulnerable groups (Pittalis et al., 2017 ) A key determinant of HIV testing behavior is knowledge of the available testing options. Evidence suggests that limited awareness of HIVST among key populations contributes significantly to its underutilization (Lippman et al., 2018). Furthermore, structural and psychosocial factors, including stigma, healthcare discrimination, and doubts about the reliability of self-testing, profoundly influence individuals’ willingness to adopt this method (Abubakari et al., 2021 ). Despite the growing recognition of HIVST’s potential, little is known about the awareness of HIVST among ARMSWs in Italy. In fact, since its approval in Italy in 2016 (Pittalis et al., 2017 ), no study has specifically examined the factors influencing this population’s engagement with oral HIV self-testing. Understanding the factors influencing awareness is crucial for designing effective interventions to improve uptake. Such interventions have the potential to enhance testing uptake and, ultimately, reduce HIV transmission within this marginalized population. This mixed-method study seeks to fill this gap by examining the levels of awareness of oral HIVST among ARMSWs in Italy while identifying key factors that shape their perceptions and engagement with this innovative testing method. Specifically, the study aimed to address the following research questions: (1) What is the level of awareness of oral HIVST among ARMSWs in Italy? and (2) What factors are associated with awareness of oral HIVST among ARMSWs? METHODS Study Design, Setting, and Participants We employed a mixed-methods sequential exploratory design, combining both quantitative and qualitative methods to thoroughly investigate the awareness of HIVST among ARMSWs in Italy. The study was conducted in partnership with Circolo Pink (Pink Refugees), a community-based nonprofit organization with established connections to the target population in Italy. Data collection was carried out in secure and accessible locations within their office spaces in Verona and a partner institution in Turin, Northern Italy. The criteria for participation included: (1) being a refugee from the Sub-Saharan Africa region, (2) currently living in Italy, (3) being at least 18 years old, (4) having fluency in English or Italian, (5) self-identifying as a sex worker, and (6) having engaged in sex work within the last six months with someone of the same sex. Data Collection Procedures During the qualitative phase, we carried out 20 in-depth interviews (IDIs) and two focus group discussions (FGDs) with ARMSWs between September and October 2023 to explore their experiences, barriers, and facilitators related to HIV testing and awareness of HIVST. All FGDs and IDIs were conducted face-to-face at Pink Refugees and its affiliated locations, audio-recorded with consent, and complemented by comprehensive field notes. Insights from the qualitative component informed the creation and distribution of a structured survey to 150 ARMSWs in December 2023, evaluating the broader applicability of the qualitative findings regarding awareness of HIVST. We utilized RedCap, a secure mobile survey platform, to gather quantitative data. The survey link was shared online with participants after the research assistants explained the purpose of the survey and the steps involved in completing it. Due to the concealed nature of RMSWs, we adopted a venue-based and snowball recruitment strategy through Pink Refugees. Two trained peer-research assistants, who were also ARMSWs, facilitated recruitment by identifying and engaging their peers during weekly meetings at Pink Refugees. Additional participants were recruited through referrals from FGD participants for IDIs and online surveys. Study Variables The primary outcome of this study was awareness of HIVST, assessed through both qualitative and quantitative methods. For the qualitative assessment, a semi-structured interview guide was used to explore themes related to HIV testing experiences, awareness of HIVST, barriers to testing, and factors influencing awareness of HIVST. Awareness was explored by showing participants a short video demonstrating the OraQuick HIVST process. After viewing, participants were asked: "Before today, have you seen or heard of this type of HIV testing?" Participants were asked open-ended questions about their perceptions of HIVST, previous testing experiences, and potential facilitators or challenges in using self-testing kits. For the quantitative survey, awareness of HIVST was assessed using structured questions. Participants were first provided with a brief description of the HIV self-test: " The Oral HIV self-test is an innovative and convenient method for HIV testing, which involves individuals performing the test on themselves using oral saliva. It eliminates the need for laboratory equipment and can be conducted at home or any preferred location ." Following this, awareness was measured using the following questions: Awareness of HIVST : "Have you ever heard of an HIV self-test?" (Response options: Yes/No) In addition, we examined correlates of awareness of HIVST across three key domains: socio-demographic and structural factors, healthcare access and testing behavior, and sex work-related factors as presented in Table 1. Table 1 Study variables Variable Description Coding Primary Outcomes Awareness of HIVST Ever heard of an HIV self-test 1 = Yes, 0 = No Socio-Demographic & Structural Factors Age Participant's age 0 = 18-24, 1 = 25+ Gender Identity Self-identified gender 1 = Man 2 = Transgender 3 = non-binary Education Highest level of education completed 1 = Primary or less 2 = Secondary or more Marital Status Current marital status 0 = Unmarried 1 = Married Number of Children Number of children 0 = No children 1= One or more children Religious Affiliation Whether the participant belongs to any religion 0 = No religion 1 = Belong to a religion Rank of Religiosity How religious the participant is 0 = Not religious 1 = Religious Length of Stay in Italy How long participant has been in Italy 0 = A year or less 1 = More than a year Sexual Orientation Participant’s sexual orientation 0 = Gay 1 = Bisexual Sex role Sexual role preference 0 = Top 1 = Bottom 2= Versatile (Verse) Employment Beyond Sex Work Any other job apart from sex work 0 = No 1 = Yes Healthcare Access & Testing Behavior Distance to Healthcare Facility (Km) Distance in kilometers 0 = 1 – 5km 1 = 6km or more Healthcare frequency Frequency of accessing healthcare 0 = Never 1 = Have ever Health Insurance status Covered by health insurance 0 = No 1 = Yes Immigration challenge in healthcare access Encountered difficulties in access healthcare due to immigration status 0 = No 1 = Yes Experienced stigma or discrimination at the hospital Experienced stigma or discrimination at the hospital 0 = No 1 = Yes Awareness of testing facilities Do you know where to go for STI/HIV testing and care? 0 = No 1 = Yes Tested for STI Ever tested for any STI 0 = Never tested 1 = Ever tested Tested for HIV Ever tested for HIV 0 = Never tested 1 = Ever tested HIV test frequency Frequency of HIV testing 0 = Once a year or less 1 = More than once a year HIV test result Self-reported HIV test result 0 = Negative 1 = Positive Awareness of HIVST Ever heard of HIV self-testing 0 = No 1 = Yes Ever used HIVST Used an HIV self-test before 0 = No 1 = Yes Sex Work-Related Factors Venue for meeting client Where participants find clients 0 = Offline 1 = Online No. of client in past 2month (Men) Number of male clients in the past 2 months 0 = Less than 20 1 = 20 or more No. of client in past 2 month (Women) Number of female clients in the past 2 months 0 = Less than 10 1 = 10 or more Vaginal sex Engaged in vaginal sex 0 = No 1 = Yes Condom use for vaginal sex Consistency of condom use for vaginal sex 0 = Sometimes/Never 1 = Always Anal sex Engaged in anal sex 0 = No 1 = Yes Condom use for anal sex Consistency of condom use for anal sex 0 = Sometimes/Never 1 = Always Lubricant use for anal sex Consistency of lubricant use for anal sex 0 = Sometimes/Never 1 = Always Transactional condomless sex Engaged in unprotected transactional sex 0 = No 1 = Yes Data analysis Descriptive statistics were used to summarize the socio-demographic characteristics of respondents, reported as frequencies and percentages for categorical variables and means with standard deviations or medians with interquartile ranges for continuous variables. Awareness of HIVST was dichotomized as 1 (aware) and 0 (not aware). An initial chi-square analysis was performed to examine the relationship between awareness of HIVST, and the independent variables. Variables that showed statistical significance (<0.05) in the chi-square analysis were then included in a multiple logistic regression model to explore their relationship with Awareness of HIVST. Analyses were considered statistically significant at p<0.05. For qualitative data, we transcribed IDIs and FGDs verbatim and analyzed them using a summative content analysis process. To ensure interrater reliability, two independent researchers reviewed each transcript, summarized recurring themes related to HIVST awareness, and wrote independent summaries. The researchers then met to consolidate their independent summaries into a single summary for each transcript, ensuring all salient themes were captured and discrepancies addressed through discussion. The lead author then reviewed each summary, categorized key themes, and iteratively refined them by revisiting transcripts. The final themes were organized based on our research questions to provide context for the quantitative findings. Ethical Approval Ethical approval for this study was granted by the National Ethics Committee for Clinical Trials under the Italian Ministry of Health (AOO-ISS - 04/07/2023 - 0031228). As part of the process, the senior author and Principal Investigator presented the study during a special session with the Italian ethics committee, received immediate feedback, and provided a commitment to participant protection, including obtaining written or oral informed consent and collecting and transferring anonymous data for vulnerable populations. Hence, participants' identifiers were not linked to their data, especially in the qualitative parts of the study. Written informed consent was sort from all IDI and FGD participants before data collection commenced. Participation in the survey was voluntary, and informed consent was implied through the completion and submission of the survey after participants reviewed an online information sheet outlining the study's purpose, confidentiality, and their rights. RESULTS Sociodemographic Characteristics of Respondents A total of 150 male sex workers participated in the study. The mean age was 30.6 years (SD = 5.9), with the average age at which they commenced sex work being 23.3 years (SD = 4.6). The majority (96.67%, n = 145) identified as men, while 2% (n = 3)identified as transgender and 1.33% (n=2) as non-binary. More than half (57.33%, n = 97) were unmarried, while 35.33% (n = 53) were married. Educational attainment varied, with 49% (n = 74) having completed senior high school or vocational training, 26% (n = 39) having tertiary education, and 4.67% (n = 7) having no formal education. Most participants (87.33%, n = 131) had official refugee status, and 57.33% (n = 86) originated from Nigeria. In addition to the survey, 35 ARMSWs participated in the qualitative phase of the study. Participants in the IDIs had an average age of 28 years, while the 15 participants in the FGDs had an average age of 32.1 years. Participants were primarily from Nigeria and Cameroon, with a few from Côte d'Ivoire. Awareness of Oral HIVST among ARMSWs Among the respondents, 45% (n=67) had heard of HIVST, while 55% (n=83) were unaware. Of those aware of HIVST, 47.76% (n=32) had used a self-testing kit to check their HIV status. The primary sources of HIVST kits included community centers (n = 13, 40.62%), pharmacies (n = 8, 25.00%), hospitals (n = 8, 25.00%), and sexual health clinics (n = 8, 25.00%). Table 2: Awareness and Perceptions of HIV Self-Testing Variable Frequency (n) Percentage (%) Have you heard of the HIV self-testing kit? (n = 150) Yes 67 44.67 No 83 55.33 Have you ever used an HIV self-testing kit to check your HIV status? (n = 67) Yes 32 47.76 No 35 52.24 Please specify where you obtained the HIV self-testing kit (n = 32) LGBTQ+ Community Center 13 40.62 Sexual Health Clinic 7 21.88 Hospital 7 21.88 Pharmacy 8 25.00 Qualitative findings on awareness of HIVST among ARMSWs Participants’ awareness of HIVST varied, with many encountering it for the first time through engagement with the study team, while others had prior exposure to it in different settings. The findings are categorized into two themes: First-time Exposure to HIVST and Prior Awareness of HIVST. First-time Exposure to HIVST For several participants, this study was their first introduction to HIVST. Through a demonstration video, the study introduced the concept to them, and they found it novel, innovative, and intriguing. Some participants found the video demonstration particularly helpful, as it clarified the testing procedure and expressed excitement about its ease of use and potential benefits, such as privacy and convenience. Wow, I didn't know about this before. This is the first time I'm hearing about it, and I believe it's something new and innovative. It's really interesting to learn about, and I think it could be very useful – IDI participant Before now, I had never heard about oral HIVST. It was only when I came across this program that I learned there is a way to test for HIV by yourself without even going to the hospital, which I find interesting and would like to know more about. – IDI participant Yeah, you people showed me a video on the way they used to test for HIV, and it's very easy. I love it like that. It's very easy. I've never seen this kind of video before. That is my first time, and it's very good to grab that kind of opportunity…[I nod] Yeah, it's very easy. You put it in your mouth; you can just test it yourself. You don't have to worry, and you don't have to be going to the doctor too, you do it yourself. – IDI participant No, actually no. Before you showed me the video, I had not heard of or seen this kind of testing before. – IDI participant Prior Awareness of HIVST While many participants encountered HIVST for the first time through the study, a few had prior knowledge or experience with self-testing. Some had seen it used by clients or peers, while others had been trained to use it through peer-led community-based programs and interventions in their home countries. Encounters with HIVST Through clients or peers Some participants had seen HIVST kits used by clients or acquaintances in Italy and their home countries. They found the technology beneficial, particularly for its privacy and convenience. Yes, yes, there was a client….in Nigeria... I love what he did; he first asked me, Are you HIV-free?’ And I said ‘yes’, he said ‘to be on a safer path, can we run a test?’ I said, ‘Oh, we have to go to the hospital to…?’ he said, ‘No, I have my kits.’ he went into the room, brought the kits, and we did the test. For me, it was very safe, private, and convenient. – IDI participant “Yes, I saw it at a client’s house here in Italy. It should be made available for all, and if possible, it should be free so most people who are ignorant about their health might see it as an advantage too, as I know myself. It saves time, it's convenient, and it’s confidential.” – FGD participant Encounters with HIVST Through Community-based Training Programs A few participants had been exposed to HIVST through community-based training programs in their home country. Some had even been trained to use and distribute the kits to their peers in their communities. I have—yes, I have. Like I said, when I was in Nigeria, I worked with a peer-led group. I had friends who trained us at home on how to use these self-testing kits. We received the kits from an organization called ‘The Population Council in Lagos and brought them home. Our house served as a community center where people came and went, offering support to one another. Because of this, our home became a place where self-testing kits were introduced and used. The training helped us understand how to use them properly. Before this, I didn’t know where to find these kits, but through that experience, I learned a lot about self-testing. – FGD participant Bivariate Analysis of Factors Associated with Awareness of Oral HIVST among ARMSWs Table 5 presents chi-square test results examining associations between sociodemographic factors, healthcare access, testing behavior, sex work-related characteristics, and awareness of HIVST among ARMSWs. Factors significantly associated with awareness of HIVST included education level (χ² = 6.18, p = 0.013), healthcare frequency (χ² = 8.36, p = 0.004), healthcare access challenges (χ² = 5.11, p = 0.024), experiences of stigma or discrimination in healthcare settings (χ² = 7.48, p = 0.012), Knowledge of STI/HIV testing and care center (χ² = 17.77, p = 0.000), ever tested for STI (χ² = 13.10, p = 0.000). Additionally, sex work-related factors such as avenue for meeting clients (χ² = 5.21, p = 0.022), number of male clients in the past two months (χ² = 14.08, p < 0.001), condom use during anal sex (χ² = 13.45, p = 0.029), lubricant use for anal sex (χ² = 4.37, p = 0.037), and transactional condomless sex (χ² = 7.48, p < 0.001) were also significantly associated with awareness of HIVST among ARMSWs Table 5: Chi-square Analysis of factors associated with Awareness of Oral HIVST among ARMSWs Variable Awareness of HIVST (n=150) Yes (n=67, (44.7%) No (n=83, (55.3%) P-value Age 0.857 Young Adult (18 -24) 9 (42.86) 12 (57.14) Adult (25+) 58 (44.96) 71 (55.04) Education 0.013* Primary or less 10 (27.03) 27 (72.97) Secondary or more 57 (50.44) 56 (49.56) Gender Identity 0.266 Man 64 (44.14) 81 (55.86) Transgender 1 (33.33) 2 (66.67) non-binary 2 (100.00) 0 (0.00) Marital Status 0.565 Unmarried 22 (41.51) 31 (58.49) Married 45 (46.39) 52 (53.61) Number of Children 0.160 No children 40 (50.00) 40 (50.00) One or more children 27 (38.57) 43 (61.43) Religious Affiliation 0.163 No religion 8 (32.00) 17 (68.00) Belong to a religion 59 (47.20) 66 (52.80) Rank of Religiosity 0.071 Not religious 10 (66.67) 5 (33.33) Religious 57 (42.22) 78 (57.78) Length of Stay in Italy 0.476 A year or less 26 (41.27) 37 (58.73) More than a year 41 (47.13) 46 (52.87) Sexual Orientation 0.814 Gay 48 (45.28) 58 (54.72) Bisexual 19 (43.18) 25 (56.82) What role do you play during sex? 0.499 Top 28 (44.44) 35 (55.56) Bottom 10 (35.71) 18 (64.29) Versatile (Verse) 29 (49.15) 30 (50.85) Any other job apart from sex work 0.604 Yes 13 (40.62) 19 (59.38) No 54 (45.76) 64 (54.24) Distance to Healthcare Facility (Km) 0.647 1 – 5km 34 (46.58) 39 (53.42) 6km or more 33 (42.86) 44 (57.14) Healthcare frequency 0.004* Never 6 (20.69) 23 (79.31) Have ever 61 (50.41) 60 (49.59) Health Insurance Status 0.061 Yes 31(54.39) 26 (45.61) No 36(38.71) 57 (61.29) Immigration challenge in healthcare access 0.024* Yes 34 (55.74) 27 (44.26) No 33 (37.08) 56 (62.92) Experienced stigma or discrimination at the hospital 0.012* Yes 36 (37.11) 61(62.89) No 31(58.49) 22(41.51) Do you know where to go for STI/HIV testing and care? 0.000* Yes 54 (58.06) 39 (41.94) No 13 (22.81) 44 (77.19) Tested for STI 0.000* Never tested 10 (22.22) 35(77.78) Ever tested 57 (54.29) 48 (45.71) Tested for HIV 0.598 Never tested 27 (42.19) 37 (57.81) Ever tested 40 (46.51) 46 (53.49) HIV test frequency 0.540 Once a year or less 18 (50.00) 18 (50.00) More than once a year 23 (43.40) 30 (56.60) HIV test result 0.908 Negative 49 (44.95) 60 (55.05) Positive 18 (43.90) 23 (56.10) Venue for meeting client 0.022* Offline 66 (47.14) 74 (52.86) Online 1 (10.00) 9 (90.00) No. of client in past 2month (Men) <0.001* Less than 20 48 (58.54) 34 (41.46) 20 or more 19 (27.94) 49 (72.06) No. of client in past 2month (Women) 0.496 Less than 10 19 (46.34) 22 (53.66) 10 or more 1 (33.33) 2 (66.67) Vaginal sex 0.227 Yes 44(41.51) 62(58.49) No 23(52.27) 21(47.73) Condom use for vaginal sex 0.167 Sometimes/Never 38 (57.58) 28 (42.42) Always 8 (40.00) 12 (60.00) Anal sex 0.142 Yes 52 (41.94) 72 (58.06) No 15 (57.69) 11 (42.31) Condom use for anal sex 0.029* Sometimes/Never 49 (41.53) 69 (58.47) Always 13 (68.42) 6 (31.58) Lubricant use for anal sex 0.037* Yes 40 (39.60) 61 (60.40) No 21 (60.00) 14 (40.00) Transactional condomless sex <0.001* No 21 (29.17) 51(70.83) Yes 46 (58.97) 32(41.03) Univariate and Multivariate logistic regression analysis of factors influencing awareness of HIVST among ARMSWs Table 6 presents the results of crude (unadjusted) and adjusted multiple logistic regression models assessing factors associated with awareness of HIVST among ARMSWs. In the unadjusted model, significant predictors of awareness to use HIVST included education level (secondary or higher: cOR = 2.75, 95% CI: 1.22 - 6.20, p = 0.015), healthcare frequency (ever accessed healthcare in Italy: cOR = 3.10, 95% CI: 1.48–10.25, p = 0.006), immigration related healthcare access challenge (yes: cOR = 2.13, 95% CI: 1.48 - 10.25, p = 0.025), experienced stigma or discrimination at the hospital (insured: cOR = 2.09, 95% CI: 1.21–3.60, p < 0.008), Knowledge of STI/HIV testing and care center (yes: cOR = 6.21, 95% CI: 5.10–7.45, p < 0.001), tested for STI (ever tested: cOR = 4.16, 95% CI: 1.87 - 9.26, p < 0.001), number of male clients in the past two months (≥20 clients: cOR = 1.97, 95% CI: 0.94-2.69, p<0.001), condom use for anal sex (always: cOR = 3.05, 95% CI: 1.08 – 8.58, p = 0.039), lubricant use for anal sex (always: cOR = 2.29, 95% CI: 1.04 – 5.02, p = 0.039), and engagement in transactional condomless sex (yes: cOR = 3.49, 95% CI: 1.77 – 6.89, p < 0.001). In the adjusted model, only two factors remained significantly associated with awareness of HIVST among ARMSWs. Education level (secondary or higher: aOR = 1.92, 95% CI: 0.70–5.29, p = 0.022), and tested for STI (ever tested: cOR = 2.32, 95% CI: 0.82 - 6.62, p = 0.015) Table 6: Crude (unadjusted) and adjusted multiple logistic regression Analysis of factors influencing the awareness of HIVST among ARMSWs Awareness of HIVST Unadjusted Model Adjusted Model cOR (95% CI) P-value aOR (95% CI) P-value Education Primary or less Ref Ref Ref Ref Secondary or higher 2.75 (1.22 - 6.20) 0.015* 1.92 (0.70 – 5.29) 0.022* Healthcare frequency Never (Ref) Ref Ref Ref Ref Have ever 3.10 (1.48 - 10.25) 0.006* 2.12(0.52 – 8.62) 0.291 Immigration challenge in healthcare access No Ref Ref Ref Ref Yes 2.13 (1.10 - 4.15) 0.025* 1.93 (0.87 - 4.28) 0.106 Experienced stigma or discrimination at the hospital No Ref Ref Ref Ref Yes 2.09 (1.21 - 3.60) 0.008* 1.47 (0.74 - 2.90) 0.274 Do you know where to go for STI/HIV testing and care? No Ref Ref Ref Ref Yes 6.21 (5.10 – 7.45) 0.000* 0.49 (0.188 - 1.27) 0.143 Tested for STI Never tested Ref Ref Ref Ref Ever tested 4.16 (1.87 - 9.26) 0.000* 2.32 (0.82 - 6.62) 0.015* No. of client in past 2month (Men) (n=150) Less than 20 Ref Ref Ref Ref 20 or more 1.97 (0.94 - 2.69) <0.001* 0.52 (0.22 - 1.25) 0.144 Condom use for anal sex (n= 137) Sometimes/Never Ref Ref Ref Ref Always 3.05 (1.08 - 8.58) 0.035* 1.24 (0.74 – 2.09) 0.418 Lubricant use for anal sex No Ref Ref Ref Ref Yes 2.29 (1.04 - 5.02) 0.039* 1.49 (0.58 – 3.81) 0.403 Transactional condomless sex No Ref Ref Ref Ref Yes 3.49 (1.77 – 6.89) <0.001* 0.98 (0.39 - 2.42) 0.96 cOR (Crude odds ratio); aOR(Adjusted odds ratio); 95% CI – (95% Confidence interval); *(P≤ 0.05) Discussion Our study provides novel insights into the factors associated with awareness of oral HIVST among ARMSWs in Italy. With only 45% of respondents aware of HIVST, and fewer than half of these having ever used a kit, the findings underscore a significant gap in the reach of innovative HIV prevention strategies within this marginalized group, reinforcing concerns about the limited reach of self-testing interventions among key populations (Figueroa et al., 2015; Harichund & Moshabela, 2018; Pantelic et al., 2018). This aligns with studies showing low HIVST awareness among migrant and sex worker communities due to structural barriers, stigma, and inadequate outreach (Burke et al., 2017; M. M. Chanda et al., 2017; Elorreaga et al., 2022; Pal et al., 2016; C. Wang et al., 2020). Higher educational attainment was a significant predictor of HIVST awareness, with participants who had secondary or higher education being almost twice as likely to be aware of HIVST. This finding is consistent with research demonstrating that education enhances health literacy, facilitating access to information and engagement with novel health interventions (Bayati et al., 2018; Guerras et al., 2022; Kawuki et al., 2023; Mohamud & Aslam, 2024). Moreover, individuals with higher education may be better positioned to navigate the complex healthcare environment in Italy, facilitating access to information and resources related to HIV prevention. Similarly, prior engagement with healthcare, particularly STI testing, was strongly associated with HIVST awareness. Those who had ever been tested for STIs were more than twice as likely to be aware of HIVST, reinforcing the role of healthcare interactions in disseminating self-testing knowledge (Nambi et al., 2024) Qualitative findings revealed that many participants had never heard of HIVST before this study, underscoring the absence of targeted promotion efforts. Some had seen self-testing kits in clients' homes but were unaware of their availability for personal use. This highlights the critical role of social networks in HIV information-sharing, as reported in other studies on sex workers and migrants (Barrington et al., 2018; Nambi et al., 2024; Sarafian, 2012; Zhou et al., 2024). Those who learned about HIVST expressed enthusiasm for its convenience, privacy, and ease of use, findings consistent with global evidence that self-testing is highly acceptable among populations facing stigma and discrimination (Bogart et al., 2021). This underscores how targeted health education can play a critical role in increasing HIVST awareness and uptake.(Abubakari et al., 2021) Although several variables, including immigration challenges in healthcare access, stigma or discrimination at hospitals, venue for meeting clients, number of male clients, condom use, lubricant use, and transactional condomless sex, were significantly associated with HIVST awareness in bivariate analyses, they lost significance in the adjusted model. Their strong significance in the chi-square and unadjusted models suggests that these factors may still play an important role in shaping awareness of HIVST, although confounded by other factors. Notably, individuals facing immigration-related healthcare challenges and stigma at hospitals were more likely to be aware of HIVST, suggesting that experiences of exclusion may drive reliance on alternative HIV prevention strategies(Dakpui et al., 2024). This aligns with studies showing that key populations who anticipate discrimination in healthcare settings often seek health services information through peer networks and community organizations rather than formal health systems (G. M. Abubakari, Owusu-Dampare, et al., 2021a; He et al., 2020; McGowan et al., 2022). These findings suggest that healthcare access difficulties may still indirectly influence HIVST awareness, even if their direct effect was not significant in our adjusted model. Similarly, the venue for meeting clients and the number of male clients were also significantly associated with HIVST awareness in bivariate analyses. Although online-based sex workers typically have less engagement with HIV services (Derksen et al., 2022; UNAIDS, 2017), our study found that those meeting clients online were more likely to be aware of HIVST. This could be due to the increased availability of digital resources and health promotion campaigns targeting online spaces, which may provide a more accessible and private avenue for HIV prevention information (Bailey et al., 2021; Blake et al., 2024). Additionally, sex workers with a higher number of male clients tended, and those engaging in transactional condomless sex tend to have more HIVST awareness, potentially due to increased exposure to HIV prevention messaging and a heightened perceived vulnerability (M. Chanda et al., 2017; Wong et al., 1994). While these associations did not remain significant in the adjusted model, their strong significance in the chi-square and unadjusted models indicates they may still play a key role in shaping HIVST awareness. These findings point to important considerations for the promotion and implementation of HIVST in this population. Given the reported low awareness of HIVST among ARMSWs in Italy, a significant promotional effort is needed to bridge the information gap. Notably, some participants reported having seen HIVST kits being used by clients, establishing the need for targeted interventions not only for sex workers but also for their clients, as engaging clients in HIVST initiatives can promote early detection, reduce transmission, normalize testing, and support a more comprehensive HIV prevention strategy(Huysamen & Richter, 2020; Lowndes et al., 2007; Mulberry et al., 2019; Ngugi et al., 2002). Recruiting and training community peers to lead awareness campaigns could be effective, as peer-led interventions have been shown to increase HIV testing uptake (Abu-Ba’are et al., 2024; G. M. Abubakari, Owusu-Dampare, et al., 2021b; G. M. R. Abubakari et al., 2021; Shangani et al., 2017). Additionally, integrating HIVST education into existing STI and sexual health programs can leverage routine healthcare interactions to enhance knowledge. Given the strong association between prior STI testing and HIVST awareness, healthcare providers in Italy should incorporate HIVST discussions into routine STI screenings. Ensuring that HIVST kits are affordable and accessible, particularly through community centers and outreach programs, will also be crucial. Limitations While the study offers valuable insights, several limitations must be acknowledged. First, all data were self-reported and based on hypothetical future preferences, which may have been influenced by social desirability bias, particularly regarding HIVST endorsements. Second, the cross-sectional design limits our ability to determine causality, meaning that observed associations might be both a cause and a consequence of other factors. Third, the use of respondent-driven sampling means the findings primarily reflect connected ARMSWs in Italy, limiting generalizability to less networked youth. Further research is needed to assess actual HIVST use as testing, education, and support become more widely available. Conclusion In summary, our findings highlight the urgent need for targeted HIVST awareness initiatives among ARMSWs in Italy. Education and prior STI testing play key roles in awareness, suggesting that interventions should focus on health literacy and engagement with healthcare services. Community-based outreach, peer-led education, and healthcare-provider involvement are critical strategies for improving uptake. Future research should explore long-term behavioral changes following HIVST promotion efforts to assess their impact on testing rates and linkage to care. Declarations Disclosures. 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In Europe, African migrants face multiple structural and social barriers that limit their access to HIV prevention, testing, and treatment services (Ndumbi et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; UNAIDS, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Among this group, African refugees experience distinct and compounded challenges that further restrict their healthcare access (Jakab et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Kanengoni-Nyatara et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the long history of men engaging in sex work (Kaye, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2014\u003c/span\u003e), HIV research and interventions in globally and Europe have largely focused on female sex workers (Giomi et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Platt et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Trani et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), leaving a critical gap in understanding the experiences of African refugee male sex workers (ARMSWs). In this context, limited research suggests that economic instability forces many into precarious working conditions, limiting their ability to negotiate safe sex practices (Bacio, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Rinaldi, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Scott et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Legal and administrative barriers, including restrictive immigration policies and fear of deportation, discourage healthcare engagement, particularly among those who are undocumented (Galanis et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ndumbi et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Language and cultural barriers further hinder access to health services, as many struggle to navigate healthcare systems that lack culturally competent providers(Lagi et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Societal and internalized stigma, coupled with fears of disclosure, deters many sex workers in Europe from routine HIV testing, increasing the likelihood of undiagnosed infections and continued transmission (Adeyinka et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Macioti et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Rinaldi, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Moreover, many refugees endure traumatic migration experiences, including violence, overcrowded detention centers, and extreme social isolation, leading to significant psychological distress that further inhibits healthcare engagement (Altin \u0026amp; San\u0026ograve;, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Perreira \u0026amp; Ornelas, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Theisen-Womersley \u0026amp; Theisen-Womersley, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Vukčević Marković et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHIV testing services (HTS) play a crucial role in addressing the HIV epidemic in Italy (Galli et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These services are primarily delivered through client-initiated testing and counseling (CITC), where individuals voluntarily seek testing at healthcare facilities, community-based centers, or through outreach programs (WHO, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Additionally, provider-initiated testing and counseling (PITC) are integrated within clinical settings; here, healthcare providers routinely recommend HIV testing to patients, especially those accessing services for sexually transmitted infections (STIs) or other conditions associated with higher HIV risk (Galli et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). National guidelines in Italy emphasize the importance of regular HIV testing, particularly for key populations at higher vulnerability (M. Galli et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Nevertheless, significant barriers to HTS persist. Stigma, fear of discrimination, concerns regarding confidentiality, and limited service accessibility, especially among undocumented migrants and marginalized groups, continue to impede optimal testing rates. Data indicate that many individuals within these groups, especially migrants and sex workers, remain unaware of their HIV status (Alvarez-del Arco et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Lagi et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Studies have further demonstrated that low awareness of testing options, the fear of a positive diagnosis, and concerns over confidentiality all contribute to a reluctance to seek testing (Deblonde et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; den Daas et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Mirandola et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The persistent failure of traditional healthcare systems to effectively address these issues underscores the need for innovative and alternative testing strategies.\u003c/p\u003e \u003cp\u003eIn this context, HIV self-testing (HIVST) has emerged as a promising tool to increase testing coverage, particularly among populations that face entrenched healthcare disparities. HIVST enables individuals to test in the privacy of their own homes, a feature that is particularly important for those confronting discrimination and legal uncertainties, such as migrant MSWs (Dakpui et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Figueroa et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018a\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018b\u003c/span\u003e; Jamil et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Johnson et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Z. Wang et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2018a\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2018b\u003c/span\u003e; World Health Organization, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2016a\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The World Health Organization strongly recommends HIV self-testing as an essential strategy to expand access to HIV services (World Health Organization, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2016b\u003c/span\u003e) In support of this recommendation, Italy approved the use of HIVST in 2016, marking a significant step in enhancing early diagnosis and intervention for HIV among its most vulnerable groups (Pittalis et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA key determinant of HIV testing behavior is knowledge of the available testing options. Evidence suggests that limited awareness of HIVST among key populations contributes significantly to its underutilization (Lippman et al., 2018). Furthermore, structural and psychosocial factors, including stigma, healthcare discrimination, and doubts about the reliability of self-testing, profoundly influence individuals\u0026rsquo; willingness to adopt this method (Abubakari et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the growing recognition of HIVST\u0026rsquo;s potential, little is known about the awareness of HIVST among ARMSWs in Italy. In fact, since its approval in Italy in 2016 (Pittalis et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), no study has specifically examined the factors influencing this population\u0026rsquo;s engagement with oral HIV self-testing. Understanding the factors influencing awareness is crucial for designing effective interventions to improve uptake. Such interventions have the potential to enhance testing uptake and, ultimately, reduce HIV transmission within this marginalized population. This mixed-method study seeks to fill this gap by examining the levels of awareness of oral HIVST among ARMSWs in Italy while identifying key factors that shape their perceptions and engagement with this innovative testing method. Specifically, the study aimed to address the following research questions: (1) What is the level of awareness of oral HIVST among ARMSWs in Italy? and (2) What factors are associated with awareness of oral HIVST among ARMSWs?\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy Design, Setting, and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe employed a mixed-methods sequential exploratory design, combining both quantitative and qualitative methods to thoroughly investigate the awareness of HIVST among ARMSWs in Italy. The study was conducted in partnership with Circolo Pink (Pink Refugees), a community-based nonprofit organization with established connections to the target population in Italy. Data collection was carried out in secure and accessible locations within their office spaces in Verona and a partner institution in Turin, Northern Italy. The criteria for participation included: (1) being a refugee from the Sub-Saharan Africa region, (2) currently living in Italy, (3) being at least 18 years old, (4) having fluency in English or Italian, (5) self-identifying as a sex worker, and (6) having engaged in sex work within the last six months with someone of the same sex.\u003c/p\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cp\u003eDuring the qualitative phase, we carried out 20 in-depth interviews (IDIs) and two focus group discussions (FGDs) with ARMSWs between September and October 2023 to explore their experiences, barriers, and facilitators related to HIV testing and awareness of HIVST. All FGDs and IDIs were conducted face-to-face at Pink Refugees and its affiliated locations, audio-recorded with consent, and complemented by comprehensive field notes. Insights from the qualitative component informed the creation and distribution of a structured survey to 150 ARMSWs in December 2023, evaluating the broader applicability of the qualitative findings regarding awareness of HIVST. We utilized RedCap, a secure mobile survey platform, to gather quantitative data. The survey link was shared online with participants after the research assistants explained the purpose of the survey and the steps involved in completing it. Due to the concealed nature of RMSWs, we adopted a venue-based and snowball recruitment strategy through Pink Refugees. Two trained peer-research assistants, who were also ARMSWs, facilitated recruitment by identifying and engaging their peers during weekly meetings at Pink Refugees. Additional participants were recruited through referrals from FGD participants for IDIs and online surveys.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eStudy Variables\u003c/h3\u003e\n\u003cp\u003eThe primary outcome of this study was awareness of HIVST, assessed through both qualitative and quantitative methods. For the qualitative assessment, a semi-structured interview guide was used to explore themes related to HIV testing experiences, awareness of HIVST, barriers to testing, and factors influencing awareness of HIVST. Awareness was explored by showing participants a short video demonstrating the OraQuick HIVST process. After viewing, participants were asked: \u003cem\u003e\u0026quot;Before today, have you seen or heard of this type of HIV testing?\u0026quot;\u0026nbsp;\u003c/em\u003eParticipants were asked open-ended questions about their perceptions of HIVST, previous testing experiences, and potential facilitators or challenges in using self-testing kits.\u003c/p\u003e\n\u003cp\u003eFor the quantitative survey, awareness of HIVST was assessed using structured questions. Participants were first provided with a brief description of the HIV self-test:\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThe Oral HIV self-test is an innovative and convenient method for HIV testing, which involves individuals performing the test on themselves using oral saliva. It eliminates the need for laboratory equipment and can be conducted at home or any preferred location\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n\u003cp\u003eFollowing this, awareness was measured using the following questions:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAwareness of HIVST\u003c/strong\u003e: \u003cem\u003e\u0026quot;Have you ever heard of an HIV self-test?\u0026quot;\u003c/em\u003e (Response options: Yes/No)\u003c/p\u003e\n\u003cp\u003eIn addition, we examined correlates of awareness of HIVST across three key domains:\u0026nbsp;\u003cstrong\u003esocio-demographic and structural factors, healthcare access and testing behavior, and sex work-related factors\u003c/strong\u003e as presented in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1 Study variables\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"649\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003eVariable\u003c/td\u003e\n \u003ctd valign=\"top\"\u003eDescription\u003c/td\u003e\n \u003ctd valign=\"top\"\u003eCoding\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003eAwareness of HIVST\u003c/td\u003e\n \u003ctd\u003eEver heard of an HIV self-test\u003c/td\u003e\n \u003ctd\u003e1 = Yes, 0 = No\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003eSocio-Demographic \u0026amp; Structural Factors\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eParticipant\u0026apos;s age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 = 18-24, 1 = 25+\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender Identity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSelf-identified gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 = Man\u003c/p\u003e\n \u003cp\u003e2 = Transgender\u003c/p\u003e\n \u003cp\u003e3 = non-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHighest level of education completed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 = Primary or less\u003c/p\u003e\n \u003cp\u003e2 = Secondary or more\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCurrent marital status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 = Unmarried\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 = Married\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNumber of Children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNumber of children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 = No children\u003c/p\u003e\n \u003cp\u003e1= One or more children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eReligious Affiliation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eWhether the participant belongs to any religion\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No religion\u003c/p\u003e\n \u003cp\u003e1 = Belong to a religion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRank of Religiosity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHow religious the participant is\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 = Not religious\u003c/p\u003e\n \u003cp\u003e1 = Religious\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLength of Stay in Italy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eHow long participant has been in Italy\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 = A year or less\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 = More than a year\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSexual Orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eParticipant\u0026rsquo;s sexual orientation\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Gay\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 = Bisexual\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSex role\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eSexual role preference\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Top\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 = Bottom\u003c/p\u003e\n \u003cp\u003e2= Versatile (Verse)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEmployment Beyond Sex Work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAny other job apart from sex work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare Access \u0026amp; Testing Behavior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDistance to Healthcare Facility (Km)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDistance in kilometers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 = 1 \u0026ndash; 5km\u003c/p\u003e\n \u003cp\u003e1 = 6km or more\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHealthcare frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFrequency of accessing healthcare\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 = Never\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 = Have ever\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHealth Insurance status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCovered by health insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImmigration challenge in healthcare access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEncountered difficulties in access healthcare due to immigration status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExperienced stigma or discrimination at the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eExperienced stigma or discrimination at the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAwareness of testing facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eDo you know where to go for STI/HIV testing and care?\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTested for STI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eEver tested for any STI\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Never tested\u003c/p\u003e\n \u003cp\u003e1 = Ever tested\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTested for HIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eEver tested for HIV\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Never tested\u003c/p\u003e\n \u003cp\u003e1 = Ever tested\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHIV test frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eFrequency of HIV testing\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Once a year or less\u003c/p\u003e\n \u003cp\u003e1 = More than once a year\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHIV test result\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eSelf-reported HIV test result\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Negative\u003c/p\u003e\n \u003cp\u003e1 = Positive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAwareness of HIVST\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eEver heard of HIV self-testing\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEver used HIVST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eUsed an HIV self-test before\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex Work-Related Factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVenue for meeting client\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003eWhere participants find clients\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Offline\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 = Online\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo. of client in past 2month (Men)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003eNumber of male clients in the past 2 months\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Less than 20\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 = 20 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo. of client in past 2 month (Women)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of female clients in the past 2 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Less than 10\u003c/p\u003e\n \u003cp\u003e1 = 10 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVaginal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEngaged in vaginal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCondom use for vaginal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConsistency of condom use for vaginal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Sometimes/Never\u003c/p\u003e\n \u003cp\u003e1 =\u0026nbsp;Always\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAnal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEngaged in anal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCondom use for anal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConsistency of condom use for anal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Sometimes/Never\u003c/p\u003e\n \u003cp\u003e1 =\u0026nbsp;Always\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLubricant use for anal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConsistency of lubricant use for anal sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = Sometimes/Never\u003c/p\u003e\n \u003cp\u003e1 =\u0026nbsp;Always\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTransactional condomless sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEngaged in unprotected transactional sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 = No\u003c/p\u003e\n \u003cp\u003e1 = Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003eData analysis\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics were used to summarize the socio-demographic characteristics of respondents, reported as frequencies and percentages for categorical variables and means with standard deviations or medians with interquartile ranges for continuous variables. Awareness of HIVST was dichotomized as 1 (aware) and 0 (not aware). An initial chi-square analysis was performed to examine the relationship between awareness of HIVST, and the independent variables. Variables that showed statistical significance (\u0026lt;0.05) in the chi-square analysis were then included in a multiple logistic regression model to explore their relationship with Awareness of HIVST.\u0026nbsp;Analyses were considered statistically significant at p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003eFor qualitative data, we transcribed IDIs and FGDs verbatim and analyzed them using a summative content analysis process. To ensure interrater reliability, two independent researchers reviewed each transcript, summarized recurring themes related to HIVST awareness, and wrote independent summaries. \u0026nbsp;The researchers then met to consolidate their independent summaries into a single summary for each transcript, ensuring all salient themes were captured and discrepancies addressed through discussion. \u0026nbsp;The lead author then reviewed each summary, categorized key themes, and iteratively refined them by revisiting transcripts. The final themes were organized based on our research questions to provide context for the quantitative findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was granted by the National Ethics Committee for Clinical Trials under the Italian Ministry of Health (AOO-ISS - 04/07/2023 - 0031228). As part of the process, the senior author and Principal Investigator presented the study during a special session with the Italian ethics committee, received immediate feedback, and provided a commitment to participant protection, including obtaining written or oral informed consent and collecting and transferring anonymous data for vulnerable populations. Hence, participants\u0026apos; identifiers were not linked to their data, especially in the qualitative parts of the study. Written informed consent was sort from all IDI and FGD participants before data collection commenced. Participation in the survey was voluntary, and informed consent was implied through the completion and submission of the survey after participants reviewed an online information sheet outlining the study\u0026apos;s purpose, confidentiality, and their rights.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eSociodemographic Characteristics of Respondents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 150 male sex workers participated in the study. The mean age was 30.6 years (SD = 5.9), with the average age at which they commenced sex work being 23.3 years (SD = 4.6). The majority (96.67%, n = 145) identified as men, while 2% \u0026nbsp;(n = 3)identified as transgender and 1.33% (n=2) as non-binary. More than half (57.33%, n = 97) were unmarried, while 35.33% (n = 53) were married. Educational attainment varied, with 49% (n = 74) having completed senior high school or vocational training, 26% (n = 39) having tertiary education, and 4.67% (n = 7) having no formal education. Most participants (87.33%, n = 131) had official refugee status, and 57.33% (n = 86) originated from Nigeria. In addition to the survey,\u0026nbsp;\u003cstrong\u003e35 ARMSWs participated in the qualitative phase of the study.\u003c/strong\u003e Participants in the IDIs had an average age of 28 years, while the 15 participants in the FGDs had an average age of 32.1 years. Participants were primarily from Nigeria and Cameroon, with a few from Côte d'Ivoire.\u003c/p\u003e\n\u003ch3\u003eAwareness of Oral HIVST among ARMSWs\u003c/h3\u003e\n\u003cp\u003eAmong the respondents, 45% (n=67) had heard of HIVST, while 55% (n=83) were unaware. Of those aware of HIVST, 47.76% (n=32) had used a self-testing kit to check their HIV status. The primary sources of HIVST kits included community centers (n = 13, 40.62%), pharmacies (n = 8, 25.00%), hospitals (n = 8, 25.00%), and sexual health clinics (n = 8, 25.00%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Awareness and Perceptions of HIV Self-Testing\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"585\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave you heard of the HIV self-testing kit?\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n = 150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave you ever used an HIV self-testing kit to check your HIV status?\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(n = 67)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlease specify where you obtained the HIV self-testing kit\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n = 32)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLGBTQ+ Community Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSexual Health Clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePharmacy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative findings on awareness of HIVST among ARMSWs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants’ awareness of HIVST varied, with many encountering it for the first time through engagement with the study team, while others had prior exposure to it in different settings. The findings are categorized into two themes: First-time Exposure to HIVST and Prior Awareness of HIVST.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFirst-time Exposure to HIVST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor several participants, this study was their first introduction to HIVST. \u0026nbsp;Through a demonstration video, the study introduced the concept to them, and they found it novel, innovative, and intriguing. Some participants found the video demonstration particularly helpful, as it clarified the testing procedure and expressed excitement about its ease of use and potential benefits, such as privacy and convenience.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWow, I didn't know about this before. This is the first time I'm hearing about it, and I believe it's something new and innovative. It's really interesting to learn about, and I think it could be very useful – IDI participant\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBefore now, I had never heard about oral HIVST. It was only when I came across this program that I learned there is a way to test for HIV by yourself without even going to the hospital, which I find interesting and would like to know more about. – IDI participant\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYeah, you people showed me a video on the way they used to test for HIV, and it's very easy. I love it like that. It's very easy. I've never seen this kind of video before. That is my first time, and it's very good to grab that kind of opportunity…[I nod] Yeah, it's very easy. You put it in your mouth; you can just test it yourself. You don't have to worry, and you don't have to be going to the doctor too, you do it yourself. – IDI participant\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNo, actually no. Before you showed me the video, I had not heard of or seen this kind of testing before. – IDI participant\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003ePrior Awareness of HIVST\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eWhile many participants encountered HIVST for the first time through the study, a few had prior knowledge or experience with self-testing. Some had seen it used by clients or peers, while others had been trained to use it through peer-led community-based programs and interventions in their home countries.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eEncounters with HIVST Through clients or peers\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eSome participants had seen HIVST kits used by clients or acquaintances in Italy and their home countries. They found the technology beneficial, particularly for its privacy and convenience.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYes, yes, there was a client….in Nigeria... I love what he did; he first asked me, Are you HIV-free?’ And I said ‘yes’, he said ‘to be on a safer path, can we run a test?’ I said, ‘Oh, we have to go to the hospital to…?’ he said, ‘No, I have my kits.’ he went into the room, brought the kits, and we did the test. For me, it was very safe, private, and convenient. – IDI participant\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Yes, I saw it at a client’s house here in Italy. It should be made available for all, and if possible, it should be free so most people who are ignorant about their health might see it as an advantage too, as I know myself. It saves time, it's convenient, and it’s confidential.” – FGD participant\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eEncounters with HIVST Through Community-based Training Programs\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eA few participants had been exposed to HIVST through community-based training programs in their home country. Some had even been trained to use and distribute the kits to their peers in their communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI have—yes, I have. Like I said, when I was in Nigeria, I worked with a peer-led group. I had friends who trained us at home on how to use these self-testing kits. We received the kits from an organization called ‘The Population Council in Lagos and brought them home. Our house served as a community center where people came and went, offering support to one another. Because of this, our home became a place where self-testing kits were introduced and used. The training helped us understand how to use them properly. Before this, I didn’t know where to find these kits, but through that experience, I learned a lot about self-testing. – FGD participant\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBivariate Analysis of Factors Associated with Awareness of Oral HIVST among ARMSWs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 5 presents chi-square test results examining associations between sociodemographic factors, healthcare access, testing behavior, sex work-related characteristics, and awareness of HIVST among ARMSWs. Factors significantly associated with awareness of HIVST included education level (χ² = \u0026nbsp;6.18, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.013), healthcare frequency (χ² = 8.36, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.004), healthcare access challenges (χ² = 5.11, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.024), experiences of stigma or discrimination in healthcare settings (χ² = 7.48, \u003cem\u003ep\u003c/em\u003e = 0.012), Knowledge of STI/HIV testing and care center (χ² = 17.77, \u003cem\u003ep\u003c/em\u003e = 0.000), ever tested for STI (χ² = 13.10, p = 0.000). Additionally, sex work-related factors such as avenue for meeting clients (χ² = 5.21, p = 0.022), number of male clients in the past two months (χ² = 14.08, p \u0026lt; 0.001), condom use during anal sex (χ² = 13.45, p = 0.029), lubricant use for anal sex (χ² = 4.37, p = 0.037), and transactional condomless sex (χ² = 7.48, p \u0026lt; 0.001) were also significantly associated with awareness of HIVST among ARMSWs\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Chi-square Analysis of factors associated with Awareness of Oral HIVST among ARMSWs\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness of HIVST (n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=67, (44.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=83, (55.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.857\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYoung Adult (18 -24)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (57.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdult (25+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58 (44.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71 (55.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.013*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (27.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27 (72.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57 (50.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56 (49.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender Identity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e64 (44.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e81 (55.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTransgender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enon-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (100.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.565\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUnmarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (41.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31 (58.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMarried\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e45 (46.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52 (53.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Children\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.160\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOne or more children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27 (38.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43 (61.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eReligious Affiliation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.163\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo religion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (32.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (68.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBelong to a religion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e59 (47.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66 (52.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRank of Religiosity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.071\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNot religious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReligious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57 (42.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78 (57.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLength of Stay in Italy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.476\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eA year or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26 (41.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37 (58.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMore than a year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41 (47.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46 (52.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual Orientation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.814\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (45.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58 (54.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBisexual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (43.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (56.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat role do you play during sex?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.499\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTop\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (44.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35 (55.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBottom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (35.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (64.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVersatile (Verse)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29 (49.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30 (50.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny other job apart from sex work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (40.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (59.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54 (45.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e64 (54.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDistance to Healthcare Facility (Km)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1 – 5km\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (46.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39 (53.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e6km or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33 (42.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44 (57.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (20.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23 (79.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHave ever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61 (50.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60 (49.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHealth Insurance Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31(54.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26 (45.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;36(38.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57 (61.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eImmigration challenge in healthcare access\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.024*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (55.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27 (44.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;33 (37.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56 (62.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced stigma or discrimination at the hospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 (37.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61(62.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31(58.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22(41.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDo you know where to go for STI/HIV testing and care?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54 (58.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39 (41.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (22.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44 (77.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTested for STI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNever tested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (22.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35(77.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEver tested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e57 (54.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (45.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTested for HIV\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.598\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNever tested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27 (42.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37 (57.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEver tested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (46.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46 (53.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHIV test frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.540\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOnce a year or less\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMore than once a year\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23 (43.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30 (56.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHIV test result\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.908\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNegative\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49 (44.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60 (55.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (43.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;23 (56.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVenue for meeting client\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.022*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOffline\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66 (47.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e74 (52.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (90.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of client in past 2month (Men)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLess than 20\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e48 (58.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34 (41.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e20 or more\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (27.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49 (72.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of client in past 2month (Women)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLess than 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (46.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (53.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e10 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVaginal sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.227\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44(41.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62(58.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23(52.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21(47.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCondom use for vaginal sex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.167\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSometimes/Never\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38 (57.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28 (42.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (40.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (60.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAnal sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.142\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52 (41.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72 (58.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (57.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (42.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCondom use for anal sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.029*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSometimes/Never\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49 (41.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69 (58.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (68.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;6 (31.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLubricant use for anal sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.037*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40 (39.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61 (60.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 (60.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (40.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTransactional condomless sex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21 (29.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51(70.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46 (58.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32(41.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eUnivariate and Multivariate logistic regression analysis of factors influencing awareness of HIVST among ARMSWs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 6 presents the results of crude (unadjusted) and adjusted multiple logistic regression models assessing factors associated with awareness of HIVST among ARMSWs. In the unadjusted model, significant predictors of awareness to use HIVST included education level (secondary or higher: cOR = 2.75, 95% CI:\u0026nbsp;1.22 - 6.20, p = 0.015), healthcare frequency (ever accessed healthcare in Italy: cOR = 3.10, 95% CI: 1.48–10.25, p = 0.006), immigration related healthcare access challenge (yes: cOR = 2.13, 95% CI: 1.48 - 10.25, p = 0.025), experienced stigma or discrimination at the hospital (insured: cOR = 2.09, 95% CI: 1.21–3.60, p \u0026lt; 0.008), Knowledge of STI/HIV testing and care center (yes: cOR = 6.21, 95% CI: 5.10–7.45, p \u0026lt; 0.001), tested for STI (ever tested: cOR = 4.16, 95% CI: 1.87 - \u0026nbsp;9.26, p \u0026lt; 0.001), number of male clients in the past two months (≥20 clients: cOR = 1.97, 95% CI: 0.94-2.69, p\u0026lt;0.001), condom use for anal sex (always: cOR = 3.05, 95% CI: 1.08 – 8.58, p = 0.039), lubricant use for anal sex (always: cOR = 2.29, 95% CI: 1.04 – 5.02, p = 0.039), and engagement in transactional condomless sex (yes: cOR = 3.49, 95% CI: 1.77 – 6.89, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eIn the adjusted model, only two factors remained significantly associated with awareness of HIVST among ARMSWs. Education level (secondary or higher: aOR = 1.92, 95% CI: 0.70–5.29, p = 0.022), and tested for STI (ever tested: cOR = 2.32, 95% CI: 0.82 - 6.62, p = 0.015)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Crude (unadjusted) and adjusted multiple logistic regression Analysis of factors influencing the awareness of HIVST among ARMSWs\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"620\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness of HIVST\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadjusted Model\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted Model\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ecOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eaOR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary or less\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.75 (1.22 - 6.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.015*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.92 (0.70 – 5.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.022*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare frequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNever \u003cstrong\u003e(Ref)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHave ever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.10 (1.48 - 10.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.12(0.52 – 8.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.291\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eImmigration challenge in healthcare access\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.13 (1.10 - 4.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.025*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.93 (0.87 - 4.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced stigma or discrimination at the hospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.09 (1.21 - 3.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.008*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.47 (0.74 - 2.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDo you know where to go for STI/HIV testing and care?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.21 (5.10 – 7.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.49 (0.188 - 1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTested for STI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNever tested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEver tested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.16 (1.87 - \u0026nbsp; 9.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.32 (0.82 - 6.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.015*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of client in past 2month (Men) (n=150)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLess than 20\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e20 or more\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.97 (0.94 - 2.69)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.52 (0.22 - \u0026nbsp; 1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCondom use for anal sex (n= 137)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSometimes/Never\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.05 (1.08 - 8.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.035*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.24 (0.74 – 2.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.418\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLubricant use for anal sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.29 (1.04 - 5.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.039*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.49 (0.58 – 3.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTransactional condomless sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRef\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.49 (1.77 – 6.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.98 (0.39 - 2.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ecOR (Crude odds \u0026nbsp;ratio); aOR(Adjusted odds ratio); 95% CI – (95% Confidence interval); \u0026nbsp; *(P≤ 0.05)\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study provides novel insights into the factors associated with awareness of oral HIVST among ARMSWs in Italy. With only 45% of respondents aware of HIVST, and fewer than half of these having ever used a kit, the findings underscore a significant gap in the reach of innovative HIV prevention strategies within this marginalized group, reinforcing concerns about the limited reach of self-testing interventions among key populations (Figueroa et al., 2015; Harichund \u0026amp; Moshabela, 2018; Pantelic et al., 2018). This aligns with studies showing low HIVST awareness among migrant and sex worker communities due to structural barriers, stigma, and inadequate outreach (Burke et al., 2017; M. M. Chanda et al., 2017; Elorreaga et al., 2022; Pal et al., 2016; C. Wang et al., 2020).\u003c/p\u003e\n\u003cp\u003eHigher educational attainment was a significant predictor of HIVST awareness, with participants who had secondary or higher education being almost twice as likely to be aware of HIVST. This finding is consistent with research demonstrating that education enhances health literacy, facilitating access to information and engagement with novel health interventions\u0026nbsp;(Bayati et al., 2018; Guerras et al., 2022; Kawuki et al., 2023; Mohamud \u0026amp; Aslam, 2024). Moreover, individuals with higher education may be better positioned to navigate the complex healthcare environment in Italy, facilitating access to information and resources related to HIV prevention. Similarly, prior engagement with healthcare, particularly STI testing, was strongly associated with HIVST awareness. Those who had ever been tested for STIs were more than twice as likely to be aware of HIVST, reinforcing the role of healthcare interactions in disseminating self-testing knowledge (Nambi et al., 2024)\u003c/p\u003e\n\u003cp\u003eQualitative findings revealed that many participants had never heard of HIVST before this study, underscoring the absence of targeted promotion efforts. Some had seen self-testing kits in clients' homes but were unaware of their availability for personal use. This highlights the critical role of social networks in HIV information-sharing, as reported in other studies on sex workers and migrants\u0026nbsp;(Barrington et al., 2018; Nambi et al., 2024; Sarafian, 2012; Zhou et al., 2024). Those who learned about HIVST expressed enthusiasm for its convenience, privacy, and ease of use, findings consistent with global evidence that self-testing is highly acceptable among populations facing stigma and discrimination (Bogart et al., 2021). This underscores how targeted health education can play a critical role in increasing HIVST awareness and uptake.(Abubakari et al., 2021)\u003c/p\u003e\n\u003cp\u003eAlthough several variables, including immigration challenges in healthcare access, stigma or discrimination at hospitals, venue for meeting clients, number of male clients, condom use, lubricant use, and transactional condomless sex, were significantly associated with HIVST awareness in bivariate analyses, they lost significance in the adjusted model. \u0026nbsp; Their strong significance in the chi-square and unadjusted models suggests that these factors may still play an important role in shaping awareness of HIVST, although confounded by other factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNotably, individuals facing immigration-related healthcare challenges and stigma at hospitals were more likely to be aware of HIVST, suggesting that experiences of exclusion may drive reliance on alternative HIV prevention strategies(Dakpui et al., 2024). This aligns with studies showing that key populations who anticipate discrimination in healthcare settings often seek health services information through peer networks and community organizations rather than formal health systems (G. M. Abubakari, Owusu-Dampare, et al., 2021a; He et al., 2020; McGowan et al., 2022). These findings suggest that healthcare access difficulties may still indirectly influence HIVST awareness, even if their direct effect was not significant in our adjusted model.\u003c/p\u003e\n\u003cp\u003eSimilarly, the venue for meeting clients and the number of male clients were also significantly associated with HIVST awareness in bivariate analyses. Although online-based sex workers typically have less engagement with HIV services (Derksen et al., 2022; UNAIDS, 2017), our study found that those meeting clients online were more likely to be aware of HIVST. This could be due to the increased availability of digital resources and health promotion campaigns targeting online spaces, which may provide a more accessible and private avenue for HIV prevention information (Bailey et al., 2021; Blake et al., 2024). Additionally, sex workers with a higher number of male clients tended, and those engaging in transactional condomless sex tend to have more HIVST awareness, potentially due to increased exposure to HIV prevention messaging and a heightened perceived vulnerability (M. Chanda et al., 2017; Wong et al., 1994). While these associations did not remain significant in the adjusted model, their strong significance in the chi-square and unadjusted models indicates they may still play a key role in shaping HIVST awareness.\u003c/p\u003e\n\u003cp\u003eThese findings point to important considerations for the promotion and implementation of HIVST in this population. Given the reported low awareness of HIVST among ARMSWs in Italy, a significant promotional effort is needed to bridge the information gap. Notably, some participants reported having seen HIVST kits being used by clients, establishing the need for targeted interventions not only for sex workers but also for their clients, as engaging clients in HIVST initiatives can promote early detection, reduce transmission, normalize testing, and support a more comprehensive HIV prevention strategy(Huysamen \u0026amp; Richter, 2020; Lowndes et al., 2007; Mulberry et al., 2019; Ngugi et al., 2002).\u003c/p\u003e\n\u003cp\u003eRecruiting and training community peers to lead awareness campaigns could be effective, as peer-led interventions have been shown to increase HIV testing uptake\u0026nbsp;(Abu-Ba’are et al., 2024; G. M. Abubakari, Owusu-Dampare, et al., 2021b; G. M. R. Abubakari et al., 2021; Shangani et al., 2017). Additionally, integrating HIVST education into existing STI and sexual health programs can leverage routine healthcare interactions to enhance knowledge. Given the strong association between prior STI testing and HIVST awareness, healthcare providers in Italy should incorporate HIVST discussions into routine STI screenings. Ensuring that HIVST kits are affordable and accessible, particularly through community centers and outreach programs, will also be crucial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003cbr\u003e\u003c/strong\u003eWhile the study offers valuable insights, several limitations must be acknowledged. First, all data were self-reported and based on hypothetical future preferences, which may have been influenced by social desirability bias, particularly regarding HIVST endorsements. Second, the cross-sectional design limits our ability to determine causality, meaning that observed associations might be both a cause and a consequence of other factors. Third, the use of respondent-driven sampling means the findings primarily reflect connected ARMSWs in Italy, limiting generalizability to less networked youth. Further research is needed to assess actual HIVST use as testing, education, and support become more widely available.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, our findings highlight the urgent need for targeted HIVST awareness initiatives among ARMSWs in Italy. Education and prior STI testing play key roles in awareness, suggesting that interventions should focus on health literacy and engagement with healthcare services. Community-based outreach, peer-led education, and healthcare-provider involvement are critical strategies for improving uptake. Future research should explore long-term behavioral changes following HIVST promotion efforts to assess their impact on testing rates and linkage to care.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosures.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbu-Ba\u0026rsquo;are GR, Torpey K, Guure C, Nelson LE, Jeon S, McMahon J, Leblanc NM, Shamrock OW, Zigah EY, Apreku A (2024) Status-neutral community-based multilevel intervention to address intersectional stigma and discrimination, and increase HIV testing, PrEP, and ART uptake among YGBMSM in Ghanaian Slums: A clustered randomized control trial protocol. 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Global Health Res Policy 9(1):6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s41256-024-00346-1\u003c/span\u003e\u003cspan address=\"10.1186/s41256-024-00346-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV, Self-testing, sex workers, awareness","lastPublishedDoi":"10.21203/rs.3.rs-6383201/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6383201/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHIV 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\u0026thinsp;=\u0026thinsp;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\u0026thinsp;=\u0026thinsp;1.92, p\u0026thinsp;=\u0026thinsp;0.022) and prior STI testing (aOR\u0026thinsp;=\u0026thinsp;2.32, p\u0026thinsp;=\u0026thinsp;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\u0026rsquo;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.\u003c/p\u003e","manuscriptTitle":"\"Yes, I Saw It at a Client’s House\": Factors Associated with Oral HIV Self-Testing Awareness Among African Refugee Male Sex Workers in Italy—A Mixed-Methods Study- BGSH-022","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-09 05:08:06","doi":"10.21203/rs.3.rs-6383201/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb86ed57-1b97-4292-b9d2-2173b410cd69","owner":[],"postedDate":"April 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":46835011,"name":"Sociology"},{"id":46835012,"name":"Sexual \u0026 Reproductive Medicine"},{"id":46835013,"name":"Infectious Diseases"}],"tags":[],"updatedAt":"2025-04-09T05:08:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-09 05:08:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6383201","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6383201","identity":"rs-6383201","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}