Provider-Initiated HIV Testing for Migrants in Spain A Qualitative Study with Health Care Workers and Foreign-Born Sexual Minorities

Introduction
Provider-initiated HIV testing (PITC) is increasingly adopted in Europe. The success of the approach at identifying new HIV cases relies on its effectiveness at testing individuals most at risk. However, its suitability to reach populations facing overlapping vulnerabilities is under researched. This qualitative study examined HIV testing experiences and perceptions amongst Latin-American migrant men who have sex with men and transgender females in Spain, as well as health professionals’ experiences offering HIV tests to migrants in Barcelona and Madrid.

Methods
We conducted 32 in-depth interviews and 8 discussion groups with 38 Latin-American migrants and 21 health professionals. We imported verbatim transcripts and detailed field work notes into the qualitative software package Nvivo-10 and applied to all data a coding framework to examine systematically different HIV testing dimensions and modalities. The dimensions analysed were based on the World Health Organization "5 Cs" principles: Consent, Counselling, Connection to treatment, Correctness of results and Confidentiality.

Results
Health professionals reported that PITC was conceptually acceptable for them, although their perceived inability to adequately communicate HIV+ results and resulting bottle necks in the flow of care were recurrent concerns. Endorsement and adherence to the principles underpinning the rights-based response to HIV varied widely across health settings. The offer of an HIV test during routine consultations was generally appreciated by users as a way of avoiding the embarrassment of asking for it. Several participants deemed compulsory testing as acceptable on public health grounds. In spite of—and sometimes because of—partial endorsement of rights-based approaches, PITC was acceptable in a population with high levels of internalised stigma.

Conclusion
PITC is a promising approach to reach sexual minority migrants who hold high levels of internalised stigma but explicit extra efforts are needed to safeguard the rights of the most vulnerable.