Figure 1: Barriers to accessing testing and treatment for HIV in MSM and interventions aimed at addressing the different barriers The barriers are divided into three different levels: patient, healthcare provider, and institutional/policy. The different barriers are connected to each level they affect through arrows (patient=blue, healthcare provider=red, and institutional/policy=green). Each barrier can affect one or more levels. The interventions are linked to the barrier they seek to address through black arrows if identified as such in the literature, or purple and yellow if identified as addressing a barrier through interviews.

Barrier	Description
Barrier	Description
Patient barriers
Stigma	Stigma associated with being HIV positive
Culture	Cultural barriers, such as language or religion, preventing patients to seek testing or treatment for HIV
Incorrect perception of risk	Not seeking testing because the patient does not consider themselves to have engaged in any risky behaviours
Cost of testing	Perceived cost of testing
Cost of treatment	Perceived cost of treatment
Fear of test result	Fear of receiving an HIV positive test result
Fear of disclosure	Fear of personal information and/or test results being disclosed to third parties
Trust in testing services	Distrust of testing services
Lack of knowledge about HIV	Lack of knowledge about how HIV is transmitted and how one can become infected
Lack of knowledge about where to get tested	Lack of knowledge about the different ways to get tested
Lack of time	Lack of time for patients to seek testing (e.g. limited opening times of clinics)
Healthcare provider barriers
Stigma	Concerns from health providers that offering HIV testing to high-risk populations will stigmatise patients
Concerns over offending patients	Concerns from health providers about making assumptions about a patient's risk and therefore worries about offering the test without clinical reason and patient acceptability
Lack of knowledge/training	Lack of knowledge about HIV including symptoms and related illnesses, and health providers not feeling equipped for HIV management after diagnosis
Lack of familiarity with recommendations and guidelines	Health providers not familiar with guidelines and recommendations for HIV testing
Lack of time	Lack of time for healthcare providers to offer and conduct HIV testing outside of traditional sexual health settings, including the time to provide pre- and post-test counselling
Lack of resources	Limited number of staff and/or limited training offered to staff on HIV testing and treatment
Cost	High cost of HIV testing and counselling associated with the test result
Policy/institutional barriers
Access to health services	Difficulty in accessing testing facilities, mainly related to geographical barriers. This could be due to distance that needs to be covered to reach testing centres.
Recommendations and guidelines	Lack of a national strategy against HIV, resulting in a lack of guidelines and recommendations promoting testing and/or treatment for HIV in MSM.
Laws and regulation	Criminalisation of HIV transmission. This refers to legal ruling on voluntary transmission of HIV to others.

Table 1: Description of each of the barriers to HIV testing and treatment used in the pre-interview survey

Barrier	Description	Rating
Barrier	Description	0	1	2	3	4
Patient barriers
Stigma	Stigma associated with being HIV positive
Culture	Cultural barriers, such as language or religion, preventing patients to seek testing or treatment for HIV
Incorrect perception of risk	Not seeking testing because the patient does not consider themselves to have engaged in any risky behaviours
Cost of testing	Perceived cost of testing
Cost of treatment	Perceived cost of treatment
Fear of test result	Fear of receiving an HIV positive test result
Fear of disclosure	Fear of personal information and/or test results being disclosed to third parties
Trust in testing services	Distrust of testing services
Lack of knowledge about HIV	Lack of knowledge about how HIV is transmitted and how one can become infected
Lack of knowledge about where to get tested	Lack of knowledge about the different ways to get tested
Lack of time	Lack of time for patients to seek testing (e.g. limited opening times of clinics)
Healthcare provider barriers
Stigma	Concerns from health providers that offering HIV testing to high risk populations will stigmatise patients
Concerns over offending patients	Concerns from health providers about making assumptions about a patient's risk and therefore worries about offering the test without clinical reason and patient acceptability
Lack of knowledge/training	Lack of knowledge about HIV including symptoms and related illnesses, and health providers not feeling equipped for HIV management after diagnosis
Lack of familiarity with recommendations and guidelines	Health providers not familiar with guidelines and recommendations for HIV testing
Lack of time	Lack of time for healthcare providers to offer and conduct HIV testing outside of traditional sexual health settings, including the time to provide pre- and post-test counselling
Lack of resources	Limited number of staff and/or limited training offered to staff on HIV testing and treatment
Cost	High cost of HIV testing and counselling associated with the test result
Institutional/policy barriers
Access to health services	Difficulty in accessing testing facilities, mainly related to geographical barriers. This could be due to distance that needs to be covered to reach testing centres.
Recommendations and guidelines	Lack of a national strategy against HIV, resulting in a lack of guidelines and recommendations promoting testing and/or treatment for HIV in MSM.
Laws and regulation	Criminalisation of HIV transmission. This refers to legal ruling on voluntary transmission of HIV to others.

Intervention	Description
Intervention	Description
Self-testing	HIV tests that can be performed by the patient at home
Rapid HIV tests	Rapid tests that can be performed using bodily fluids other than blood
Risk assessment questionnaires	Questionnaires that can be filled in by patients and/or doctors to assess the patient’s risk of HIV infection
Voluntary anonymous partner referral	Patients who engage in unprotected sex can refer partners for testing
Social marketing media campaigns	Campaigns targeting at risk populations to encourage seeking testing for HIV
Mobile testing service	Mobile units offering HIV testing services
Testing in various settings	Testing performed in settings other than specialist healthcare services (not only in specialised clinics) but also in pharmacies, hospitals and General Practitioners
Regular sexually-transmitted infection screening	Including regular sexually transmitted infection screenings in national/international recommendations

	Researcher	Policymaker	Clinician	NGO/charity	Total conducted
UK	0	3	4	2	9
France	3	2	0	0	5
Poland	1	2	1	0	4
Pan-European	2	5	0	2	9
TOTAL	6	12	5	4	27

	Number of individuals contacted	Number of interviews conducted	Response rate
UK	24	9	37.5%
France	18	5	27.8%
Poland	22	4	18.1%
Europe	24	9	37.5%

Country	Interview code
UK	INT1
	INT2
	INT4
	INT6
	INT8
	INT13
	INT16
	INT19
France	INT5
	INT9
	INT20
	INT22
	INT23
	INT26
Poland	INT10
	INT14
	INT24
	INT27
Europe	INT3
	INT7
	INT12
	INT15
	INT17
	INT18
	INT21
	INT25
	INT28

Intervention	Description	Rating
Intervention	Description	0	1	2	3	4
Self-testing	HIV tests that can be performed by the patient at home
Rapid HIV tests	Rapid tests that can be performed using bodily fluids other than blood
Risk assessment questionnaires	Questionnaires that can be filled in by patients and/or doctors to assess the patient’s risk of HIV infection
Voluntary anonymous partner referral	Patients who engage in unprotected sex can refer partners for testing
Social marketing media campaigns	Campaigns targeting at risk populations to encourage seeking testing for HIV
Mobile testing service	Mobile units offering HIV testing services
Testing in various settings	Testing performed in settings other than specialist healthcare services (not only in specialised clinics) but also in pharmacies, hospitals and General Practitioners
Regular sexually-transmitted infection screening	Including regular sexually transmitted infection screenings in national/international recommendations

Tables at a glance