br Discussion Our study found that of MSM from
Discussion Our study found that 62.6% of MSM from Natal had been tested for HIV before. This rate was higher than the national average of 37% estimated for the general Kif15-IN-2 in 2011 and the 51.6% found by Brito et al. in MSM from 10 Brazilian cities in 2009. These rates are rather disappointing as MSM is a group with a high prevalence of HIV infection. The World Health organization and the Centers for Disease Control and Prevention (CDC) in United States, recommend that persons at high risk for HIV infection should be screened for HIV at least annually.17, 18 It should be pointed out that testing at any time was accounted for, rather than being restricted to the last year. If only testing in the previous year were considered the rate would be even lower (46.2%). Previous studies conducted in Argentina, Peru, and China showed HIV testing rates varying between 48% and 58%,9, 11, 19 but studies from United States and Puerto Rico had a much better result (82–90%).20, 21 Lack of knowledge about HIV transmission is one of the reasons that lead to low perceived risk of being infected. Hall et al. found that testing was higher among high school students if they were taught at school about AIDS or HIV. Although adequate knowledge about HIV transmission was not significantly associated with HIV testing, it is noteworthy the low level of knowledge, despite the high educational level. The percentage of adequate knowledge in a study with the Brazilian general population was much higher, reaching 57.1%, but Guimarães et al. indicate a decrease in the proportion of MSM with adequate HIV knowledge from 35.2% in 2009 to 23.7% in 2016. Campaigns carried out by the Ministry of Health in Brazil have focused primarily on condom use as a way to avoid HIV infection, leaving aside clarification on situations that have no risk of transmission, such as sharing a meal or use of public toilets. In our country, AIDS is still a topic rarely addressed in schools, and even when this approach is carried out, it is usually not systematic. The school is often the only place where young people can receive reliable information. However, most often school teachers are NOT well prepared, and may end up delivering incomplete information. Alternative interventions like peer education and internet and social media strategies to access MSM have proven to be useful in studies from Peru and United States.19, 24 In 2015, a team of governmental, research, and non-governmental organizations in the city Curitiba in South Brazil launched and evaluated a multi-component implementation science project to improve HIV outcomes for MSM. This project, called “A Hora é Agora” (“The Time is Now”) implemented a web-based platform and associated mobile application designed to provide HIV prevention information, allowing for self-assessment of risk and delivering HIV self-test kits. The project exceeded all expectations with 7352 HIV self-test requests over 24 months, as the initial goal was to distribute 1000 test kits per year, and was able to reach a large percentage (31%) of MSM who had never been tested before, with those between 18 and 28 years old reporting a higher percentage of first-time testers (36%) than those 29 years or older (18%). The same project is now being implemented in the city of São Paulo. Younger age was associated with never testing for HIV in this study, which is worrisome since the last national epidemiological report data showed that the HIV epidemic is increasing in this group. A study evaluating sexual risk behavior among MSM from 10 Brazilian cities showed that to be aged 25 years or less was independently associated with higher scores of risky behavior. A recent study from Germany also showed that younger age (<25 years) was associated with lower rates of HIV testing. The very absence of testing could be a contributing factor to the increased number of infections in this population, since people with HIV on antiretrovirals are less likely to transmit the virus than those who do not use them, a category which include HIV carriers that have not been diagnosed.29, 30 The proposal of treatment as prevention relies on a model of universal testing, reinforcing that barriers to HIV testing will become more relevant to the full spectrum of HIV care. Maximizing testing opportunities and reducing barriers to regular testing should be a central component of HIV prevention programs.