Nearly one in 30 people in the world live in a country other than their place of birth (1). The focus on migrant health has been growing in recent years, with increasing recognition that the multi-faceted and heterogeneous nature of health risks, including those related to infectious disease prevention and control, can occur throughout the migration process (2). However, limited availability of quality data, and in some cases, access to publicly subsidised healthcare hamper efforts to address the health needs of migrants (3).

Over a quarter of people living in Australia (29.7%) were born overseas (4). In the early 2010s, migration-related HIV cases were predominantly diagnosed in people from sub-Saharan Africa (SSA), who acquired HIV before arriving in Australia (5). More recently, there has been an increase in the number of new HIV diagnoses in Australia among gay, bisexual or other men who have sex with men (GBMSM) from Asia (6). Migrants living in high-income countries are reported to have a lower self-perceived risk of HIV infection, language barriers, and concerns with confidentiality and privacy (7–10). Moreover, migrant GBMSM may face additional cultural and healthcare system barriers such as unfamiliarity with the local health system, distrust of health providers, and privacy concern, further hindering their access to HIV testing in conventional settings (11–13). Between 2014 and 2019, HIV diagnoses among Australian-born GBMSM declined by 44%, which likely occurred due to improved coverage of HIV testing and treatment, and implementation of PrEP across Australia (14). However, this success was offset by increased diagnoses among people born in other countries resulting in a relatively stable number of annual diagnoses overall (15). Surveillance data from 2018 suggest that migrant GBMSM in Australia are three times more likely to be undiagnosed for HIV and three times more likely to be diagnosed late than Australian-born GBMSM (14). Delays in testing lead to delayed treatment (16), and untreated HIV infections can disproportionately contribute to HIV transmissions (17–19). Together, this evidence underscores the urgent need to develop a better understanding of the needs of migrant GBMSM and improve access to earlier HIV testing, diagnosis, linkage to care, and bolster targeted prevention strategies.

Medicare, Australia's universal health care scheme, is available to all Australian citizens and permanent residents. Medicare also covers temporary migrants from ten countries in Europe and New Zealand through reciprocal healthcare agreements (RHCA) (20). With access to Medicare, migrants from RHCA countries have full access to free HIV testing. In comparison, migrants from non-RHCA countries can access free testing through public-funded programmes that are unevenly distributed across Australia or private insurance, which may require reimbursable upfront payments (21, 22). Previous studies found that migrants ineligible for subsidised healthcare through RHCA were more likely to be diagnosed with HIV later than those born in Australia or countries covered by the RHCA agreement (23, 24). In addition, studies on HIV and hepatitis B virus care in Australia have demonstrated that the issue of ineligibility for subsidised healthcare places additional psychological and financial pressure on migrants (25, 26).

HIV self-testing (HIVST) enables people to test for HIV conveniently and privately and is a promising tool to improve HIV testing uptake among migrant GBMSM (27, 28). Studies from several countries have confirmed that access to HIVST kits increases HIV testing uptake and frequency among GBMSM (29–32). More recently, HIVST kits have been successfully implemented in several countries to test underserved populations during the COVID-19 pandemic (33–35). To initiate or scale-up HIVST among GBMSM, various approaches to distribute HIVST kits have been evaluated globally, including through home delivery, pharmacies, vending machines, online purchasing, sexual or social networks, or social enterprise health campaigns—all of which have shown favourable outcomes (36–38). However, globally, little is known about the preferences of migrant GBMSM for accessing HIVST through these different channels.

Discrete choice experiments (DCEs) are a methodology to understand user preferences for goods and services that are not yet widely available in the market (39). Within a DCE, individuals are asked to state their preference between different goods or services on offer, with each of the goods or services described by their underlying characteristics or attributes (40). Data from DCEs can be used to identify the trade-offs that individuals are willing to make between the attributes describing a good or service (41). This method has been widely employed to quantitatively estimate user and provider preferences towards HIV testing services in various settings (42–46). In this paper, we compare the preferences for HIV testing services and HIVST kit distribution among GBMSM in Australia, assessing the impact on preferences of differences in country of birth and access to an RHCA for Medicare.

Of the 1,606 men recruited between December 2017 and January 2018, 583 were migrants born overseas, with 420 and 163 participated in the DCE-Test survey and the DCE-kits survey, respectively. Table 1 presents the participants' sociodemographic characteristics, sexual behaviours, and HIV testing behaviours. Among the 419 (72%) migrant men born in non-RHCA countries, 127 (30%) were from Southeast Asia, 101 from other Asian countries (24%), 25 from Sub-Saharan Africa (6%) and 166 from other non-RHCA countries (40%). For migrants, the median time since arrival in Australia was seven years. Overall, migrant participants were younger and had higher education levels than those born in Australia. Compared to Australian-born men, a lower proportion of migrants had tested for HIV at a general practise and a higher proportion had tested at community services. In addition, 141 (24%) migrant men and 197 (19%) Australian-born men reported having delayed their HIV testing because no HIVST was available.

In light of the increasing number of HIV diagnoses among migrant GBMSM in Australia, expanding HIV testing coverage among this group is critical to prevent onward transmission in undiagnosed men. Previous research emphasises the need to identify testing strategies that effectively target migrants who may face various obstacles to accessing HIV testing (52). Our study extends the limited literature on HIV testing for migrant populations by identifying heterogeneous preferences towards HIV testing services. To our knowledge, this is the first study that informs optimisation of access and uptake of HIV self-testing among migrants, especially those who cannot easily access Medicare-subsidised health services.

Unlike Australian-born GBMSM and men from RHCA countries, the cost of an HIV test was the most important attribute for GBMSM from non-RHCA countries. This finding is consistent with previous studies that find that promoting free or reduced-cost HIV services among undertested people who have constrained access to healthcare improves their engagement in the HIV cascade (23, 53–56). In Australia, free HIV testing services are available through state government-funded sexual health centres and community-based health services, regardless of their Medicare status (21, 22). Raising awareness among migrants of services that offer free HIV care in Australia may help improve testing uptake. But, it is worth noting that free or low-cost services are not uniformly available across the country and tend to be concentrated in capital cities and regional centres.

Furthermore, given the preferences of all GBMSM, an ideal HIV testing kit would be a saliva-based test that has high accuracy, a short window period and allows them to test by themselves. However, albeit with a general preference for oral-fluid tests, currently there is no oral-fluid rapid test for self-testing in Australia that is regulatory approved. In addition, the oral self-tests are likely to be less sensitive than blood-based self-tests and all self-tests for HIV, regardless of whether it is saliva or blood-based test, have reduced sensitivity during the window period (57, 58). To date, the Australian Therapeutic Goods Administration (TGA) has approved only one HIVST that uses a blood sample (59). The availability of blood-based HIVST may appeal to those who value accuracy the most but may not be the kit those who prefer an easy-to-use and painless test want to purchase. Our study showed that oral testing is the preferred option for migrants from non-RHCA countries, especially older men born in South East Asia countries. Consequently, to reach this group of migrants, it is important to have different types of test kits available in the market to give them more choice.

Consistent with previous Australian research, our findings suggest that HIVST is acceptable to migrant men (60). In addition, compared to Australian GBMSM, a higher proportion of migrant men had previously used HIVST, and a higher percentage (about a quarter of men) reported that they had delayed HIV testing because HIVST was not available. The Atomo HIV self-test kit was approved for marketing in Australia at the end of 2018. The initial regulation restricted the sale of HIVST kits to online purchasing or through approved health organisations (59). Our findings from latent class models show that over half of non-RHCA migrants most preferred to get the HIVST kits through pharmacies, which could be ideal for those who do not want to make a medical appointment or wait for long periods before testing. Our results support the recent decision of Australian TGA to allow HIVST to be sold in pharmacies at the end of 2021. Further research is needed to fully understand the impact of changes in the accessibility of HIVST on its uptake.

In addition, migrants from the non-RHCA country group also showed a stronger preference for accessing the kits in medical clinics. In our study, nearly two-thirds of the men from the non-RHCA country group were born in Southeast Asia and Sub-Saharan Africa. Studies have shown that migrants from Sub-Saharan Africa and Asia often prefer some level of assistance to perform HIVST when they conduct their first or second test, as support from healthcare workers may ensure the accuracy of results (61–63). The majority of men in our study had not previously used an HIVST kit, which may explain a preference for assisted HIVST to ensure correct use, at least for the first time. Further studies are needed to understand the factors affecting migrant GBMSM from Asia and Africa to identify and respond to their specific needs and better tailor HIVST interventions to this group.

The strength of this study is its exploration of HIV testing preferences among migrant GBMSM compared with Australian-born GBMSM. Until this study, the availability of preference data from this underserved population was limited, mainly due to the small sample size of previous DCE studies and a lack of targeted recruitment of migrant GBMSM (46). Another strength is that we used the established methodology of DCE to quantitatively measure preference heterogeneity (64). There are a few limitations that should be noted. First, all surveys were presented in English, which might affect the generalizability of the findings to non-English speaking migrants. Language barriers could potentially impede migrants' access to healthcare in facilities (65). Our findings that migrants from the non-RHCA group preferred accessing HIVST in a clinic may not apply to migrants who do not speak English. Second, we did not assess men's residency status in Australia but used the eligibility for RHCA as a proxy for access to subsidised healthcare in Australia, similar to previous studies (23). Some men from the non-RHCA country group may have access to subsided healthcare after receiving permanent residency in Australia. If this is so, our result may underestimate the role of Medicare in determining the preferences of migrant men towards the cost of HIV testing services. Conversely, it is also possible that men from the RHCA eligible group, who are young and healthy, may not be aware of the scheme and therefore not register for temporary access to Medicare. Future research on migrants could include visa status and Medicare status to better understand differences among this population group.

In summary, our study indicates that low-cost and high performing self-testing kits might improve HIV testing among migrant GBMSM in Australia, especially those from non-RHCA countries. Our study highlights differences in HIV self-testing kit distribution preferences that can inform future HIVST implementation projects targeting migrants. However, until now, no HIVST kit distribution strategies have thus far been tailor-designed to reach migrant GBMSM in Australia. Providing targeted testing services and supports for migrant men is essential to get newly arrived men tested shortly after arrival to prevent onward transmission in this population. These findings emphasise the importance of expanding the availability and ease of access to multiple types of HIVST kits in Australia to optimise the uptake of HIVST among migrant men.

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

This study obtained ethical approval from the New South Wales South Eastern Sydney Local District Human Research Ethics Committee (17/147) and Alfred Health Human Research Ethics Committee (486/17). The patients/participants provided their written informed consent to participate in this study.

The study was designed by YZ, JO, RL, DS, KS, MJ, AH, KJ, BB, MH, JK, and RG. YZ, JO, VW, RG, and FT-P were involved in data analysis and interpretation. YZ and JO contributed to the writing of the manuscript. All authors contributed to the interpretation results, provided advice of the draft, and approved the final draft of submission.

This study was funded by the Australian National Health and Medical Research Council (Grant Nos. APP1104781 and 568971). EC and JO are supported by an Australian National Health and Medical Research Council (NHMRC) Emerging Leadership Investigator Grant (GNT1172873 and GNT1193955, respectively). CF was supported by an NHMRC Leadership Investigator Grant (GNT1172900).

The contents in this article are those of the authors alone and do not necessarily reflect the view of the World Health Organisation.

AH was employed by Thorne Harbour Health. KJ was employed by ACON. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.