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Behavioral, Normative, and Control Beliefs of Filipino Men Who Have Sex with
Men on Repeat HIV Testing and Counseling

Article in Acta Medica Philippina · February 2021

DOI: 10.47895/amp.vi0.2905

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 ORIGINAL ARTICLE

Behavioral, Normative, and Control Beliefs

of Filipino Men Who Have Sex with Men
on Repeat HIV Testing and Counseling
Samuel Brando H. Piamonte, MA

Department of Social Sciences, College of Arts and Sciences, University of the Philippines Los Baños

ABSTRACT

Introduction. The Philippines faces an increasing incidence of HIV. Timely and regular HIV testing can be a
preventive method against HIV infection because early detection of the virus leads to early access to treatment. This
can lead to viral suppression in which the virus becomes undetectable and untransmittable. Repeat HIV testing is
recommended to men who have sex with men (MSM) and other individuals with previous or ongoing risk of acquiring
HIV. Following the Reasoned Action Approach model, providing behavioral interventions in promoting retesting
among MSM first needs the identification of their salient beliefs toward a repeat test.

Method. A qualitative cross-sectional study was conducted. Thirty HIV non-reactive MSM from a community-
based HIV testing and counseling center took part in the study. Participants were asked questions designed to
elicit salient behavioral, normative, and control beliefs toward a repeat HIV test three to six months following the
receipt of the non-reactive HIV screening test result.

Results. The most salient belief on the positive consequence of a repeat test was having peace of mind with
one’s status; while the most salient belief on the disadvantages was investing in time and travelling as well as
experiencing pain from the needlestick. Close friends were the most cited normative referent. Accessibility of
facilities and time were believed to be the most salient facilitator and barrier, respectively.

Conclusion. HIV/AIDS counselors and administrators can become key persons in increasing regular HIV testing
by bringing messages that address the unearthed salient beliefs of MSM toward repeat testing. The salient
beliefs extracted from the participants can provide basis for behavioral interventions; however, a formal test
through a quantitative study of a larger sample is warranted to identify beliefs that significantly affect attitudinal,
normative, and control factors of retest intention.

Key Words: behavioral beliefs, normative beliefs, control beliefs, prevention and control, HIV testing and counseling, men
who have sex with men

Introduction

Epidemiology of HIV in the Philippines

There has been a rising incidence of HIV in the
Philippines. According to the Department of Health
(DOH)1, an average of two cases of HIV infection per day
were documented in 2009 which increased to seven cases in
2011, 13 in 2013, 22 in 2015, and 32 in 2018. In December
2018 alone, 877 new cases of HIV seropositive individuals
were recorded which comprised 8% of the 11,427 new cases
in the year 2018. Most of the recorded cases in December
Corresponding author: Samuel Brando H. Piamonte, MA were males (96%). Median age was 28 years old where
Department of Social Sciences
College of Arts and Sciences
half of the cases belonged to the 25-34 age cohort; while
University of the Philippines Los Baños, College 4031 about one-third was aged 15 to 24. Highest incidence was
Email: shpiamonte@[Link] recorded in the National Capital Region (NCR) as well as

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Beliefs of MSM on Repeat HIV Testing and Counseling

its peripheral regions, CALABARZON (i.e., Region IV-A) Beliefs and The Reasoned Action Approach
and Central Luzon (i.e., Region III). These demonstrate that The Reasoned Action Approach (RAA) is a behavior
individuals who tested positive come from the youth sector change model which states that behavioral change can be
and major metropolitan areas. attained by providing interventions that target the salient
Sexual contact among men who have sex with men beliefs of the target population.12 Thus, in order to provide
(MSM) has also been reported as the most predominant mode interventions aiming to increase routine VCT, it is a must to
of transmission of the virus from January 1984 to December identify the target population’s beliefs toward a repeat test.
2018. This confirms that the rate of HIV is exploding RAA posits beliefs play a vital role in explaining
among the MSM subpopulation in the Philippines.2 The behavioral intentions and actual behavioral performance.
high probability of transmitting the virus through receptive It states that the immediate antecedent of performing a
anal intercourse gives an important explanation to the high behavior is one’s intention to do it; while intention is driven
incidence of HIV among MSM.3 by attitude toward the behavior, injunctive and descriptive
Identifying one’s HIV status can be attained through norms, and perceived behavioral control. Attitude toward
HIV testing. It can either be client-initiated voluntary the behavior refers to the positive and negative evaluations
counseling and testing (VCT) or provider-initiated testing (i.e. instrumental attitude) and experiences (i.e. experiential
and counseling (PITC).4 In VCT, clients seek HIV testing attitude) one might have when engaging in the behavior
and counseling (HTC) services in order for them to know of interest. Injunctive norm refers to the perceived social
their HIV status on their own initiative. Thus, testing relies pressure to perform the behavior; while descriptive norm
on the clients’ intention. On the other hand, in PITC, reflects what others typically do with regard to the said
health care providers recommend HIV testing to individuals behavior, i.e. whether they would perform it or not. Finally,
visiting health facilities to be part of their medical care. perceived behavioral control refers to the perceived ease or
A surveillance report from the DOH revealed that difficulty in the conduct of behavior.
MSM are engaging in risky sexual behaviors.5 Age at first Personal characteristics, according to the model, shape
sex was during 15 years of age. About a quarter did not use beliefs which serve as the foundations of the intention’s
condom or lubricant for anal sex for the past 12 months. determinants. Beliefs about the instrumental and experiential
Around a quarter also reported to be a client of a male sex consequences of behavioral performance form attitude
worker in the past twelve months. Despite engaging in high toward the behavior. Beliefs on who would approve or
risk behaviors, 78% reported to have never tested for HIV. disapprove such performance form injunctive norms; while
Studies have documented personal and structural barriers beliefs on who would also conduct or not conduct the said
in engaging in VCT among Filipino MSM.6-8 Among behavior form descriptive norms. Finally, beliefs about the
these are not seeing the need to get tested despite engaging facilitating factors and barriers in doing the behavior of
in risky sexual behaviors, issues of morality, expenses, time, interest direct perceived behavioral control.
distance, and fear of side effects of anti-retroviral drugs. The model does not tell what interventions are effective;
In the USA, the Centers for Disease Control and yet it can provide guidelines how to develop and pretest
Prevention recommends at least annual HIV testing behavioral interventions such as persuasive communication,
for sexually active gays or bisexual men; although they face-to-face discussions, observational modeling, or what have
mentioned that some sexually active gays and bisexual men you.13 First is to conduct an elicitation study to determine the
may benefit from a more frequent HIV testing, specifically accessible beliefs of the population through a small sample.
every three to six months.9 It is not advisable to recommend The second step is conducting a correlational study to 1) assess
the general population to undergo retesting.10 The WHO the contribution of behavioral attitude, norms, and perceived
listed situations and settings where retesting is warranted. behavioral control on intention, 2) determine the effects of
Among listed candidates for repeat tests include key intention and perceived behavioral control on behavior; and
populations including men who have sex with men, those 3) assess contribution of beliefs towards attitude, norms, and
with indeterminate status, and those who have previous and perceived behavioral control. The final step is to implement
ongoing risk of acquiring HIV. the intervention the investigators have decided to conduct.
Repeat testing among the key population and those Among studies using the Theory of Planned Behavior
who are in ongoing risk of HIV exposure is important (TPB), an early formulation of the RAA, there is little
because early detection of the virus means that the person attention given to elicitation studies.14 Thus, this current
living with HIV can be linked to care early. Thus, the virus study focuses on this first step and contributes to the body
will be managed immediately and progression to Acquired of literature on belief elicitation within the RAA framework.
Immunodeficiency Syndrome (AIDS) could be prevented. Aside from providing basis for intervention, the unearthed
When left untreated, very high viral load also makes beliefs can also be used to create belief-based measures of
people living with HIV highly contagious to their sexual behavioral attitude, injunctive and descriptive norms, and
partners.11 In order to promote repeat testing to the key perceived behavioral control in order to quantitatively test
populations, interventions for behavior change is warranted. the predictive validity of the RAA.15

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 Beliefs of MSM on Repeat HIV Testing and Counseling

This study was part of a larger project aiming to identify months: a) unprotected anal sexual intercourse, b) multiple
the incidence and determinants of a repeat VCT for HIV anal sex partners, c) multiple oral sex partners, d) sex under
after three to six months among men who have sex with the influence of alcohol, e) sex under the influence of drugs,
men. The larger project used the RAA model because 1) or f ) trading money for sex (i.e. bought or sold sex). Those
it has not been used to explain repeat VCT; and 2) it is a who served as participants of another project requiring
new formulation of the TPB; thus, this new model needs regular testing every three months were not eligible for the
further testing. As reiterated previously, elicitation techniques study since this research focused on client-initiated testing
have been given attention for studies using the TPB as where conduct of a repeat test relies on intention.
framework; thus, this current study which serves as the
exploratory part of the larger study. Data and Method
This study intended to unearth important beliefs toward Questions made to elicit top-of-the-mind beliefs
a repeat VCT three to six months following receipt of a non- were based on Fishbein and Ajzen’s question format.12 The
reactive HIV screening test result using the RAA model. questions were adjusted to the behavior being studied by
Specifically, it aimed to identify 1) the behavioral beliefs of this research which was repeat VCT. In this study, repeat
MSM that capture attitude toward the behavior; 2) their VCT was defined as client-initiated HIV testing and
normative beliefs which refer to the referents putting pressure counseling within three to six months following receipt of a
to conduct a repeat VCT; and 3) their control beliefs to non-reactive test result, i.e., from the day of data gathering.
highlight factors that may facilitate or impede a repeat VCT. Clients were asked to enumerate their answers to
the following questions — 1) “What do you think are the
Methodology advantages and disadvantages of repeating the HIV test
within the next three to six months?”; 2) “What would
Study Design be the things that you would like/enjoy and dislike/hate
This current research utilized a qualitative cross-sectional about repeating the HIV test within the next three to six
study design to address the objectives of the study. The RAA months?”; 3) Who are the persons who would approve/
model served as a guide in what kind of beliefs should be support or disapprove/not support you about repeating the
extracted among the pool of participants, while Fishbein HIV test within the next three to six months?”; 4) “Who
& Ajzen’s recommendations on identifying these beliefs are the persons who would repeat or conduct an HIV test/
were followed.12 would not repeat or would not conduct an HIV test within
the next three to six months?”; and 5) “What do you think
Research participants are the factors that might facilitate/make it easy or hinder/
The study was conducted at a community-based make it difficult for you to repeat the HIV test within the
HTC center in Mandaluyong City, Philippines. After next three to six months?.” After enumeration of answers for
communication of HIV test results and conduct of post-test each question, clients were asked to explain their answers
counseling session, HIV/AIDS counselors informed their to provide elaboration.
respective HIV non-reactive MSM client that a study on The first two questions elicited instrumental and
repeat HIV testing was being conducted at the study site. experiential beliefs, respectively. The third and fourth
The counselors told their respective clients that if they are questionsv asked about injunctive and descriptive normative
interested in participating, permit to disclose their HIV beliefs, respectively. Finally, the last question inquired about
non-reactive result to the Principal Investigator (PI) of control beliefs. The interviews were audio recorded to allow
the research should be given to avoid breach of privacy. If transcription of verbatim responses.
permitted, the PI took over the counseling room to explain
the succeeding steps of the study. An informed consent Analysis of Data
form was handed over to the client after expressing interest Interviews were transcribed verbatim. Beliefs were sorted
to participate; and screening proceeded once the agreement from most emitted to least; and those which cumulatively
section of the consent form had been signed. accounted for 75% (starting from most emitted to least) were
Godin & Kok (1996) on their review of the TPB considered as salient belief as recommended by Fishbein
recommended a sample size of 25 in order to elicit behavioral, & Ajzen.12 Many of the enumerated answers were direct;
normative and control beliefs.16 However, for this study, it while a few were not. Thus, the PI initially did two rounds of
was increased to 30 to further enrich the data. Invitation analyses of data to compare if the same set of salient beliefs
and screening stopped once 30 eligible participants have would appear. At third step, the program manager of the
already been interviewed. The following were the inclusion study site's HIV testing operations assisted in the analyses.
criteria: 1) biologically male who has sexual experience with At final step, two HIV/AIDS-trained volunteers also
other men, 2) aged 18 years or older, 3) studying, working, or assisted in analyzing the data. All steps yielded the similar
residing in Metro Manila, 4) non-reactive to HIV antibodies, salient beliefs. Results were given to three individuals after
and 5) has engaged in any of the following for the past six the said four rounds of analyses. Two hold PhD degrees in

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Beliefs of MSM on Repeat HIV Testing and Counseling

social science disciplines and one holds a PhD in an allied Table 1. Percentage distribution of behavioral beliefs
health discipline. No further comment was given by the Behavioral Belief Frequency Percentage
evaluators and the beliefs emitted were accepted as is; thus, Instrumental Behavioral Beliefs
the analyses after the fourth round of analyses were retained. Advantages (n = 64)
Peace of mind 13 20.31
Ethical considerations Knowing one’s status 12 18.75
Confirming a negative status 10 15.63
Prior to data gathering, ethics clearance was obtained
Early detection and access to treatment 5 7.81
from the University of the Philippines Manila Research Monitoring/knowing health status 4 6.25
Ethics Board (2018-021-01). The study adhered with the Practicing HIV prevention 4 6.25
guidelines of the Data Privacy Act of 2012 (RA 10173) and Capacity to engage more in sex 4 6.25
Others (non-salient beliefs) 12 18.75
the Philippine HIV and AIDS Policy Act (RA 1116).
The project was explained to all clients referred by the Disadvantages (n = 32)
Investing time and travelling 7 21.88
counselors. An informed consent form for their participation Worry or anxiety about the result 6 18.75
in the screening and interview processes was administered. Seeing familiar people 2 6.25
Data gathering started after obtaining written informed Getting a positive result 1 3.13
consent from the client. All participants were assigned Pain brought by the needle 1 3.13
Perception that people judge you 1 3.13
codes in encoding in the database of participants and (None) 14 43.75
during transcription. All forms of data were destroyed Experiential Behavioral Beliefs
after publication of results and only the PI had previous Likeable things (n = 47)
access to these. Peace of mind 13 27.66
Knowing one’s status 8 17.02
Results Meeting other people 5 10.64
Confirming a negative status 4 8.51
Engaging in counseling sessions 4 8.51
Thirty-eight clients were screened for the elicitation Monitoring/knowing health status 2 4.26
study. The average age of the 30 eligible participants was 26 (None) 2 4.26
(SD = 5.58). Majority self-identified as a male (90.00%). Others (non-salient beliefs) 10 19.15
Two clients self-identified as “bakla” or translated loosely, Unlikeable things (n = 38)
Pain brought by the needle 9 23.68
“gay” (6.67%). Majority of the participants were exclusively Worry or anxiety about the result 8 21.05
or more attracted to the same sex (66.67%). Table 1 Investing time and travelling 6 15.79
presents the emitted behavioral beliefs of the participants. Perception that people judge you 4 10.53
Getting a positive result 4 10.53
Others (non-salient beliefs) 7 18.42
Behavioral Beliefs
Many of the responses from both type of behavioral
beliefs overlapped. The following were perceived to be both Confirming a negative status. Participants also stated
advantages and things one would like when engaging in a re-assurance of a non-reactive result as one advantage of
repeat test after three to six months. Guided by the RAA, conducting a retest.
these beliefs form positive attitudes toward a repeat test. “Repeating the HIV test is for the assurance and
Peace of mind. One of salient beliefs mentioned by the accuracy of your previous test result. If you have sex
participants was having peace of mind. Participants reported again after your test result, the succeeding test result
that they were anxious or worried about their status that it might not confirm the previous one.”
might be reactive that is why when they receive a negative
HIV test result on a repeat test, they would have a feeling Monitoring and knowing health. For others, engaging in
of security. a repeat HIV test was a means to monitor and secure one’s
“I am always nervous whenever I get tested even health. Absence of HIV for these individuals meant absence
if I do not engage in sex with others; thus, peace of of HIV-related diseases or complications; and they can live
mind. I have about three friends living with HIV. healthy and longer.
You’ll just be surprised that your friends have HIV.” “If we repeat the test, it would be better because
you can monitor your health. So, if you engage in sex
Knowing one’s status. Participants also highlighted that many times, it is important that you do regular check-
one advantage of undergoing a retest is knowing one’s status. ups; thus, that would be an advantage.”
“Awareness and knowledge are very important.
You being aware of yourself, of your condition, you The following were unique modal beliefs in terms of
would know how to fought [sic] on things; you know advantages of a repeat voluntary screening for HIV for the
how to deal with this, so there. That’s the main reason next three to six months after baseline screening.
why I would normally get (re)tested.”

4 ACTA MEDICA PHILIPPINA

 Beliefs of MSM on Repeat HIV Testing and Counseling

Early detection and access to treatment. For the respondents, Worry or anxiety about the result. Participants reported
repeating the HIV test early means that there is a possibility worry or anxiety as one consequence of repeating the HIV
of early detection of the virus and consequently, early access test. That is why when they receive a non-reactive result, they
to medications. feel relieved as stated previously.
“If ever I would get positive in the repeat test, “For me, disadvantage would be being nervous
early detection would be better. The earlier that you again about the result despite I know I am negative
know that you are HIV positive, the better because you because I engage in blood donations.”
can immediately start treating it.”
Investing time and travelling. Time and distance are
Practicing HIV prevention. Participants reported that common issues among the participants. One even said that
HIV testing is a form of prevention. One said that if he travelling from an adjacent city would take him an hour while
became positive on a repeat test, he will be more cautious of for some, it would take more than one hour especially for
his sexual behaviors. Another said that he would discontinue those who would be coming from the extreme northern and
having sex if in the repeat test, he will be positive for HIV. southern parts of NCR.
“Of course, a repeat test would determine if I “Time is important to me. So, most of the time, I am
should still continue my habits. If ever I received a busy with work. I have a lot of things to do and if I go
positive test result, definitely I should discontinue sex here, I need to spend the rest of the day to get my results.”
because, otherwise, I’m spreading HIV.”
Getting a positive result. For some participants, this is a
Capacity to engage more in sex if non-reactive. Respon- disadvantage and/or a thing that they would not like during
dents mentioned that when they receive a negative HIV a retest. Reasons vary why it is a disadvantage and unlikeable.
test result on their repeat test, it would enable them to One participant mentioned that you would take medications
have sex with others. This is especially true when potential if you are HIV-positive. Another mentioned that you might
sexual partners ask for HIV status. contribute to its spread.
“I would have ease of having sex. In the circle “I would dislike getting a positive result. I know
where I belong, when you are not sure about your that I’m positive, and then definitely, that would affect
status, it would be hard for you to get someone for sex. my heath. I’m not sure if in the future I would still be
Sometimes, they ask your status. In my case, I don’t alive. I’m much worried also that I might spread HIV
want to have sex when I’m not sure of my status.” which I don’t like. As much as possible, I should avoid
spreading the disease.”
On the other hand, the following points are the unique
experiential beliefs of the participants with regard to repeat Pain brought by the needle. Many participants shared that
HIV testing. when they repeated the test, they would again experience the
Meeting other people. Some respondents reported that pain brought by the needlestick during blood extraction.
one thing they would like for a repeat test is meeting other “I am afraid of the needle. I am afraid of the
persons and such community testing center can be a venue procedure.”
for friendship building.
“In this kind of community or organization, you Perception that people judge you. Respondents perceived
meet people. We (MSM) are not accepted by society. So, that they might get judged by the persons in the clinic for
we look for people like us. When you go to Manila, there their sexual activities when they repeat the HIV test. They
are a lot of gay and bisexual men so it’s an opportunity think that people would remember them having a test
to meet them unlike in the province.” previously and that they might be sexually active for engaging
a repeat test.
Engaging in counseling sessions. Participants reported “People might think that I am sexually active –
engaging in counseling as a likeable thing that they would that I always have sex with others.”
experience when they will engage in a retest because they
would be able to privately tell their intimate stories. Many participants reported that there are no
“ You could share your experiences privately or disadvantages in repeating HIV test for the next three to
secretly during the one-on-one counseling. I could tell six months nor there are things they would dislike about it.
my biggest experience about sex.” However, a few reported that one disadvantage of a retest
is having a possibility of seeing familiar people. One even
There were also responses that overlapped as both said that when someone he knows see him getting tested,
disadvantages and dislikable things for the participants. that person might ask why he would get tested for HIV.
These beliefs form negative attitudes toward a repeat test. This belief was reported especially of those who have not
disclosed their sexual orientation.

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Beliefs of MSM on Repeat HIV Testing and Counseling

“I am not out of the closet, especially to my partners also play a role in building a supportive environment
work. So, someone might see me in this kind of facility in having a repeat test. Others say that their sexual partners
where men who have sex with men usually visit.” also encourage them to have a retest. In case of being in a
relationship, one said that they do not engage in safe sex often
Normative Beliefs and that his partner encourages him to engage in a retest.
Table 2 presents the percentage distribution of the “My partner and I do not engage in safe sex. We
emitted normative referents of the clients. rarely engage in protected sex. So, he tells me to get
No persons were believed to disapprove or the a retest.”
participants to repeat the test. Some participants also reported
that no one supports or encourages them to repeat the test; Family members. The family is also a recurring normative
thus, VCT is more likely self-initiated. For others, however, referent among the participants. For members who are out of
there are persons who would approve them to do so, namely their closet, their family or family members also play a vital
the following. role in having a retest for the next three to six months. One
Close friends. Participants emphasized that it is their shared that his sister supports him to do so while another
close or best friends who would encourage them to repeat reported that it is his mother who plays that role. A first-time
the test after three to six months. These are also the persons tester shared:
who also know the sexuality of the participant as well as “Actually, it’s my first time to get tested. My family
his sexual activities. would tell me that if I receive a non-reactive result,
“I would count my close friends. They are the ones then I should get another test after three to six months.”
who know about my sexuality and sexual activities. They
are also the ones who would support me to get tested.” In terms of descriptive normative beliefs, the participants
cited that they do not know anyone who would not repeat the
HIV/AIDS counselors. Another set of individuals that HIV test. Some participants also reported that they do not
were reported to give support toward retesting was the know anyone who would get a test soon. Similar to injunctive
counselors of the testing center. normative beliefs, other participants also reported that their
“My counselor said that my HIV test covers friend/s and romantic or sexual partner/s would also get
activities prior to March 21 so the succeeding ones were tested after the three to six-month period. In addition to
not covered. So, he told me to get a repeat test.” these, colleagues were included as referents.
Close friends. Some friends was also believed to get tested
Romantic or sexual partners (including persons being dated). soon. Thus, close friends can provide a normative pressure
Some participants were currently dating someone or were to the participants when it comes to repeat HIV testing. A
in a relationship during the conduct of the interview. Their participant shared that he has a friend who also engaged in
risky sexual behaviors; thus, his friend would also get tested
Table 2. Percentage distribution of normative beliefs within three to six months.
“I have a friend who might get tested by December
Normative Belief Frequency Percentage
or November because of engagement in unprotected
Injunctive normative beliefs
sex. Moreover, my friend does not have peace of mind
Would support a test/retest (n = 47)
Close friend 17 36.17 because of engaging in unsafe sex.”
Counselor 8 17.02
Romantic/Sexual partner 7 14.89 Romantic or sexual partners (including persons being dated).
None 6 12.77 The same is also true for romantic or sexual partners. These
Family 6 12.77
Others (non-salient beliefs) 3 6.38 are also individuals supportive of the behavior and individuals
Would not support a test/retest (n = 30) who would also get a retest for HIV for the succeeding
None 28 93.33 months. One participant shared that he and his partner do
Friend 1 3.33 not use condom; thus, a repeat test would confirm their status.
Heterosexual peer 1 3.33 “My partner and I were talking about a repeat
Descriptive normative beliefs test because we engage in unprotected sex. We intend to
Would conduct a test/retest (n = 36) repeat the test.”
Close friend 17 47.22
Romantic/Sexual partner 6 16.67
Colleague 4 11.11 Colleagues Participants described their workmates or
(None) 6 16.67 colleagues as sexually active that is why these individuals
Others (non-salient beliefs) 3 8.33 would also get tested soon. One noted that his workmates
Would not conduct a test/retest (n = 30) engage in sex under the influence of drugs (i.e. “partee”).
None 24 80.00
Friend 6 20.00
“Partee,” “party and play”, and “chemfun” are some of the
terminologies used to refer to sexual activities involving drugs.

6 ACTA MEDICA PHILIPPINA

 Beliefs of MSM on Repeat HIV Testing and Counseling

“I have sexually active workmates. My colleagues’ him to get tested again would facilitate his retest. Another
activities are quite alarming because they engage participant mentioned about the role of advertisements.
in “partee.” “If ever I would have a reminder, then a retest
is more probable. For me, that would be effective, like
Control Beliefs advertisements, because you will not forget about it.”
The following were the factors that would play as
facilitators and barriers for a retest. Company. Aside from reminders, having someone
Time. Participants reported that work schedule can to accompany the participant or being tested in group
enable or hinder one in repeating the HIV test. would enable them to have a test again. One participant
“Because of work, I tend to go home late. Then said that it would be enjoyable if he will be accompanied by
during weekends, I have lots of things to do. It is his friends.
possible to have a repeat test despite my schedule, but “A repeat test would be easier if I ever I would
I really work on it.” have friends who would go with me. The HIV test
would be enjoyable if I have them with me.”
Accessibility. For the participants, accessibility pertains
to both availability and being near an HIV testing center. Better HIV testing logistics. Finally, the last enabling or
For availability, one participant mentioned about having preventive factor pertains to the operations of HIV testing
mobile tests while a few mentioned about the availability of centers. According to the participants, having longer clinic
self-screening for HIV in the market. However, the latter is hours, quicker results, and lower client volume would make
not yet available in the Philippine market. a repeat test more probable.
“If ever a self-screening kit be available, then a “I would say it would be easier for me to be tested
repeat test would be easier. It would be better if we if the process is quicker. Right now, the queue takes
could buy one or if some companies distribute such.” about three hours. I would have incentive to stick to
the three to six months schedule if testing is quicker.”
Exposure to sex. Engagement in sex after receiving a
negative HIV test result can enable or prevent one to get Discussion
a retest according to the interviewed clients. If one has not
engaged in sexual activities, the likelihood to get a repeat The present study aimed to identify the salient beliefs
VCT is lower; while engaging in such engages one to take of MSM with regard to a repeat VCT three to six months
a retest. after receiving a non-reactive HIV test result. Determining
“There’s no need to get a retest if there was no these beliefs provides an important step in understanding
exposure to sex.” repeat testing since beliefs give foundation to attitudinal,
normative, and control factors that shape behavioral
On the other hand, the following are exclusively intentions. It also paves the way in identifying potential
mentioned as enabling factors for a retest to be possible. interventions to increase routine VCT. To the knowledge of
Reminder to get tested. Since individuals might forget the author, this is the first study which elicited the beliefs of
to get tested again for HIV, others suggested that having a MSM toward a repeat testing for HIV.
reminder for them to get a retest would enable them to do First, in terms of behavioral beliefs, the findings revealed
so. A participant thought that automated messages to remind peace of mind as the most salient behavioral belief. This
belief is related to other negative beliefs that repeating
Table 3. Percentage distribution of control beliefs the test might be disadvantageous and unlikeable because
Control Belief Frequency Percentage of the worry and anxiety one may experience during the
Facilitators (n = 46) testing procedures. Others also presented that one negative
Accessibility 16 34.78 consequence of repeating the test is the possibility of
Time 7 15.22 seroconversion. Clearly, these denote that individuals have
Exposure to sex 5 10.87 strong emotional response to HIV infection. This implicates
Reminder to get tested 5 10.87
Company 4 8.70 that HIV/AIDS counselors and information campaigns
Better HIV testing logistics 4 8.70 could encourage individuals at risk of acquiring the virus to
(None) 3 6.52 opt for routine testing in order for them to have peace of
Others (non-salient beliefs) 2 4.35 mind. In fact, research has documented that heterosexual
Barriers (n = 42) men of Mexican descent are more likely to seek testing if
Time 22 52.38
Accessibility 6 14.29
they foresee positive outcomes, including peace of mind.17
Exposure to sex 5 11.90 Another study revealed that one HIV testing efforts
(None) 2 4.76 conducted by pastors of an African American clergy is to
Others (non-salient beliefs) 7 16.67 encourage couples test for HIV for peace of mind.18

ACTA MEDICA PHILIPPINA 7

Beliefs of MSM on Repeat HIV Testing and Counseling

Another positive consequence is having the opportunity When it comes to normative beliefs, only a few referents
to share experiences and meeting new people. Treatment were reported. The most salient one would be one’s circle of
centers provide individual counseling to clients in order for friends. Sexual or romantic partners and colleagues also play
them to open up their sexual experiences which they could as referents to the participants. The presence of workmates
not disclose to other individuals because of stigma. These as a salient referent may be explained by the age of the
centers can also provide venues for friendship among MSM. participants since they are generally on the young working
Truly, people who are not getting timely testing because they age cohort. When asked about the characteristics of their
experience judgmental or discriminatory responses from circle of friends and workmates, participants would state
health care providers give an example of the impact of stigma that they are sexually active. This indicates that that the
against HIV testing.19 This unearthed belief suggests that participants have a sexually active network, which verifies
treatment hubs should provide a safe and secured space to national studies about youth sexual behavior.22-24
further promote timely and regular testing to clients especially Findings about the normative referents of the MSM
to the key populations; and anonymity and confidentiality suggests that friendship-based testing might increase
should be strengthened. In fact, participants have also revealed VCT uptake. In fact, interviews of persons living with
that one potential consequence of repeating the test is that the HIV suggested that encouraging friends and family to get
health care staff might judge them for being sexually active HIV tested is beneficial.25 A qualitative evaluation of a
for repeating the test. Others also reported that repeat tests friendship-based intervention indicated that both male and
might increase the possibility of being seen by known people female participants revealed multiple benefits of attending
who might question why they were in an HIV testing center. the intervention with their friends.26 These include a feeling
Other salient behavioral beliefs include knowing one’s of being more comfortable, more ease in self-expression,
status and assuring one’s status since the previous test and being able to talk about sensitive matters.
might have been done within the window period of HIV. Finally, control beliefs comprise issues of time,
Knowing one’s status is a clear advantage of HIV testing. accessibility, and better testing operations as circumstances
DOH Department Circular No. 2016-0171 (2016) stated that may affect a subsequent test. These were consistent with
that clients with reactive HIV screening test result shall be studies on Filipino uptake of HTC.5-7 Establishment of
provided immediate referral to treatment hubs.20 Their blood accessible HIV testing centers and conduct of mass testing
samples shall be sent to STD/AIDS Cooperative Central events should also remedy the problem of time and distance.
Laboratory of San Lazaro Hospital for confirmatory testing. Availability of self-screening kit in the market might aid
The clinic or hub where the client was referred to shall the problem regarding time since it would take few minutes
conduct a repeat HIV test to the client. Reactive repeat test to determine the result of the kit. As the participants also
shall be the impetus for clinical assessments and CD4 count. report dislike against the pain brought by the needle, self-
Others also said that through HIV testing, one can tests for HIV can provide a painless test because it is available
know and monitor their health. This is because they could through saliva test. One systematic review and meta-
feel secure about their health status in a way that they are analysis provided evidence that self-test has the potential
comfortable being free from HIV-related co-morbidities. to increase HIV testing.27 Some researchers have also
Prominent co-morbidities include tuberculosis, cryptococcal documented preference to oral-based self-test than blood
infection, Hepatitis B and C; and other sexually transmitted test.28,29 However, self-screening is still not yet available in
infections.21 Messages that bring awareness about the co- the Philippine market and studies about its feasibility and
morbidities of HIV could also be used by HIV/AIDS acceptability must be conducted.
counselors and HIV/AIDS program administrators. This study has several limitations. One limitation is
Negative consequences include having inconveniences, that the samples are MSM only. The results of the study
specifically investing in time and travelling to HIV testing may not be true to other key populations including injection
centers. These were consistent with findings of our Filipino drug users and sex workers since their experiences may be
studies.6-8 Time to wait for the result of the screening in the different. Interviews were conducted among MSM residing,
study site ranges from one and a half hour to two hours in working, or studying in NCR; thus, findings may not be
the study site. Even being called to get inside the phlebotomy generalizable to other MSM outside the region. These
room to have one’s blood extracted would also take time limitations suggest that beliefs of other key populations
especially if the client load is high. Furthermore, post-test must be studied as well. Lastly, this study is only the first
counseling would also take minutes depending on the skills step towards providing intervention to increase routine and
of the counselor and whether there are further questions repeat VCT. It only elicited the top of the mind beliefs of
from the client. This implicates that more centers should participants towards repeat VCT and did not formally test
be established; or at least, locations of various HIV testing the relative contribution of each belief to intention and
centers and their operating hours should be communicated behavior. Despite this, it outlines the cognitive foundation
to the clients since they may not be familiar with other of attitudinal, normative, and control factors affecting retest
testing locations. intention among MSM.

8 ACTA MEDICA PHILIPPINA

 Beliefs of MSM on Repeat HIV Testing and Counseling

CONCLUSION dam/philippines/docs/HIV/UNDPPH_Manila_Case%20Studies%
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stigmatized sector – the MSM. By understanding their men who have sex with men in Metro Manila, Philippines. PLoS
characteristics and beliefs as well as the stigma they face, One. 2018;13(7):e0200256. doi:10.1371/[Link].0200256.
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targeted approach. As the RAA would suggest, health Available from: [Link]
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submitted. Griffin S, Hardeman W, & Kinmonth AL. Eliciting salient beliefs
in research on the theory of planned behaviour: The effect of
question wording. Current Psychology: Developmental, Learning,
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The author declared no conflicts of interest. s12144-003-1019-1.
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