By Sonia Elks
SOFIA, Bulgaria, June 7 (Thomson Reuters Foundation) - When an LGBT+ charity wanted to do something about soaring rates of HIV among gay men in socially conservative Bulgaria, they turned to an unlikely ally - the dating app Grindr.
Seeking to target sexually active gay men who might not otherwise get checked, the charity offered free HIV self-testing kits to all Grindr's users in the eastern European country.
"People don't get tested because of stigma," said Ivan Dimov of Single Step, the LGBT+ youth charity behind the project.
"Testing is associated with sexuality ... Going to a testing facility outside of Sofia in a way equates to revealing to that small community that you live in that you are gay."
HIV infections are falling across the world, but eastern Europe is bucking the trend - there, the annual number of new HIV infections has roughly doubled over 20 years.
In Bulgaria, the number of gay and bisexual men being infected is rising by nearly a third year-on-year, showed data from the health ministry presented at a conference last week.
"If this continues, it will turn into an epidemic," said Professor Hristo Taskov from the National Centre for Infectious and Parasitic Diseases.
Testing is a key part of combating HIV and AIDS: people who do not know they are positive will not get access to treatment to preserve their own health and may also put partners at risk.
People who are unaware they have HIV are more likely to have unprotected sex, risking the spread of infection further, found a 2014 study in Mozambique.
Although HIV tests are anonymous, patients in Bulgaria were often required to identify themselves when they entered a health centre and reveal where they were going, said Momchil Baev, the sexual health programme manager at Single Step.
HIV testing vans used in rural areas were also highly visible and associated with stigma, he said.
The consequences of being outed could be devastating, especially outside the biggest cities, said gay men and LGBT+ health experts.
"I came out at age 17 and my mother took me to a psychiatrist to try to 'mend' me," said one gay man living in Sofia, who asked not to be identified.
"Society is homophobic in general and HIV is a complete taboo," he told the Thomson Reuters Foundation.
Coming out in rural areas is "absolutely impossible" , said Elena Birindzhieva from the LGBT+ health centre CheckPoint Sofia.
"There can be physical violence, there can be verbal aggression," she said.
Self-testing kits, which look and function much like home pregnancy tests, solve that problem by allowing complete anonymity.
Users must swipe saliva from their gums using a wand. After 20 minutes a window on the wand's handle will display one line if the test is negative and two lines if it is positive.
Grindr users were asked to fill in a survey giving basic details and were then able to order a test sent by post.
The test came with advice on HIV transmission risk, and Single Step ran a 24-hour hotline during the project to offer advice and support to those who tested positive.
More than half the 1,500 people who filled out the initial survey said they did not know their HIV status and about one in four said they never or rarely used a condom.
Almost one in three said they had never been tested for HIV before, and a further quarter had not checked their status in more than a year.
A total of 900 people ordered tests and 332 people reported their results back to Single Step, of whom ten tested positive and were diagnosed with HIV.
"I am very proud of this campaign because we really designed it to address a problem," said Dimov.
"Together we designed something very pragmatic."
The project was among a handful experimenting with HIV self-testing aimed at LGBT+ people.
A similar scheme to distribute tests via popular gay dating websites is currently taking place in the Czech Republic.
A study looking at another pilot targeting Grindr users in the U.S. city of Los Angeles in 2014 concluded such schemes had "high potential to reach untested high-risk populations".
Some critics have pointed out that asking users to test at home leaves them without expert support if they are positive.
There are also data risks for schemes run through social media - Grindr was thrust into a scandal last year when it emerged it had been sharing users' HIV status data with third-party app performance companies.
Grindr has stressed the data was only used to test new features and was never sold or available to advertisers.
Taskov also raised concerns over cost, saying the self-tests were considerably more expensive than a standard blood test.
However, advocates say that prevention is cheaper than treatment and HIV home tests have been commended by the World Health Organization, which says they have potential to reach groups who might not otherwise check their status.
"We wholeheartedly support widespread access to self-testing, ideally with free distribution campaigns focusing on populations most affected by HIV," said Daniel Simoes of the HIV testing initiative EuroTEST.
Single Step hoped their work could act as a model for other nearby countries facing similar issues over stigma, and they are already in talks with an LGBT+ group in Romania aimed at helping them to launch a similar scheme.
"It's not just this one little pilot project - I really think it can have wider impact," said Dimov.
(Reporting by Sonia Elks @soniaelks; Editing by Claire Cozens. Please credit the Thomson Reuters Foundation, the charitable arm of Thomson Reuters, that covers humanitarian news, women's and LGBT+ rights, human trafficking, property rights, and climate change. Visit http://news.trust.org)
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