Service bundling as an innovative strategy to increase HIV screening among African-born persons in the US

Background: The number of African-born persons in the US increased from 0.2 to over 1.5 million between 1980 and 2009, reflecting the same period as the expansion of the epidemic in Africa. Despite this, there is a dearth of research addressing this population's HIV screening needs, and screening rates remain low. Methods: Researchers and community partners conducted focus groups among African-born persons in New York to uncover barriers and potential facilitators of screening. We recruited 33 African-born persons (45% women) representing a wide range of African immigrants, including taxi drivers, hair-braiders, street-vendors, students, mosque and church attendees. Four focus groups were held at a community-based organization and were audiotaped, transcribed, and translated from French and Wolof to English. Results: Transcript coding guided by grounded theory analysis using ATLAS.ti® identified three previously described themes: fear of deportation; misinformation about treatment; and HIV stigma. We also identified three novel themes: 1) perceptions of public health messaging directed exclusively to Africans as stigmatizing; 2) preference for non-African counselors and testers to decrease risks of loss of confidentiality; and 3) offering additional services along with HIV screening (service bundling) makes testing more acceptable and reduces stigma of testing. Discussion: We found that culturally-tailored HIV screening that exclusively targets African immigrants, and ethnically similar counselors and testers can paradoxically lead to concerns about being stereotyped and loss of confidentiality. We also identified a novel strategy of bundling of HIV screening with other services that attenuates these concerns and increase the acceptability of HIV testing.