PSQI-based severity-ordered sleep-quality strata and associated clinical and psychosocial factors among adults with untreated obstructive sleep apnea: a multicenter cross-sectional study.

Men in fishing communities along Lake Victoria, Kenya, where HIV prevalence reaches up to 31%, remain disproportionately affected by HIV and are persistently underserved by conventional testing, prevention, and treatment services (; ; ; ). Fishermen face unique social and structural barriers, including occupational mobility, HIV stigma and limited clinic use, contributing to low rates of HIV status awareness, prevention uptake and engagement in HIV care (; ; ; ; ). In Siaya County, only 61% of adult men living with HIV were virally suppressed in 2019, compared to 74% of women, indicating a gender gap in treatment access and adherence (). Prior qualitative research has documented low awareness and misconceptions about HIV prevention options such as pre-exposure prophylaxis (PrEP) among fishermen, suggesting limited engagement with prevention services even when testing occurs (). These service gaps underscore the need for targeted, scalable strategies to enhance uptake of services across the HIV care continuum. HIV self-testing (HIVST) has the potential to facilitate progress toward the UNAIDS 95–95-95 targets by offering a convenient and private testing option for populations that are otherwise difficult to reach (; ). HIVST has shown promise as a tool to increase testing coverage among men who are less likely to access facility-based services (; ). However, increased testing does not necessarily translate into engagement with HIV prevention or treatment services. A 2023 systematic review of HIVST implementation in sub-Saharan Africa identified inconsistent patterns of post-test linkage, highlighting persistent behavioral and structural barriers (). A more recent global systematic review and meta-analysis similarly found that while HIVST increases uptake of HIV testing, the effects on linkage to confirmatory testing, prevention and treatment services vary widely, with multi-component interventions with those combining HIVST with financial incentives, peer or lay provider follow-up and facilitated referral demonstrating the most promise (). Barriers to linkage most frequently cited for men in sub-Saharan Africa encompass travel-related expenses (; ; ), lengthy clinic wait times (; ), experiences of stigma and discrimination and worries about maintaining privacy (; ). Incentives () and social support () have emerged as potential facilitators. In fishing communities, these barriers are intensified by high mobility, economic precarity and gendered norms that may prioritize income generation and breadwinning over preventive healthcare, unless illness threatens the ability to work (). Despite growing recognition that linkage is a critical bottleneck following HIVST, few studies have examined how men in highly mobile fishing communities navigate decisions about confirmatory testing, PrEP initiation, or ART engagement after self-testing.