Optimizing Veteran-Facing Materials for Vending Machine-Dispensed HIV Self-Testing: Formative Qualitative Study

Introduction

HIV screening is a critical component of prevention and early diagnosis, yet many US veterans experience barriers to routine testing [1]. Prior qualitative work in the Veterans Health Administration (VHA) suggests that concerns about stigma, confidentiality, and access can influence whether veterans seek HIV testing or follow-up care [1]. At-home HIV self-testing (HIVST) offers a complementary strategy that can expand options for screening outside traditional clinic encounters and may be particularly acceptable for individuals who prefer privacy and convenience [2]. However, HIVST remains a relatively novel approach among veterans and in VHA settings, and research studies evaluating HIVST programs must communicate clearly what participation involves and what to do after testing. Published evaluations of HIVST in veteran populations and within VHA settings remain limited, with much of the HIVST evidence base focused on nonveteran populations and distribution models outside federal health systems [3,4]. In addition, while vending machine (VM) distribution of HIVST kits has been examined outside the United States in nonveteran populations and community-based settings, there is minimal published evidence on VM HIVST kit delivery for US veterans [5,6].

Veterans are an important population for low-barrier HIV screening because HIV prevention and testing needs may intersect with mental health conditions, substance use, housing instability, rural residence, transportation barriers, and concerns about confidentiality [1]. Although the VHA provides integrated HIV prevention and treatment services, prior work suggests that routine HIV testing can still be affected by patient-, clinician-, and system-level barriers [7,8]. For veterans who prefer privacy or are not reached during routine clinical encounters, VM-based HIVST may offer a complementary access point within Veterans Affairs (VA) and VA-partnered settings [9].

Given the relative novelty of HIVST, and particularly VM-based HIVST kit distribution in VHA settings, formative input from veteran advocates living with HIV can strengthen implementation readiness by ensuring that participant-facing materials are understandable, acceptable, and actionable [10,11]. Structured veteran feedback can identify unclear terminology, confusing participation pathways, overly dense content, or language that inadvertently increases stigma, and it can guide revisions that reduce burden and improve usability. Despite increasing interest in low-barrier HIVST kit distribution models, including VM distribution, few reports describe how veterans are engaged to refine recruitment, educational, and data collection methods before a program launch, limiting reproducibility and the ability to translate these approaches into other VHA settings.

The objective of this formative study was to elicit structured feedback from a small group of veteran advocates living with HIV on recruitment, educational, survey, and interview materials for a VHA pilot evaluation of VM-dispensed HIVST kits and to transparently document how this feedback informed prelaunch revisions to these study materials.

Methods

Study Design and Setting

This was a formative qualitative study using a participatory action research [12-14] approach to refine veteran-facing recruitment and study materials prior to the launch of a pilot evaluation of VM-dispensed HIVST kits [10,11,15]. This approach was grounded in the premise that individuals with lived experience can identify potential barriers, unclear language, and acceptability concerns that may not be apparent to study teams before implementation [12-14]. Consistent with the formative purpose of the study, the analysis prioritized actionable feedback for material refinement rather than theory generation or broad characterization of veteran perspectives [10,11,15]. Reporting was guided by relevant qualitative reporting principles, and a completed SRQR (Standards for Reporting Qualitative Research) checklist is provided as Multimedia Appendix 1 [16]. The parent study is a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance)-guided preimplementation and implementation evaluation of oral-fluid HIVST kits distributed through preexisting VMs in VA health care and supportive housing settings [9].

This work was conducted at the San Francisco VA Health Care System, which serves more than 310,000 US veterans at the San Francisco VA Medical Center and 9 community-based outpatient clinics located in downtown San Francisco, Oakland, San Bruno, Santa Rosa, Clearlake, Ukiah, and Eureka, California. In the parent program, HIVST kits are stocked in 15 VMs located at the San Francisco VA Medical Center, community-based outpatient clinics (except San Bruno), and 6 partnered supportive housing buildings. Veteran advocate review activities were completed remotely (asynchronous written feedback and a virtual focus group), enabling participation across the San Francisco Bay Area.

Participants and Recruitment

We used participatory action research methodology to recruit 4 veteran advocates with HIV who resided in California [12-14]. Because the goal was targeted prelaunch materials refinement rather than thematic saturation or representative sampling, the study used a small purposive sample of veteran advocates to identify actionable feedback before implementation. Veterans were recruited through 2 nurse practitioners with expertise in HIV prevention and treatment who were embedded in outpatient primary care and infectious diseases clinics. Referred veterans were contacted by phone to solicit interest and participation (August 2025).

Veteran advocates living with HIV were intentionally recruited because the study team sought feedback from veterans with experience navigating HIV-related stigma, testing, disclosure, linkage to care, and VA-based HIV services. Their perspectives were considered particularly relevant for identifying language, design elements, and follow-up instructions that could reduce stigma and support veterans who may test alone outside a clinical encounter. However, because all reviewers were living with HIV, their baseline HIV knowledge and prior testing experiences may differ from those of veterans who have never tested, test infrequently, or have limited HIV knowledge.

We did not collect individual sociodemographic characteristics because this was a small, prelaunch formative materials review rather than a study designed to characterize veteran perspectives. Collecting detailed demographic information could have increased identifiability among a very small group of veteran advocates recruited through local HIV care networks. No minimum descriptive categories were reported because, with only 4 participants, even broad combinations of characteristics could risk deductive disclosure.

Study Materials for Review

Research study materials for review by veteran advocates included recruitment flyers (Multimedia Appendix 2), education handouts (Multimedia Appendix 3), an electronic web-based questionnaire (Multimedia Appendix 4), and a semistructured qualitative interview guide (Multimedia Appendix 5). Table 1 describes the initial design plan and features of the study materials, which were developed collaboratively by the study principal investigator (PI) and program manager.

Procedures

In September 2025, veterans were mailed electronic and paper copies of a feedback instructions sheet (Multimedia Appendix 6), a feedback documentation form (Multimedia Appendix 7), and research study materials. Veterans were instructed to mail (paper or electronic) copies of the feedback form in advance of the focus group with a 2-week turnaround time.

The research study team independently reviewed and collaboratively discussed feedback forms received prior to the focus group, which was held virtually via Zoom (Zoom Communications) for 1 hour, and was audio recorded and transcribed (September 2025). The focus group was moderated by the study PI using a standardized script, and an assistant moderator provided technical support, monitored the chat, and took notes [9]. The moderator and assistant moderator debriefed immediately after the focus group [18].

Feedback Prompts

The feedback documentation form and focus group guide included structured, open-ended prompts tailored to each study material. For the recruitment flyers, veterans were asked whether the flyer answered key questions about the study (eg, what the study is about, what participation involves, why it matters, eligibility, and how to get involved), and to comment on visual relevance and representation (including veterans and diverse populations), attention-grabbing design, readability and technical language, and ease of acting on the information (including the usefulness of the QR code and website and low-tech alternatives), along with concrete suggestions to improve engagement.

For the education handouts, prompts asked for overall impressions, relevance, clarity (including confusing sections), appropriateness of the educational level, and recommendations to remove or add materials and make the handouts more engaging. For the web-based questionnaire, veterans were asked about their overall experience and first impressions, relevance, clarity and flow, perceived intrusiveness (including whether questions about HIV self-test results felt intrusive), completion time, device used, technical issues, ease of completion, and suggestions to improve engagement and user-friendliness. For the qualitative interview guide, prompts focused on overall impressions, relevance, clarity and flow, intrusiveness, recommended deletions or additions, wording changes, and ways to make the interview more engaging. During the focus group, the moderator followed the same topical structure and used standard probes (eg, asking participants to elaborate or provide examples) to clarify and deepen feedback.

Researcher Characteristics and Reflexivity

The study PI is a clinical pharmacist practitioner and harm reduction coordinator involved in the parent HIVST VM program and moderated the focus group. Because the study team developed the materials under review, we used structured feedback forms, a standardized focus group guide, team debriefing, and an audit trail–based revision matrix to support reflexivity and reduce the risk that revisions reflected only study team assumptions.

Qualitative Analysis

We analyzed written veteran advocate feedback documents and the transcript of the audio-recorded focus group using a rapid, team-based consensus thematic approach designed for formative refinement of study materials [10,11,19,20]. Given the small number of veteran advocates and feedback sources, we did not develop a formal codebook or conduct independent line-by-line coding. Instead, 2 study team members independently reviewed each feedback source in full and documented key recommendations and candidate feedback domains using analytic notes. The team then met to discuss areas of convergence and divergence, iteratively cluster feedback into domains, and reach consensus on final domain labels and their definitions [21,22].

To ensure findings directly informed materials improvement, we created a revision matrix that mapped each feedback domain to (1) the specific study material it applied to, (2) a summary of the feedback, and (3) the resulting change or changes made. This matrix served as an audit trail linking veteran feedback to specific adaptations and informed the “feedback and revisions” tables presented in the Results section [23]. We enhanced rigor through team debriefing, documentation of analytic decisions and revisions in the matrix, and triangulation across written and group feedback sources. We did not conduct participant checking because the purpose was rapid prelaunch materials refinement, and revisions were needed before implementation. To reduce the risk of deductive identification in this small sample, we present concise paraphrased examples of feedback rather than verbatim quotes. Accordingly, findings are reported as actionable feedback domains for material refinement rather than as fully saturated qualitative themes. Feedback domains and recommendations were translated into proposed edits by the study PI, then reviewed by the study team via electronic review and verbal discussion and iteratively revised by the PI until a consensus was reached.

Data Storage

Collected data were stored in password-protected files on the San Francisco VA Health Care System network, and access was restricted to research study staff. Veteran advocates were assigned alpha-numeric identifiers, and files with identifying information will be destroyed upon study completion.

Ethical Considerations

We obtained approval from the University of California, San Francisco Institutional Review Board and the San Francisco Veterans Affairs Human Subjects Committee in August 2025 (25-43931). Veteran advocate participants provided verbal consent to participate and received compensation aligned with the time commitment for each activity (written material review and focus group participation) per protocols; 1 participant completed electronic material review only and received the written-only compensation amount.

Results

Four veteran advocates completed the structured written review of the study materials. Three of the 4 also participated in the 1-hour virtual focus group; 1 completed the written review only [10]. Because the activity was designed to refine study materials before launch rather than to generate generalizable themes, results are presented as summarized, paraphrased feedback domains and linked to material revisions in Tables 2-5.

For the recruitment flyer, veterans emphasized the need to clarify the flyer’s purpose and why participation matters beyond compensation, strengthen the call to action, and simplify eligibility and participation instructions. They also recommended reducing technical language and overall text density, updating the layout, and using imagery that more clearly reflects veterans and diverse representation. Finally, veterans supported the use of a QR code while recommending low-tech alternatives and clearer contact options and noted the importance of avoiding confusion between research recruitment and promotion of HIVST. Revisions to address these points are summarized in Table 2. Compared with the initial flyers, the revised flyer (Multimedia Appendix 8) substantially reduced procedural detail and reorganized content into brief, labeled sections that clearly separated survey versus interview pathways, highlighted compensation in plain language, and provided a simplified “getting started” call to action. Veterans also recommended making the paid nature of the study more visually salient (eg, adding dollar signs and/or images to emphasize compensation); however, these visual elements could not be incorporated due to institutional review board–related requirements.

Veteran advocates recommended streamlining the education packet to better align with at-home HIVST (rather than testing with a health care provider) and prioritize clear, actionable next steps (how to use the test, how to interpret results, and where to seek support); in response, we reduced the number and length of handouts, replaced clinic-oriented rapid oral testing materials with a self-test instruction sheet and a results and support handout, and condensed the community-based resource information while adding clear VA follow-up and crisis support resources (Multimedia Appendix 9). Revisions, including reducing the number of handouts and improving visual cohesion, are summarized in Table 3.

Veteran advocates recommended reducing questionnaire length and redundancy to minimize burden and improving clarity and usability; in response, we removed multiple items assessing perceived comfort, effort, and satisfaction with accessing HIV self-tests via the VM and clarified several question stems and response formats (eg, allowing “select all that apply” for HIV self-test use plans, testing location, and next steps) while retaining sensitivity safeguards such as “prefer not to answer” options (Multimedia Appendix 10). Content and formatting updates are described in Table 4.

For the qualitative interview guide, veterans perceived the guide as long, repetitive, and recommended consolidating overlapping sections and improving flow with clearer transitions. Feedback also supported more participant-centered, trauma-informed framing (eg, a reassuring introduction and language that reduces the risk of participants feeling judged or coerced). Veterans recommended optional questions about emotional reactions and support needs, and revisions also emphasized participant autonomy (eg, the ability to skip questions, take a break, or stop). Compared with the original interview guide, the revised guide (Multimedia Appendix 11) was reorganized into clearly labeled sections, streamlined to reduce redundancy, and strengthened with participant-centered, trauma-informed language (eg, reminders that participants may skip questions, take breaks, or stop), with added probes addressing privacy and surveillance concerns, emotional reactions to results, and support needs (Table 5).

Separate from veteran advocate feedback, the study team incorporated team-driven refinements identified during internal review to strengthen implementation-relevant domains, including more specific probes addressing privacy and surveillance concerns and barriers and facilitators to confirmatory testing and follow-up care. On the basis of early interview scheduling contacts, the study team also added questions to capture peer-to-peer distribution and support (eg, whether the HIV self-test was obtained for oneself or someone else, experiences helping another person use the test, and what resources would make peer support feasible and safe).

Across study materials, feedback consistently prioritized clarity, reduced burden, modernized graphics and formatting, and actionable next steps and resulted in concrete revisions to improve the comprehensibility and usability of veteran-facing materials.

Discussion

Principal Findings

This formative study provides a transparent example of prelaunch materials refinement for a VA-based HIVST evaluation. Structured input from a small purposive sample of veteran advocates living with HIV helped identify potential points of confusion and opportunities to improve participant-facing materials. Given the limited sample size, findings should be interpreted as targeted formative feedback on specific study materials rather than evidence of broader veterans’ preferences or the effectiveness of the revised materials. Within this scope, the feedback helped the study team revise recruitment, education, survey, and interview materials to improve clarity, reduce burden, and better communicate participation steps and follow-up options.

In addition to veteran advocate–informed revisions, the study team incorporated refinements identified through internal review and early operational learnings (eg, probes addressing privacy and confidentiality considerations, confirmatory testing and follow-up barriers and facilitators, and emerging peer-support scenarios). We describe these as team-driven updates to maintain clear attribution and transparency regarding the source of revisions. This distinction is important because formative evaluation often involves iterative cycles that integrate stakeholder feedback with implementation team learning as programs move toward launch [10].

These findings align with the formative evaluation and acceptability methods literature demonstrating that early, stakeholder-engaged approaches can improve the clarity, acceptability, and usability of participant-facing materials and study procedures prior to implementation [10,18]. Prior formative and qualitative studies of VM delivery models for HIVST similarly suggest that uptake and acceptability are shaped by end-user experience at the point of contact, including whether materials and processes are understandable and easy to navigate [24]. Participatory design work focused on HIVST communication tools also underscores the value of iteratively refining instructions and support for results interpretation to reduce user error and improve understanding [25].

For VA and similar health system settings, this work suggests that participant-facing materials should be treated as implementation components rather than administrative add-ons. In a low-barrier HIVST model, materials may shape whether veterans understand the purpose of the program, know how to use the test, feel comfortable completing study activities, and know where to seek confirmatory testing or support. Simple, low-cost adjustments, such as shorter text, clearer headings, fewer redundant questions, and materials organized around the real sequence of actions veterans take, may reduce friction during recruitment, self-testing, and follow-up.

More broadly, this formative activity contributes to efforts to expand low-barrier, patient-centered HIV prevention and screening options, particularly for populations who may experience stigma or access constraints in traditional clinical pathways. As VA and other health systems explore novel distribution models, including VM-based access points, this formative work highlights the importance of evaluating not only the physical availability of the tests but also how clearly programs communicate purpose, steps, and follow-up options.

This study has limitations. First, the formative sample was small, consisting of 4 veteran advocates, 3 of whom participated in the focus group and 1 of whom completed the written review only. The purpose of the activity was to refine study materials before launch, not to generate representative or generalizable findings about all veterans who may use VM-dispensed HIVST kits. Findings should therefore be interpreted as targeted formative feedback from a small advisory group.

Second, all veteran advocates were living with HIV. This was intentional because the study team sought input from veterans with lived experience navigating HIV-related stigma, testing, linkage to care, and VA HIV services. However, veterans living with HIV may have greater baseline HIV knowledge, more familiarity with testing and treatment systems, and different perceptions of HIVST materials than veterans who have never tested, test infrequently, or have limited HIV knowledge. Future materials testing should include veterans not living with HIV, including those with varying levels of HIV knowledge and prior testing experience.

Third, we did not collect sociodemographic characteristics. This decision was made to reduce identifiability in a very small group recruited through local HIV care networks. However, the absence of demographic information limits our ability to assess transferability across age, gender identity, race and ethnicity, sexual orientation, rurality, housing status, digital access, HIV testing history, and prior experience with VA care. Future work should include larger and more diverse samples that allow the reporting of participant characteristics while maintaining confidentiality.

Fourth, data were collected through a structured written review and one virtual focus group. This approach was practical for prelaunch materials refinement but provided limited opportunity for repeated rounds of feedback, usability testing, or formal assessment of comprehension. Fifth, our rapid, team-based consensus thematic approach did not include a formal codebook or independent line-by-line coding. This approach was appropriate for a small formative dataset focused on actionable revisions, but it may reduce reproducibility compared with more intensive qualitative analytic methods. We mitigated this limitation by maintaining an audit trail–based revision matrix linking domains to material changes. Finally, this study documents material refinement prior to launch and does not evaluate whether the revised materials improved downstream outcomes, including understanding or comprehension, recruitment yield, survey or interview completion, self-testing behavior, or linkage to confirmatory testing or care. These outcomes will be assessed in the parent implementation evaluation.

Conclusions

In this formative prelaunch study, feedback from a small group of veteran advocates living with HIV was systematically mapped to revisions in recruitment, educational, survey, and interview materials for a VA VM-based HIVST study. Veteran advocates prioritized plain-language messaging, reduced burden, clearer separation between research participation and self-testing, actionable next steps, and support framing for veterans testing outside clinical encounters. Although findings are not intended to represent all veterans or demonstrate implementation impact, this work provides a transparent, adaptable example of how stakeholder feedback can be systematically mapped to veteran-facing HIVST material revisions before implementation.