Abstract
Background
HIV/AIDS has claimed over 40.1 million lives, including youths aged 15–24 years, since the start of the epidemic in 1981. Sadly, there are still reports of poor retention in care and poor viral load suppression among the youths. Youth-friendly HIV services are intended to improve engagement in care among adolescents and young people living with HIV, but evidence on how perceived satisfaction with these services relates to retention and viral suppression in routine tertiary care remains limited. This study assessed the youths’ satisfaction with youth-friendly services (YFS) and their relationship with retention in HIV care and viral load suppression at the HIV clinic, UNTH, Enugu.
Methods
This cross-sectional survey was linked to retrospective abstraction of routine clinical data from electronic medical records. The study included all 178 active youths aged 15–24 years who received HIV care at the ART clinic between July 2022 and June 2023 and met the inclusion criteria. Satisfaction with youth-friendly services was assessed using a structured questionnaire, while clinic visit records and the most recent viral load results were abstracted from medical records. Good retention was defined as three or more documented clinic visits within the 12 months. Viral suppression was defined as viral load < 1000 copies/mL. Associations were assessed using Chi-square or Fisher’s exact tests, as appropriate.
Results
Among 178 youths, 169 (94.9%) were very satisfied with youth-friendly services, 159 (89.3%) had good retention in care, and 164 (92.1%) achieved viral suppression. Satisfaction with youth-friendly services was not significantly associated with retention in care (Fisher’s exact p = 1.000). In unadjusted analysis, retention in HIV care was significantly associated with viral load suppression (χ²=34.616, p < 0.001).
Conclusion
YFS were well rated among active youths in care, but satisfaction was not associated with retention. The findings suggest that maintaining clinic engagement may be more directly linked to viral suppression than satisfaction ratings alone. Because inactive or disengaged youths were not included, the results should be interpreted cautiously and are not generalisable to all youths enrolled in HIV care.
Clinical trial number
Not applicable.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-15182-x.
Keywords: Satisfaction, Youth-friendly services, Retention in HIV care, Viral load suppression
Introduction
Worldwide, HIV remains a major public health challenge for adolescents and young people. In 2022, an estimated 39.0 million people were living with HIV globally, including 37.5 million individuals aged 15 years and older [1]. Sub-Saharan Africa continues to bear the greatest burden of infection. Young people remain disproportionately affected [2, 3]. In Nigeria, the national HIV prevalence is estimated at 1.4%. Still, adolescents and youths remain vulnerable because of biological, behavioural, psychosocial, and structural factors that influence HIV acquisition, care-seeking, adherence, and retention in treatment [4, 5]. Although antiretroviral therapy (ART) has transformed HIV into a manageable chronic condition, its effectiveness depends on sustained engagement in care, adherence to treatment, and viral load suppression [6, 7].
Retention in HIV care is particularly challenging among adolescents and youths. Poor health-seeking behaviour, dependence on caregivers for clinic attendance, stigma, competing educational or social demands, and limited autonomy may interrupt regular clinic visits and medication adherence [5, 8, 9]. To address these barriers, youth-friendly services (YFS) were introduced to make HIV care more acceptable, accessible, equitable, appropriate, and effective for young people [9, 10]. Youth-friendly HIV service models include meaningful youth participation in programme design, flexible clinic hours, peer-led support, youth centres or youth corners, mobile or community-based HIV testing, digital adherence counselling, affordable or free services, school–clinic linkages, privacy, confidentiality, and trained providers who understand the needs of adolescents and young adults [10, 11].
Youth-centred service delivery represents a shift from provider-driven care to more participatory, client-responsive models. Evidence from youth HIV programmes shows that peer engagement, digital communication, differentiated service delivery, and supportive clinic environments can improve linkage to care, engagement in care, and retention in care [10, 12]. The Operation Triple Zero model, first implemented in Kenya, further illustrates this approach by encouraging adolescents and youths to achieve zero missed appointments, zero missed medicines, and zero viral load [13]. Despite these innovations, gaps in retention and viral suppression remain, suggesting that service availability alone may not be sufficient if young people are dissatisfied with the quality, accessibility, confidentiality, or responsiveness of care.
Client satisfaction is an important dimension of healthcare quality and may influence whether young people remain engaged in HIV services. Satisfaction with YFS may reflect whether services meet young people’s expectations regarding respectful treatment, privacy, convenience, peer support, counselling, affordability, and access to information. Dissatisfaction with care can contribute to missed visits, disengagement from treatment, and poor continuity of care [14, 15]. In HIV care, sustained engagement is essential because interruption of ART may lead to poor adherence, unsuppressed viral load, increased risk of HIV transmission, opportunistic infections, drug resistance, treatment failure, and avoidable morbidity and mortality [16, 17].
Globally, poor retention in care remains a major barrier to achieving the UNAIDS 95-95-95 targets, particularly the goals related to sustained treatment coverage and viral suppression [18, 19]. Young people are among the groups most likely to experience interruptions in care, and studies have documented suboptimal retention and viral suppression among adolescents and youths despite the expansion of HIV treatment programmes [6, 20–22]. In Nigeria, viral suppression among PLHIV aged 15–49 years remains below optimal levels, with young people contributing substantially to this gap [4]. Understanding how youths experience YFS is therefore important for improving service quality, strengthening retention, and supporting viral suppression.
This study assessed satisfaction with youth-friendly HIV services. It explored its relationship with retention in HIV care and viral load suppression among youths attending the ART clinic at the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, Nigeria. To our knowledge, evidence from south-eastern Nigeria on the relationship between perceived satisfaction with youth-friendly HIV services, retention in care, and viral load suppression among young people in routine tertiary HIV care remains limited. The findings are expected to provide context-specific evidence to guide quality improvement, strengthen youth-centred HIV service delivery, and inform interventions aimed at improving retention and viral suppression among adolescents and youths living with HIV.
Methods
Research design
This study employed a cross-sectional survey design combined with retrospective abstraction of routine clinical data from electronic medical records. Because exposure-outcome relationships were assessed at a single analytic time point, causal inference cannot be established.
Area of study
The study was carried out at the University of Nigerian Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State, Nigeria. It is a tertiary health institution and the biggest referral teaching hospital in South-Eastern Nigeria. It operates many speciality clinics, theatres, and wards. This study was confined to one clinic, the ART (also known as HIV) clinic.
ART clinic is a comprehensive ART centre with three sub-clinics: paediatric, adult, and PMTCT. The pediatric unit is the ART centre where HIV-positive infants, children, adolescents and youths receive HIV care. The youth-friendly centre is located in the pediatric unit and focuses on adolescents and young adults (ages 10 to 24). The clinic adopted and commenced the OTZ programme at UNTH in March 2020 to render YFS to empower the young people living with HIV to own their health care by enhancing retention in care, adherence to treatment and viral suppression.
Study population
The source population comprised youths aged 15–24 years who were registered for HIV care at the ART clinic. For this analysis, the accessible study population was restricted to youths who were active in care during the July 2022 to June 2023 observation period and who attended the clinic during data collection. Youths who were lost to follow-up, transferred out, deceased, inactive, or not attending during the data collection period were not included. This restriction may have led to overestimation of satisfaction, retention, and viral suppression.
Participants of the study
The participants for the study were 178 youths (15–24 years) who were active and had completed one year in the study area before the present study. Hence, the total population (census) was used, utilising the inclusion criteria. The data was collected consecutively.
STROBE and RECORD flow diagram
Registered youths aged 15–24 years in the ART clinic during July 2022–June 2023.
↓
Excluded: transferred out, deceased, inactive/lost to follow-up, incomplete records, declined participation.
↓
Eligible active youths approached.
↓
Consented/assented and completed the questionnaire.
↓
Included in final analysis: n = 178.
The total number of registered youths aged 15–24 years at the beginning of the observation period could not be reliably reconstructed from the available records; therefore, the denominator for this study was the 178 active youths identified in the clinic EMR and available for survey participation.
Inclusion criteria
All the youths aged 15–24 years who were enrolled in the ART clinic and had completed one year in the study area before the present study.
Those who gave their consent. Participants below 18 years were given assent forms, and their caregivers were available to sign their consent forms.
Instrument for data collection
Two instruments were used for data collection: a structured questionnaire and a pro forma.
The Structured Questionnaire: Appendix 1 (Supplementary File)
The researcher developed the self-administered questionnaire. It was constructed from a literature review aligned with the study’s objectives.
The questionnaire consists of two sections: A and B.
Section A consists of seven (7) questions (1–7) to elicit participants’ sociodemographic characteristics.
Section B consists of twenty-three (23) questions (8–30) to assess the level of satisfaction of the youths with YFS. It was adapted from the 8 domains of the “Best Practices for Adolescent- and Youth-Friendly HIV services – A compendium of Selected Projects in PEPFAR-Supported Countries” [11]. The instrument enabled the clients to rate how satisfied they were with care, and the extent of agreement/disagreement on statements about the friendly services they received from the facility. The options were rated on 4-point Likert scales from “very satisfied to very dissatisfied”; “extremely helpful” to “not at all helpful”; “strongly agree to strongly disagree”.
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2.
Proforma:
A pro forma was designed by the researcher to abstract data from hospital records. It was designed to suit the abstraction of the number of clinic visits in the 12 months before this study and the value of the most current viral load results of the youths seen at the HIV clinic. The children are seen at least once quarterly (July – September, 2022; October – December, 2022; January – March, 2023 and April – June 2023). The data were used to assess the outcomes of care, which include ‘rate of retention in HIV care’ and ‘viral load suppression rate among the youths.’
The number of documented clinic visits over the 12 months was used to assess retention in care. Because the routine clinic schedule was quarterly, four visits were expected. For the primary analysis, good retention was defined as ≥ 3 documented visits, reflecting sustained engagement despite possible missed or rescheduled appointments. Poor retention was defined as ≤ 2 visits. The most current viral load results from July 2022 to June 2023 were abstracted from the hospital records. Viral load results were first described in three categories: target not detected, detectable but < 1000 copies/mL, and ≥ 1000 copies/mL. For binary analysis, viral suppression was defined as viral load < 1000 copies/mL, including both target-not-detected and detectable results below 1000 copies/mL. Viral non-suppression was defined as ≥ 1000 copies/mL.
Validity of the instrument
3 HIV care experts assessed the instrument’s face and content validity at the institution. Face validity was assessed by evaluating the clarity of the statements and whether the questions applied to and were reasonable for the population being studied. As face validity is not strong evidence of a new instrument’s validity [23], content validity was also conducted to ensure the instrument was adequate for achieving the study objectives.
For content validity, the 3 validators were asked to complete 3 validation forms containing the questionnaire items, using a 2-point relevance scale (0 = not relevant; 1 = relevant) [23]. The experts rated 1 on each of the items. For each item, the item content validity index (I-CVI) was computed as the number of validators who scored 1, divided by the total number of validators. Then, the average of all I-CVIs was calculated, yielding a validity index of 1, which is considered adequate [23].
Reliability of the instrument
A reliability test was done on the instruments to ensure consistency, quality and adequacy [23]. The researcher obtained an administrative permit from the youths’ HIV clinic, Enugu State University Teaching Hospital (ESUTH), Parklane, Enugu State, another Teaching Hospital in Enugu metropolis that offers comprehensive HIV care.
A pilot test was conducted with 24 youths (10% of the 244 participants from the original sample obtained from the Electronic Medical Records of their HIV clinic) who met the inclusion criteria. The data from the pilot testing were subjected to Split-half reliability statistics, a measure of internal consistency that assesses how consistent an instrument is when divided into two halves. Hence, the items of the instrument were divided into two halves (odd numbers and even numbers). The correlation was calculated, yielding a Spearman-Brown coefficient of 0.922. The instrument showed high split-half reliability in pilot testing, with a Spearman-Brown coefficient of 0.922. Because of the limited sample size and sparse response variation in some domains, domain-specific internal consistency estimates were not calculated, and this is acknowledged as a limitation.
Ethical consideration
This study was conducted in accordance with the Declaration of Helsinki. Ethical clearance was received from the Health Research Ethics Committee of UNTH (NHREC/05/01/2008B-FWA00002458-1RB00002323). Approval was granted on 4th October 2023, before data abstraction. Written informed consent was obtained from participants (aged 18 years or older) and caregivers (of participants aged 15–17 years old), while assent was obtained from participants aged 15–17 years old. Questionnaires were completed privately, and responses were anonymised to protect adolescents’ confidentiality during participation.
Procedure for data collection
For the first part of data collection, a list of all youths (15–24 years) who were active from July 2022 to June 2023 was generated from medical records. On their quarterly appointment days, participants were given the questionnaire to complete independently, while the researcher provided necessary guidance.
For the second part of data collection, using the pro forma, the researchers abstracted data on the number of clinic visits and participants’ viral load results for July – September, 2022; October 2022 – December, 2022; January – March, 2023; and April – June, 2023.
Data analysis
The descriptive statistics – frequency, percentage, mean and standard deviation were used to organise and summarise the items of the questionnaire. Likert-scale responses were summarised primarily using frequencies and percentages. Means and standard deviations were retained as supplementary descriptive summaries to allow comparison with similar satisfaction studies. The Chi-Square test with Fisher’s exact test was used to assess relationships among satisfaction levels, demographic characteristics, retention in HIV care, and viral load. The level of significance was set at p-value < 0.05. These analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 25. There were no missing data for the primary variables analysed.
Patient satisfaction score
 |
The levels of satisfaction include: 1–25% = very dissatisfied; 26–50% = somewhat dissatisfied; 51–75% = somewhat satisfied; 76–100% = very satisfied.
In summary, 1–50% shows not satisfied with care; 51–100% shows satisfied with care.
Results
Table 1 below presents the demographic characteristics of the youths. Their ages ranged from 15 to 24 years, with a mean of 19.14 ± 2.78 years. The majority of them were males (52.2%). Almost all the youths were single (97.8%). Many had secondary education (131, 73.6%) and were students (128, 71.9%).
Table 1.
Demographic characteristics of the youths (N = 178)
| Variable | Category | Frequency (n) | Percentage (%) |
|---|---|---|---|
| Age group (years) | 15–17 | 61 | 34.3 |
| 18–20 | 57 | 32.0 | |
| ≥ 21 | 60 | 33.7 | |
| Mean ± SD | 19.14 ± 2.78 | ||
| Range | 15–24 years | ||
| Sex | Male | 93 | 52.2 |
| Female | 85 | 47.8 | |
| Marital status | Single | 174 | 97.8 |
| Married | 4 | 2.2 | |
| Educational level | No formal education | 3 | 1.7 |
| Secondary | 131 | 73.6 | |
| Tertiary | 44 | 24.7 | |
| Occupation | Student | 128 | 71.9 |
| Apprentice | 30 | 16.9 | |
| Employed | 2 | 1.1 | |
| Self-employed | 12 | 6.7 | |
| Unemployed | 6 | 3.4 | |
| Place of residence | Rural | 77 | 43.2 |
| Urban | 101 | 56.8 | |
| Cost of transportation from residence to facility | ≤ ₦1000 | 77 | 43.2 |
| > ₦1000 | 101 | 56.8 |
Abbreviations: SD = standard deviation; n = frequency; N = total number of participants
Table 2 below shows the youth’s level of satisfaction with youth-friendly services rendered at the ART clinic, UNTH. Almost all the youths were very satisfied with the services (94.9%).
Table 2.
Level of satisfaction with youth-friendly services rendered at the ART clinic n = 178
| Subscale 1: Satisfaction with youth involvement | |||||
|---|---|---|---|---|---|
| Item | VD n (%) | SD n (%) | SS n (%) | VS n (%) | Mean ± SD |
| 1 - Your involvement in making the clinic a safe place where youths come together to learn and share experiences for better coping with their health condition | 2 (1.1) | 1 (0.6) | 31 (17.4) | 144 (80.9) | 3.78 ± 0.50 |
| 2 - Your involvement in HIV care, such as keeping to clinic appointments, taking medicines and monitoring treatment | 1 (0.6) | 0 (0.0) | 50 (28.1) | 127 (71.3) | 3.70 ± 0.49 |
| 3 - Some youth are being trained and used as peer educators for other youths | 2 (1.1) | 1 (0.6) | 31 (17.4) | 144 (80.9) | 3.78 ± 0.50 |
| 4 - Your involvement in designing and implementing yearly work plans for the youths | 1 (0.6) | 2 (1.1) | 45 (25.3) | 130 (73.0) | 3.71 ± 0.51 |
| 5 - Existence and usage of technological services like phone calls and WhatsApp messaging for adherence counselling and reproductive health | 4 (2.2) | 7 (3.9) | 29 (16.3) | 138 (77.5) | 3.69 ± 0.66 |
| 6 - Regular engagement with counsellors on WhatsApp platforms | 4 (2.2) | 6 (3.4) | 34 (19.1) | 134 (75.3) | 3.67 ± 0.65 |
| Key: VD = very dissatisfied; SD = somewhat dissatisfied; SS = somewhat satisfied; VS = very satisfied | |||||
| Subscale 2: Agreement or disagreement with youth-friendly service attributes | |||||
| Item | SD n (%) | D n (%) | A n (%) | SA n (%) | Mean ± SD |
| 1 - Services are made convenient for the youth by extending services to after-school hours and weekends | 69 (38.8) | 48 (27.0) | 19 (10.7) | 42 (23.6) | 2.19 ± 1.19* |
| 2 - You access information and other services for HIV, such as counselling, clinical services, skill development, TB care and reproductive health easily | 1 (0.6) | 9 (5.1) | 38 (21.3) | 130 (73.0) | 3.67 ± 0.60 |
| 3 - Free services are provided for the youths | 0 (0.0) | 8 (4.5) | 30 (16.9) | 140 (78.7) | 3.74 ± 0.53 |
| 4 - All the information needed for your care is free of charge | 3 (1.7) | 2 (1.1) | 25 (14.0) | 148 (83.1) | 3.79 ± 0.54 |
| 5 - Health workers visit schools to introduce services available in HIV care | 4 (2.2) | 11 (6.2) | 65 (36.5) | 98 (55.1) | 3.44 ± 0.71 |
| 6 - Schools visit the clinic periodically to familiarise students with the facilities | 5 (2.8) | 10 (5.6) | 60 (33.7) | 103 (57.9) | 3.47 ± 0.73 |
| 7 - Staff welcome and treat the youths with respect | 3 (1.7) | 5 (2.8) | 33 (18.5) | 137 (77.0) | 3.71 ± 0.61 |
| 8 - Staff do not discriminate against the youths | 1 (0.6) | 1 (0.6) | 36 (20.2) | 140 (78.7) | 3.77 ± 0.47 |
| 9 - Staff provide games, sports equipment and television for youths | 0 (0.0) | 3 (1.7) | 32 (18.0) | 143 (80.3) | 3.79 ± 0.45 |
| 10 - Staff reduce your clinic’s waiting time | 3 (1.7) | 4 (2.2) | 33 (18.5) | 138 (77.5) | 3.72 ± 0.59 |
| 11 - Your folder is always secured | 0 (0.0) | 2 (1.1) | 31 (17.4) | 145 (81.5) | 3.80 ± 0.43 |
| 12 - Every discussion you had with health workers is kept confidential | 0 (0.0) | 1 (0.6) | 31 (17.4) | 146 (82.0) | 3.81 ± 0.40 |
| 13 - Peer counsellors are always available in the youth clinic | 0 (0.0) | 1 (0.6) | 24 (13.5) | 153 (86.0) | 3.85 ± 0.37 |
| 14 - Peer counsellors provide counselling to children, adolescents and youths living with HIV | 0 (0.0) | 2 (1.1) | 33 (18.5) | 143 (80.3) | 3.79 ± 0.43 |
| Key: SD = strongly disagree; D = disagree; A = agree; SA = strongly agree | |||||
| Subscale 3a: Satisfaction with services received | |||||
| Item | VD n (%) | SD n (%) | SS n (%) | VS n (%) | Mean ± SD |
| In general, how satisfied are you with the services received in the facility | 2 (1.1) | 1 (0.6) | 38 (21.3) | 137 (77.0) | 3.74 ± 0.52 |
| Key: VD = very dissatisfied; SD = somewhat dissatisfied; SS = somewhat satisfied; VS = very satisfied | |||||
| Subscale 3b: Helpfulness of the services provided | |||||
| Item | NA n (%) | NH n (%) | VH n (%) | EH n (%) | Mean ± SD |
| How helpful are the services provided in this facility | 0 (0.0) | 7 (3.9) | 36 (20.2) | 135 (75.8) | 3.72 ± 0.53 |
| Key: NA = not at all helpful; NH = not helpful; VH = very helpful; EH = extremely helpful | |||||
| Overall satisfaction with youth-friendly services | |||||
| Overall satisfaction category | Score range | Frequency, n | Percentage, % | ||
| Very dissatisfied | 0–25% | 0 | 0.0 | ||
| Somewhat dissatisfied | 26–50% | 2 | 1.1 | ||
| Somewhat satisfied | 51–75% | 7 | 3.9 | ||
| Very satisfied | 76–100% | 169 | 94.9 | ||
| Total | 178 | 100.0 | |||
| n = frequency. Any item with a mean score > 2.5 was considered accepted by respondents; rejected items were asterisked | |||||
Findings from the study (Fig. 1) revealed that youths suggested that education and transportation support be improved to increase their satisfaction.
Fig. 1.
Bar chart showing things suggested by the youths for a higher level of satisfaction. Multiple responses allowed
Table 3 below shows that the retention rate among youths in HIV care was high (89.3%).
Table 3.
Retention rate of youths in HIV care at ART clinic N = 178
| Frequency (n) | Percent (%) | |
|---|---|---|
| Total number of visits | ||
| - 1 | 8 | 4.5 |
| - 2 | 11 | 6.2 |
| - 3 | 41 | 23.0 |
| - 4 | 90 | 50.6 |
| - More than 4 | 28 | 15.7 |
| Retention rate | ||
| - Poor retention (1–2 visits) | 19 | 10.7 |
| - Good retention (> 2 visits) | 159 | 89.3 |
3 or more visits within a year imply good retention, while 2 or fewer visits imply poor retention
Table 4 below shows that most of the youths had a suppressed viral load (92.1%). Sadly, the viral load suppression in this study is below 95%.
Table 4.
Viral load of the youths N = 178
| Frequency (n) | Per cent (%) | |
|---|---|---|
| Viral load | ||
| - Target Not Detected (TND) | 161 | 90.4 |
| - Less than 1000 copies/ml | 3 | 1.7 |
| - ≥ 1000 copies/ml | 14 | 7.9 |
| Summary | ||
| - Total suppressed (viral load results with TND & less than 1000c/ml) | 164 | 92.1 |
| - Total unsuppressed (all viral load ≥ 1000 copies/ml) | 14 | 7.9 |
Results in Table 5 below show that there was no significant association between youths’ level of satisfaction with youth-friendly services and their socio-demographic characteristics, except for age and place of residence (p = 0.036). Regarding residence, youths living in urban areas were more satisfied (98.0%) than those in rural areas (90.4%).
Table 5.
Relationship between level of satisfaction and demographic characteristics of the youths
| Variable | Category | Very Satisfied n (%) | Not Very Satisfied n (%) | Test Statistic | df | p-value |
|---|---|---|---|---|---|---|
| Age group (years) | 15–17 | 59 | 2 | Fisher’s exact = 0.801 | 2 | 0.703 |
| 18–20 | 54 | 3 | ||||
| > 20 | 56 | 4 | ||||
| Sex | Male | 91 | 2 | Fisher’s exact = 0.089 | 1 | 1.000 |
| Female | 78 | 7 | ||||
| Educational level | No formal education | 3 | 0 | Fisher’s exact = 1.717 | 3 | 0.468 |
| Secondary | 126 | 5 | ||||
| Tertiary | 41 | 3 | ||||
| Marital status | Single | 165 | 9 | Fisher’s exact | 1 | 1.000 |
| Married | 4 | 0 | ||||
| Occupation | Student | 122 | 6 | Fisher’s exact = 2.792 | 4 | 0.832 |
| Apprentice | 28 | 2 | ||||
| Employed | 2 | 0 | ||||
| Self-employed | 12 | 0 | ||||
| Unemployed | 3 | 3 | ||||
| Place of residence | Rural | 70 | 7 | Fisher’s exact | 1 | 0.036* |
| Urban | 99 | 2 | ||||
| Cost of transportation | ≤ ₦1000 | 72 | 5 | Fisher’s exact | 1 | 0.735 |
| > ₦1000 | 95 | 6 |
Abbreviations: df = degree of freedom
Statistically significant at p < 0.05
Due to sparse cell counts, “very dissatisfied”, “somewhat satisfied”, and “somewhat dissatisfied” categories were merged into a single category (“Not very satisfied”) for analysis
Results in Table 6 below show that very satisfied youths did not have significantly different odds of good retention compared with youths who were not very satisfied, although the estimate was imprecise because of sparse cells and a zero cell count (OR 0.41, 95% CI 0.02–7.26; Fisher’s exact p = 1.000). High retention rates were observed across all satisfaction categories.
Table 6.
Relationship between level of satisfaction and retention in HIV care
| Satisfaction Level | Good Retention n (%) | Poor Retention n (%) | Test Statistic | df | p-value |
|---|---|---|---|---|---|
| Not very satisfied | 9 | 0 | Fisher’s exact = 0.519 | 2 | 1.000 |
| Very Satisfied | 150 | 19 |
Abbreviations: df = degree of freedom. Statistical significance set at p < 0.05
Due to sparse cell counts, “very dissatisfied”, “somewhat satisfied”, and “somewhat dissatisfied” categories were merged into a single category (“Not very satisfied”) for analysis
The results in Table 7 below show a statistically significant unadjusted association between retention in HIV care and viral load suppression (χ² = 34.616, p < 0.001). Youths with good retention had higher odds of viral suppression than those with poor retention in unadjusted analysis (OR 18.55, 95% CI 5.38–63.98; p < 0.001).
Table 7.
Relationship between retention in HIV care and viral load suppression
| Retention Status | Suppressed Viral Load n (%) | Unsuppressed Viral Load n (%) | Test Statistic | df | p-value |
|---|---|---|---|---|---|
| Good retention | 153 | 6 | Chi-square = 34.616 | 1 | < 0.001* |
| Poor retention | 11 | 8 |
Abbreviations: df = degree of freedom
Statistically significant at p < 0.05
Discussion
This study assessed youths’ satisfaction with youth-friendly HIV services. It examined their relationship with retention in HIV care and viral load suppression at a tertiary hospital in Enugu State, Nigeria. The findings demonstrate very high satisfaction with YFS, alongside high retention in care and a high rate of viral load suppression. Importantly, retention in HIV care was significantly associated with viral load suppression, underscoring retention as a critical determinant of treatment success among young people living with HIV.
Youths’ satisfaction with youth-friendly HIV services
An overwhelming majority of the youths (94.9%) reported high satisfaction with the youth-friendly HIV services provided at the ART clinic. This reflects the successful implementation of youth-responsive strategies, including peer counselling, confidentiality, respectful provider attitudes, free services, recreational activities, and digital engagement platforms. Similarly, high levels of satisfaction have been reported in other sub-Saharan African settings where youth-friendly, peer-led service delivery models have been implemented [10, 14].
The high satisfaction observed may also reflect the adoption of the Operation Triple Zero (OTZ) programme at the study site, which emphasises youth empowerment, peer support, and shared responsibility for care outcomes. Evidence from Kenya and other PEPFAR-supported countries indicates that OTZ and similar youth-centred approaches improve clinic experiences and foster a sense of ownership among youths living with HIV [11, 15].
Despite overall high satisfaction, dissatisfaction was reported with the lack of extended clinic hours, particularly after school and on weekends. This finding aligns with previous reports that rigid clinic schedules often conflict with school and vocational activities, thereby posing barriers to youth engagement in care [12, 17]. Youths’ suggestions for transport support, educational assistance, and enhanced recreational activities further underscore the role of structural and socioeconomic factors in shaping service experiences and long-term engagement in care.
Retention in HIV care among youths
The retention rate of 89.3% observed in this study is higher than rates reported in several Nigerian and regional studies among adolescents and youths [20, 21]. This suggests that the youth-friendly service model at the study facility may be effective in supporting continued engagement in care. Youth-friendly environments, peer support mechanisms, multi-month ART dispensing, and structured follow-up systems likely contributed to this relatively high retention.
Contrary to expectations, no significant association was observed between youths’ level of satisfaction and retention in HIV care. While satisfaction has been reported as a predictor of retention in other studies [14, 15], the uniformly high satisfaction in this cohort may have limited variability to detect a statistical association. Additionally, external programmatic factors such as free ART provision, appointment reminders, caregiver involvement, and OTZ support may have promoted retention regardless of individual satisfaction ratings.
Viral load suppression and its relationship with retention
The viral load suppression rate of 92.1% observed among the youths is encouraging and approaches the UNAIDS third “95” target [24]. This rate is substantially higher than national estimates among young people in Nigeria [4], and compares favourably with findings from other African settings [25]. The high suppression rate may reflect sustained ART adherence supported by peer counselling, regular follow-up, confidentiality-focused services, early ART initiation, and the use of dolutegravir-based regimens [26, 27].
Retention in HIV care was significantly associated with viral load suppression in this study. Youths who were well retained in care were far more likely to achieve viral suppression than those with poor retention. This finding reinforces the central role of consistent clinic attendance in ensuring uninterrupted access to ART, adherence support, and timely monitoring. Poor retention has been linked to treatment interruptions, virologic failure, drug resistance, and increased HIV transmission risk, whereas sustained retention supports viral suppression and the public health goal of “undetectable equals untransmittable” [28].
Sociodemographic factors associated with satisfaction
Among the sociodemographic variables examined, only place of residence was significantly associated with satisfaction. Youths residing in urban areas reported higher satisfaction than those living in rural areas. This disparity likely reflects differences in transportation costs, travel time, access to information, and familiarity with health services [20, 22]. Rural youths often face greater logistical and financial barriers, which may negatively influence their perceptions of care despite receiving similar clinical services. Similar urban–rural differentials in satisfaction have been reported elsewhere [29].
Implications for practice and policy
These findings highlight the importance of sustaining and strengthening youth-friendly HIV services as a strategy for improving retention and viral load suppression among youths. Health facilities should prioritise flexible clinic hours, expand school- and community-based outreach, and address structural barriers such as transportation and food insecurity. Integrating youth feedback into service design and evaluation remains essential to ensure services remain responsive to their evolving needs. Nurses and other frontline healthcare providers play a pivotal role in delivering YFS by using respectful communication, maintaining confidentiality, and providing psychosocial support. Strengthening these components, alongside peer-led and empowerment-based programmes such as OTZ, may further consolidate gains in retention and viral suppression.
Conclusion
This study demonstrates that youths accessing HIV care at UNTH reported very high satisfaction with youth-friendly HIV services, alongside high levels of retention in care and viral load suppression. Although satisfaction with YFS was not independently associated with retention in care, retention was strongly associated with viral load suppression, underscoring its critical role in achieving optimal HIV treatment outcomes among youths. However, these findings should be interpreted as associations rather than causal effects.
The findings suggest that comprehensive youth-friendly service models—characterised by peer support, confidentiality, respectful provider attitudes, free services, and youth empowerment initiatives such as the Operation Triple Zero programme—can support sustained engagement in care and favourable virologic outcomes. However, gaps related to service accessibility, particularly limited after-school and weekend clinic hours, as well as transportation and educational support needs, highlight areas requiring further programmatic strengthening.
Overall, improving and sustaining retention in HIV care should remain a central focus of youth-centred HIV programmes, as it directly influences viral suppression and broader public health goals, including reduced HIV transmission and AIDS-related morbidity and mortality. Addressing structural barriers and incorporating youths’ feedback into service planning may further enhance the effectiveness and equity of youth-friendly HIV services in Nigeria and similar settings.
Strengths and limitations
This study provides context-specific evidence on youth-friendly HIV services and treatment outcomes in a tertiary care setting in southeastern Nigeria. The use of routine clinic records for retention and viral load data strengthens the reliability of outcome measures. However, the cross-sectional and retrospective design limits causal inference. Because the study included only active youths in care, youths who had disengaged from care, transferred, died, or were lost to follow-up were not represented. This selection process may overestimate satisfaction, retention, and viral suppression and may reduce the ability to detect associations between satisfaction and outcomes. Because of the limited sample size and sparse variation in responses in some domains, domain-specific internal consistency estimates were not calculated. Satisfaction was self-reported and may be subject to social desirability bias. Additionally, the single-facility setting with an established youth-friendly programme may limit generalisability to other facilities, particularly primary or resource-constrained settings.
Recommendations
Based on the findings of this study, the researchers recommend that:
YFS and the OTZ programme should be strengthened by considering after-school or weekend service options, improving appointment systems, and expanding peer-led support.
Transport-related barriers should be assessed during routine visits, and eligible youths should be linked to available social support or implementing-partner assistance.
Policy makers in HIV management should collaborate with facility staff, implementing partners, community-based organisations, clients and the government to work on the listed items in Fig. 1 for service improvement.
Enhance outreach to schools and communities to strengthen linkages between health facilities, schools, youth clubs, and community-based organisations to improve awareness of available services, reduce stigma, and facilitate early linkage and sustained engagement in care.
The clinic should periodically conduct youth satisfaction surveys and use the findings to guide service improvement.
Future evaluations should include youths who are lost to follow-up or disengaged from care to better assess the relationship between satisfaction and retention.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Abbreviations
- AIDS
Acquired Immunodeficiency Syndrome
- ART
Antiretroviral Therapy
- ARV
Antiretroviral
- EMR
Electronic Medical Records
- ESUTH
Enugu State University Teaching Hospital
- HIV
Human Immunodeficiency Virus
- I-CVI
Item Content Validity Index
- NA
Not at all helpful
- NACA
National Agency for the Control of AIDS
- NH
Not so helpful
- OTZ
Operation Triple Zero
- PEPFAR
President’s Emergency Plan for AIDS Relief
- PLHIV
People Living with HIV
- PMTCT
Prevention of Mother-To-Child Transmission
- SD
Standard Deviation
- SPSS
Statistical Package for Social Sciences
- TB
Tuberculosis
- TND
Target Not Detected
- UNAIDS
Joint United Nations Programme on HIV/AIDS
- UNTH
University of Nigeria Teaching Hospital
- VD
Very Dissatisfied
- VH
Very Helpful
- VS
Very Satisfied
- WHO
World Health Organisation
Author contributions
Conception – OCE, EC, IPN, OCC, OIL Design of the work – OCE, EC, EGC, NCO, IPN, OCC, OIL Acquisition and analysis – OCE, EC, EGC, NCO, CUV, NC Interpretation of data – OCE, EC, EGC, NCO, CUV, NC, IPN, OCC, OIL Drafting/Revision of the paper – OCE, EC, CUV, NC All authors read and approved the submitted version and agree to be responsible and accountable for their contribution to the work.
Funding
No external funding was received for this study.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethical approval and consent to participate
Ethical approval was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital (NHREC/05/01/2008B-FWA00002458-1RB00002323). Informed consent to participate was obtained from those who were 18 years old or older, and caregivers of participants aged 15–17 years old, while assent was obtained from those 15–17 years old as well, in compliance with the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.