‘I will welcome this one 101%, I will so embrace it’: a qualitative exploration of the feasibility and acceptability of HIV self-testing among men who have sex with men (MSM) in Lagos, Nigeria

Abstract

Men who have sex with men (MSM) are disproportionately affected by HIV in Nigeria. A key strategy in reducing transmission is to increase HIV testing uptake and linkage to treatment for those who test positive. HIV self-testing (HIVST) is an innovative strategy with the potential to increase uptake of HIV testing among key populations at higher risk for HIV. We conducted 23 in-depth-interviews with MSM and two focus group discussions with key opinion leaders to explore perceptions about the feasibility and acceptability of oral HIVST among MSM in Lagos, Nigeria. HIVST was highly acceptable because it was considered convenient to use, painless, private and addressed concerns about stigma. Concerns cited by participants included comprehensibility of instructions to perform and interpret results correctly, as well as lack of support mechanisms to facilitate post-test follow-up and linkage to care. Provision of adequate pre-test information was considered vital as part of the kit distribution process to ensure seamless use of HIVST kits. One-on-one peer-to-peer distribution strategies and retail outlets that facilitate anonymous pick-up are potential distribution channels identified in this study. Overall, our findings suggest that an HIVST program that incorporates these considerations would improve access to HIV testing among MSM in Nigeria.

Introduction

Men who have sex with men (MSM) are disproportionately affected by HIV in Nigeria and findings from the Integrated Biological and Behavioural Surveillance Surveys (IBBSS) showed that the prevalence among MSM increased from 17.2% in 2010 to 22.9% in 2014, while the prevalence declined for other key population groups such as female sex workers [1, 2]. Population-based studies in various cities in Nigeria have shown HIV prevalence estimates among MSM to range from 23% in Lagos to 35% in Abuja, which is up to 10 times higher than the HIV prevalence among the general population of adult males (3.3%) [3–5]. MSM constitute a hidden population in Nigeria because of prohibitive laws that criminalize same-sex sexual relationships and high levels of homophobia, stigma, discrimination and ostracism [3, 6–8]. This often results in poor access to HIV and sexual health services among MSM. For example, only 65% of MSM ever had an HIV test according to the IBBSS 2014 [2].

Increasing uptake of HIV testing is an important HIV prevention strategy. Challenges with facility-based HIV testing include stigma associated with the HIV testing process, long waiting times and privacy concerns [9]. Innovative HIV testing strategies that maximize confidentiality, privacy and stigma reduction are key to bridging the disparities in increasing the uptake of HIV testing and linking HIV positive MSM to care and treatment. HIV self-testing (HIVST) is an HIV testing option that has the potential to address barriers to uptake of HIV testing because it can be performed by conducting an oral fluid- or blood-based test in the privacy of a person’s home using a simple kit. HIVST as a screening test is performed in private and provides information that the user needs to act upon to receive additional support, such as confirmatory testing, counseling and treatment [10]. Thus, HIVST is a rapid screening test and reactive test results require further testing and linkage to care. There is a large body of evidence indicating that HIVST addresses privacy and confidentiality issues associated with facility-based testing [9, 11–13]. In addition, HIVST could increase testing frequency, which is recommended for higher risk groups, including MSM [14, 15]. The acceptability and feasibility, however, varies by context, and this needs to be established prior to adopting specific access or distribution strategies, particularly for a population like MSM in an environment with high levels of stigma and discrimination [9, 10, 16]. Key issues that need to be contextualized include: the process for obtaining the kit; providing adequate information about the use of the kit and strategies to ensure linkage to care if HIV positive [10].

Nigeria has achieved milestones in testing and approving oral-based HIVST products for use. National guidelines for HIVST in Nigeria have been developed and launched; no approach has, however, been identified for distribution of HIVST kits in Nigeria. HIVST is reported to be available over the counter at retail pharmacies but it is unclear about utilization or linkage to post-test services. This formative study explored MSM perceptions of oral HIVST and potential barriers to and facilitators of HIVST use. In addition, it sought to identify operational and contextual issues that might affect the distribution of HIVST kits to MSM in the Nigerian context and the potential for linkage to care. This HIVST implementation science project is one of the first to be implemented among MSM in Nigeria and is a particularly important contribution to Nigeria’s HIVST guidelines [17].

Methods

Study design

This qualitative descriptive study was conducted as part of the formative phase of a multiphase study to explore the perceptions of MSM regarding the acceptability of oral HIVST for HIV testing and the feasibility of using MSM key opinion leaders (KOLs) to deliver HIVST kits to MSM. In this formative phase, semi-structured in-depth interviews (IDIs) with MSM and focus group discussions (FGDs) with KOLs were conducted.

Theoretical framework for the study

The information–motivation–behavioral (IMB) skills model was used as the conceptual approach to understand the considerations of MSM about adopting HIVST as shown in Fig. 1 [18]. The model posits that HIV prevention IMB skills as well as the self-efficacy to act increases the likelihood of uptake of HIV prevention behavior [18–20]. The model guided the exploration of information needs of clients, motivations and behavioral skills supporting HIVST uptake. Elements of the ecology model were adapted to understand health systems and structural barriers to linkage to care.

Fig. 1.

Theoretical framework for HIVST acceptability and uptake.

Study site

The study was conducted in November 2016 in Lagos state, South-West Nigeria. Lagos state is the smallest state by size but has 27.4% of the urban population of Nigeria. In 2015, Lagos state was estimated to have a population of 24.6 million people; metropolitan Lagos is the most populous city in Africa with ∼20 000 people per square kilometer [21]. Over 60% of country’s commercial and industrial investments take place in Lagos and it is regarded as the financial hub of Nigeria. Lagos is one of the most ethnically diverse states in Nigeria as a result of increasing rural urban migration.

Lagos has a large population of MSM and a high HIV burden among MSM [3]. A mapping and characterization exercise conducted by Lagos state government in 2015 estimated the population of MSM in the state to be 4828. Findings from the IBBSS show that HIV prevalence among MSM in Lagos increased from 25.4% in 2007 to 41.4% in 2014 and this was the highest in Nigeria [1, 2]. The HIV prevalence in Lagos state among the general population is 1.4% [4]. The study was conducted at the Population Council’s community health center (CHC) in Lagos, Nigeria. The CHC is staffed by trained sensitized staff and provides a safe space for confidential KP-friendly clinical and community services.

Study participants and data collection procedure

As HIVST programs had not been implemented in Nigeria at the time of this study, it was conducted to understand preferred channels for obtaining and using the HIVST kits as well as potential barriers for follow-up or linkage to care. IDIs were used to explore the acceptability of oral HIVST and barriers to utilization among MSM. FGDs with KOLs explored contextual narratives about the feasibility of using KOLs as a distribution strategy for oral HIVST kits.

In-depth interviews

KOLs referred MSM within their network for the study. Twenty-three MSM who met the eligibility criteria were recruited to participate in this study. Participants had to be aged 16 and above, be cisgender male, have had anal intercourse (receptive or insertive) with another man in the past 6 months, and self-report being HIV negative or of unknown HIV status during the past 3 months. To ensure that perspectives of MSM who had previously tested negative for HIV and those who had never tested was adequately explore, the sample was diversified based on HIV testing history. KOLs recruited participants from their own large social networks of MSM. Interested participants were invited to an MSM-friendly drop-in clinic operated by the Population Council, screened for eligibility, and if eligible, consent was taken and interviews were conducted in private consulting rooms. Before the interviews, MSM participants were shown an actual HIVST kit (OraQuick Rapid HIV ½ Antibody Test, OraSure Technologies) and a video to explain the procedures for testing. Trained interviewers conducted the IDIs in Pidgin English using a semi-structured interview guide and focused on capturing information on opinions of the HIVST kits, how it can be distributed to MSM in Nigeria, and what mechanisms need to be in place to ensure safe and appropriate distribution and use of the test kits. Nigerian Pidgin English was used because it is a widely spoken language spoken across Nigeria especially in Metropolitan areas such as Lagos and among young people.

Focus group discussions

Two FGDs were conducted with a total of 12 KOLs (6 per group) to investigate the feasibility and operational aspects of using KOLs to distribute HIVST kits. The KOLs who participated in the FGDs were selected from a pool of KOLs trained by the Population Council as HIV Counselors and peer educators for an MSM‐friendly program at the CHC in Lagos, Nigeria. The KOLs were respected members of the MSM community who were successful in referring peers to the CHC, they had to be at least 18 years of age, completed secondary school and had real‐time information about at least 10 physical and virtual MSM hotspots. The KOLs have also previously worked with the drop-in clinic operated by Population Council. FGDs explored KOL’s perspectives on the distribution of HIVST kits, recommendations for how tools and instructional materials can facilitate accurate use of HIVST kits, and strategies to provide post-test counseling and linkages to care for HIVST users.

Ethical considerations

The study protocol received ethical approvals from the Population Council Institutional Review Board and the Health Research Ethics Committee of the College of Medicine at the University of Lagos. All procedures performed in studies involving human participants were in accordance with the ethical standards of the Population Council Institutional Review Board and the Health Research Ethics Committee of the College of Medicine of the University of Lagos and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. All participants except KOLs received a 1500-naira ($7.50) reimbursement for their time and travel.

Data analysis

The interviews were recorded digitally, transcribed verbatim, reviewed by the lead author and transferred to NVivo 11 software for analysis. The research team consisted of the Study Investigator and three experienced qualitative researchers who read all transcribed IDIs and FGDs to familiarize themselves with the data and the coding process was guided by themes emerging from the data as well as priori codes. The researchers coded the same transcripts to ensure consistent application of the codes, discussed discrepancies and contributed to the development of a thematic framework of codes through consensus. The analytical strategy was thematic analysis, and this was used to explore emergent patterns and themes within the data [22, 23]. The coders understood the local context and one of them was involved in conducting the interviews. Their understanding of the local context enhanced the interpretation of the data to reflect participants views; iterative discussions mitigated the risk of coders representing their perceptions of the data and increasing the trustworthiness of the analysis process. The research team hosted community meetings after the study to present findings and receive feedback.

Results

Two-thirds of the IDI participants were between 16 and 24 years of age, and almost all had completed at least secondary education (Table I). The majority was single, 12 of the participants self-identified as gay and 9 as bisexual; about half had never tested for HIV. Overall, the majority of the participants reported they were willing to use the oral HIVST because it addressed critical barriers to HIV testing among MSM.

Table I.

Characteristics of MSM IDI participants (N = 23)

Demographic features		Number of MSMs (N = 23)
Age group	16–24 years	17
	25 and above	6
Highest educational level	Certificate/trade school	1
	Completed secondary school	13
	Tertiary education	9
Marital status	Single and living with male sex partner	6
	Single, not living with male sex partner	14
	Married to a woman	3
Sexual orientation	Gay/attracted to men only	12
	Bisexual	9
	Straight/heterosexual	2
Status of HIV testing	Never tested	10
	Tested/most recent test result was negative	13
FGD (n = 12)
Age group	16–24 years	7
	25 and above	5
Marital status	Single	12
Highest educational level	Certificate/trade school	4
	Completed secondary school	2
	Tertiary education	6
Years of experience as a KOL	<12 months	9
	12–24 months	0
	>24 months	3

Findings are discussed along five thematic areas: perceived facilitators, perceived barriers, partner testing, preferred distribution channels and considerations for linkage to care (Table II). The quotes are labeled ‘PT’ to represent participants that previously tested and ‘NT’ to represent never tested. Age is separated into two categories: <25 (participants under 25 years) and 25+ (participants 25 years and above).

Table II.

Facilitators and barriers of oral HIVST uptake

Perceived facilitators of oral HIVST	Convenient
	Easy to use
	Pain-free
	Addresses issues of privacy and stigma
Perceived barriers of oral HIVST (information needs)	Low literacy and poor comprehensibility of instructions
	Misconceptions about mode of HIV transmission
Preferred distribution channels	One-on-one distribution through KOLs
	Peer-to-peer distribution
	Pharmacies/retail outlets
Barriers to linkage to care	Denial of a positive HIV test result
	Perception of HIV as a death sentence
	Belief in religious/traditional healers
	Lack of information about follow-up services

Perceived facilitators of oral HIVST

Convenient

There was consensus across the interviews that oral HIVST is convenient because there is no need to wait in long queues at the health facilities. Several KOL participants acknowledged the potential for HIVST to increase uptake of HIV testing and facilitate regular testing, especially for working class MSM who were only available to test during the weekend when test centers are closed. Some participants were impressed by the fact that HIVST could be used anytime and anywhere they felt comfortable. The potential for HIVST to improve regular HIV testing among those who had previously tested and facilitate testing among those who had never tested was acknowledged by many who reported that HIVST could be conveniently worked into their everyday lives.

This is an improvement on what has been before; now people don't have to get pricked with the needle … this is very easy, so many people will welcome this new initiative … more confidentiality with it and reduced waiting time at HIV testing facilities. (IDI, 25+, PT)

Easy to use and pain-free

The easy to use, pain-free HIV testing process of oral HIVST was an attraction for the majority of respondents who reported that they dreaded repeated needle pricks from conventional HIV testing.

I think, with what I have seen, it’s easier, it’s confidential and there is no fear of you being pierced to get the HIV test done. (IDI, 25+, PT)

I will welcome this one 101%, I will so embrace it, because I won’t have the fear of pricking anymore. (IDI, 25+, PT)

Interviewer: So can you tell me why you have never tested for HIV?

R14: Well … when it comes to that, I’m always scared because of the needle. This HIV self-test kit I have just seen, is okay by me because a lot of people outside there, they are always scared like me, they won’t be scared again if they know about this one. (IDI, 25+, NT)

HIVST addresses concerns of privacy and stigma related to facility-based HIV testing

Privacy concerns were critical in deciding whether to seek HIV testing, which underpinned the decision not to test among many participants, particularly those who had never tested. Participants expressed concerns that they were reluctant to visit conventional HIV testing centers because they feared that confidentiality could be breached by counselors disclosing their HIV status to other MSM or family members, or that they could be seen by other community members. MSM participants mentioned that the MSM community is closely networked, implying that information sharing occurred very easily through social media and during community activities. Most participants reported that HIVST had the potential to address stigma and privacy concerns associated with visiting HIV testing centers or other HIV testing venues.

The MSM community is a very small and close-knit community and … when it is a member of the community that is testing them, they believe the tester already knows their status, the tester knows who they know. Though as a counselor tester, you shouldn't disclose people’s status to other people, but this client already has that mentality that once the tester knows, other people within my circle know …. (IDI, 25+, PT)

I would have gone for HIV like last year or so, but I wasn't feeling comfortable around the area, it was in an open place with people … I was not comfortable enough because people were there and maybe when they give you your result, your expression will show you are HIV positive. (IDI, 25+, NT)

Perceived barriers to HIVST

Information needs and comprehensibility of the instructions

Several KOL participants flagged that a large proportion of the MSM community members they catered to were not literate enough to comprehend written instructions. As correct use of the oral HIVST kit is hinged on clear comprehension of the written instructions, the risk of errors resulting from incorrect use of the kits was viewed as a significant barrier to use. There was consensus that the instructional manual of the oral HIVST kit should use formats that can be understood at different literacy levels to be considerate of the information needs of potential users. Some participants reported that MSM who had literacy issues would benefit from videos, pictorial instructions and translation of written instructions into local languages.

We have the lower [socio-economic] class MSM, those who cannot read, the illiterates … those people who cannot read and write … they don't know how to do it [HIVST]. (FGD [KOL], 25+, PT)

In addition, there were some misunderstandings about the oral HIVST kit among participants. Some MSM participants inferred that because the oral HIVST collects a sample from the mouth, there must be HIV in the saliva and mouth and that saliva could be a mode of transmission for HIV. They recommended that explicit information related to how the virus is not present in saliva needs to be included in the HIVST information leaflet.

You have to really educate people that there is not enough HIV in the mouth to transmit the virus, just knowing that the virus is there in the mouth. (FGD [KOL], <25, NT)

Potential for coercive testing

The risk of coercion to use the self-test kits (e.g. parents coercing their children and sex partners coercing their partner) was articulated by both KOL and MSM participants. This was a concern because of the ease of administering the test at home. There were significant concerns that parents could force their children to test for HIV, thereby prompting MSM to be more hidden and increasing the risk of stigma and ostracism.

… there are ways people can use it in a harmful way, just like whereby you have a family member or may be a community member that is sick and you are forcing him or her to use the test kit, it is harmful, like forcing them to use it against their own wish …. (FGD [KOL], 25+, PT)

… the only disadvantages I am seeing, because for parents to sit their children down and carry the test on them and know their status, they might be discriminating and shouting that how do you come to contract this (HIV), that is the only disadvantages I see. (IDI, <25, NT)

One of the most mentioned perceived barriers was the potential for poor linkage to HIV care and treatment upon receiving an HIV positive self-test result. This is discussed in a later section specifically on linkage to care and treatment.

Distribution channels

Privacy in obtaining and using the kits

The most important concern with regard to obtaining the HIVST kits was related to how privately MSM can receive the kits. While they acknowledged that the HIVST process affords them privacy, participants pointed out that uptake would likely be low if the kits were only accessible at venues that compromised their anonymity. They favored distribution channels that were private and reduced stigma associated with being seen collecting an HIVST kit. Such channels included sessions with peer educators or KOLs, community dialogs within the MSM networks and through friends.

If the kit is placed in the market for people to get, the stigma around HIV will not let people say that they want to go and buy it because even those people, they will feel that I am buying it … because I already have it (HIV) just because of the stigma. (FGD [KOL], 25+, PT)

We would like to get it hidden, yes hidden, because some people will like to behave like saints, they wouldn’t want to get such things, they will be concerned about ‘how will this person see me?’ So, I believe hidden because the other person doesn’t know I got it. (IDI, <25, PT)

One-on-one distribution through KOLs and peer-to-peer distribution

We explained to participants how KOLs would distribute the HIVST kits to their large peer groups as part of the upcoming pilot distribution intervention and were asked to react to the intervention. Participants indicated that they considered KOLs to be respected members of the MSM community with the capacity to reach their peers through face-to-face interactions, social media and social events. Participants also indicated that they would prefer if the KOL had experience using the self-test kit on themselves so that the KOL would be knowledgeable about every aspect of HIVST.

In our community, there are certain people that command respect and attention. By their charisma, they can easily gather community members. Those are such persons we should engage with distribution, because they will know how to reach their peers. (FGD [KOL], 25+, PT)

I would want it to come from somebody that have passed through it, I would rather take it from somebody I know, that have used it. (IDI, 25+, PT)

Some KOLs reported that their capacity to reach different types of MSM during conventional HIV testing sessions (peer sessions, community dialogs) was limited because some MSM do not want the KOL to know their HIV status, given the close-knit nature of the MSM community. Consequently, KOLs embraced HIVST because they could provide information to their peers about the kit and give their peers the kits to test privately. For KOLs distributing kits to be a viable strategy, the KOLs would have to maintain confidentiality in their interaction with their peers and let their peers know that they do not have to tell their test result to the KOL.

Like going for an MSM outreach, going to test MSM people in the party and a lot of them will say they don't want to do test because they know your face, because you are their friend … they don't want you to know their status and because of that they don't want to do the test …. So, I think this will really help them, if we can introduce this, for them to do it by their self. (FGD [KOL], 25+, PT)

The MSM community was described as highly diverse in terms of age, socio-economic status, sexual identity and marital status. Married MSM and young MSM were more inclined to receive the kits discreetly to keep the HIV testing process hidden from their spouses and parents, respectively. Peer-to-peer channels from trusted MSM within their demographic groups were preferred by some participants.

Talking of the high class MSM … they call them ‘red bulls’ on the island, if you want to reach them, you have to go to their house, they don't even need your money, they will host you … let the younger ones go for younger ones, then let the middle class go for the middle class and let the upper class go for the upper class …. (FGD [KOL], 25+, PT)

Married men definitely will want to be hidden about it, you have to explain to your wife why you are testing for HIV. People in the lower class what if they are dependent on their parents; younger people, teenagers, minors … you'd have to be very discrete about the kit. So, that would affect the way they easily access it. (IDI, <25, NT)

Other distribution channels

While the majority of MSM participants was in favor of peer distribution by KOLs, a few others preferred to obtain the kits from a wide variety of places. The preference for a variety of places was based on the perceived convenience of obtaining the self-test kit whenever it was needed as opposed to being restricted to KOLs or peers. Party venues were also considered important distribution channels and they were preferred over pharmacies and retail outlets because MSM could pick up an HIVST kit anonymously. Another issue identified with picking up HIVST kits from retail outlets, such as pharmacies, was that the personnel would be poorly equipped to provide counseling services.

Yes, like I said earlier we should be able to get it, maybe anywhere, in the hospital, chemist, SHOPRITE, shopping malls. (IDI, <25, PT)

As an MSM, the only place I will like to receive this kit, or accept it, is where I know it's confidential, and in the party, I know that everybody is collecting his kit. (IDI, <25, PT)

Partner testing

There were mixed accounts about the potential of oral HIVST to increase uptake of HIV testing among partners of MSM. While some participants opined that the use of the kit would increase partners’ awareness about their status and risk, others believed it would increase conflicts and mistrust within the relationship. There was consensus, however, that partners would be more receptive to use the kit if MSM shared positive experiences about using the kits, presented information about using the kits in a suggestive manner and allowed their partners to use the kit privately. Testing in relationships was recognized as a defining issue for the future of the relationship because knowing partners’ status was identified as key to personal health. The negative aspects of partner testing, as mentioned by participants, included damaging their relationship and difficulties around disclosure after testing if one partner tests positive.

… you can give your partner but it is not a must that your partner … will do it in your front, is a private something. So a partner can decide to do it at his or her own will. (IDI, 25+, PT)

If one person turns to be reactive, it will cause so much damage … it could lead to a break-up, it could lead (someone to say). ‘You are the person that infected me, how come?’ (FGD [KOL], 25+, PT)

Barriers to linkage to care

One of the biggest concerns raised by both MSM and KOL participants was that because self-testers would be testing on their own, they would not be receiving assistance and counseling on how to access HIV care and treatment if they self-tested positive. This section highlights the various perceptions and beliefs held by MSM that prevent them from seeking HIV care and treatment and cannot be addressed through post-test support since self-testers are testing without the immediate support of any providers.

Denial of a positive HIV test result

Because self-testers would be testing alone, MSM participants were concerned that many MSM would be in denial of their HIV positive test result and ultimately not seek HIV treatment. Participants spoke about the difficulty of accepting an HIV positive status and the fear of living with HIV.

There is this anxiety and sometimes fear … before running the test … Denial! Some people even when they are positive don't believe it, they need time to process it and sadly, there’s little one can do …. But then, with the self-test kit people might not know and it will just be with the person battling it, inside him or herself. (IDI, 25+, PT)

I thought of it like it is private, if one is positive, they might not want to come out, I don't know I thought of it also, since it is a private thing, the person might be positive, and they still have this idea that I am not positive …. (IDI, 25+, PT)

Perception of HIV as a death sentence

Lack of linkage to post-test support for follow-up was flagged as a potential disadvantage to using HIVST. Many MSM have a strongly held belief that a positive HIV test result was synonymous with a ‘death sentence’ reinforced by stigma and discrimination from family and society. Many participants perceived that although HIVST increased privacy, some people may not reach out for counseling or support after conducting the HIVST.

I remembered someone who tested positive and he was looking for where he could commit suicide, the counselor gave him advise before he could calm down …. (IDI, <25, PT)

… some people are always scared going to know their HIV status because they think that anyone that is HIV positive is close to his or her death, like the person is going to die very soon. (IDI, <25, NT)

Stigma as barrier to HIV treatment

Stigma associated with being identified as MSM was a major barrier to accessing post-test counseling services and commencing antiretroviral treatment for those who self-test HIV positive.

Number one is self-discrimination, in the sense that since the normal pre-test counseling is not there before he did the test, the oral test for himself, when the result is out, the thought of how did I get this thing will cover his mind, because no pre-test counseling, so that is number one and number two, who is he going meet or how is he going to tell them that this is what is wrong with me, that is the referral part of it … how will he refer himself to the facility. (FGD [KOL], 25+, PT).

Belief in traditional/religious healers as barriers to HIV treatment

Participants explained that some people were inclined to seek ‘divine healing’ for HIV in Nigeria. The belief in faith healing or traditional herbs was viewed by KOLs as a barrier to HIV treatment after HIV testing reveals a positive result.

Nigerians now we believe so much in all those thing, religious parol (slang) that T. B. Joshua will heal me or my pastor will heal me, and everything! or they have all those herbs, herbs! They believe the religious setting. (IDI, 25+, NT)

When we go out for the normal HIV test … and they are reactive, you find it hard to bring them to care because … they don't believe, some of them believe in faith healing while others because of the stigma, they don't want to accept the fact that they are positive. (FGD [KOL], 25+, PT)

Information about follow-up

One of the most important points highlighted throughout the interviews about facilitating linkage to care was providing adequate information before the kit was given to MSM. Providing information about the steps involved in the testing process, hotline numbers for guidance and information about HIV testing centers was considered vital. Most participants considered it useful for HIV program implementers to identify accessible HIV testing centers that adopt a non-judgmental approach to MSM and committed to protecting their confidentiality.

Places where they are welcomed … not random hospital were you are not free to tell the doctor about your sex life so that you can tailor their services to one’s needs … where one will feel at home and at ease to access care. (IDI, 25+, PT)

There are some communities where you can't easily find HIV walk in centers where people can go to access care. So those kinds of people are the lower rank of the society that can barely feed him or herself to find it get money to go to the center, because what he is thinking as of that time is how to live to the next day. (IDI, 25+, PT)

Discussion

This was one of the first studies to explore the acceptability and feasibility of HIVST among MSM in Nigeria, a population that still needs increased coverage of and experience great barriers to HIV testing. We found that the oral HIVST was considered highly acceptable among MSM because it addressed key concerns: privacy, convenience of testing and a pain-free testing experience. Privacy offered by the HIVST addresses issues related to stigma and discrimination which is a major barrier to uptake of facility-based HIV testing. These findings are consistent with other studies that documented ease of testing, painless testing, convenience and privacy of testing as facilitators of oral HIVST [14, 24–29]. In addition to encouraging MSM who have never tested to get tested for the first time, HIVST could facilitate regular testing and increase testing frequency.

Concerns related to comprehensibility of HIVST instructions, privacy in obtaining the kits and support mechanisms for post-test follow-up and linkage to care are similar to challenges of HIVST documented in other studies [30, 31]. Comprehensibility of HIVST user instructions across different literacy levels is an important consideration in a developing country like Nigeria to ensure that potential users are not excluded because of their level of literacy. The use of instructional videos, pictorial illustrations and translation of written instructions into local languages is useful strategies in a country like Nigeria with different dialects [29, 32, 33]. The WHO guidelines on HIVST recommend varied approaches, such as directly assisted HIVST (trained providers demonstrate the use of the kit while HIVST is being performed) and unassisted HIVST (users follow the instructions and test themselves) [14]. A hybrid of both approaches may be beneficial for MSM who are illiterate by enabling them to understand correct use of the kit through demonstration and subsequently using the kit privately with helplines they can call for additional support.

Participants suggested that uptake of the HIVST may be low if MSM perceive that the process of obtaining the kit compromised their privacy and would stigmatize them. One-on-one peer-to-peer distribution strategies and retail outlets that facilitate anonymous pick-up are potential channels for HIVST pick-up among MSM identified in this study. Findings from the follow-up survey component of this implementation science project using a KOL distribution strategy to reach 319 MSM with HIVST kits showed that the most acceptable channels to receive HIVST kits were from community-based organizations and peers/KOL [34]. Distribution strategies for HIVST kits should also reflect the diverse needs of MSM across different demographic groups. Maintaining privacy in the process of obtaining self-test kits was reported as a critical factor in facilitating uptake of oral HIVST in a previous acceptability study [12].

We found that the fear of knowing one’s status was reinforced by stigma and perceived lack of support for those who test HIV positive. The fear of knowing one’s status expressed by some participants as a reason why MSM may not be inclined to test for HIV is not specific to HIVST but may compound issues with linkage to care if they test positive and do not seek post-test support. Fear has been identified as a major barrier to uptake of HIV testing and linkage to care [24, 28]. The limitations of HIVST in reaching people who are not inclined to test because of the fear of testing HIV positive has been documented [32]. HIVST kit distribution programs should be linked with strategies that provide information about the benefits of testing in general. Provision of adequate pre-test information as part of the kit distribution process can be useful in addressing misconceptions that may arise about HIV transmission mechanisms and the use of HIVST.

The HIVST procedures rely heavily on the user’s decision and action to seek help [10]. Linkage to care has been identified as the most critical consideration for providing HIV support services for those who self-test HIV positive [13]. A vital strategy for facilitating linkage to care discussed by participants was for program planners to identify upfront accessible referral centers that provide MSM-friendly services and provide information about these centers during HIVST kit distribution. This strategy will help MSM who utilize HIVST to view it as part of a process and may avert delays in decision making about follow-up testing and linkage to care for those who test positive. Findings from other studies suggest that MSM who know about an HIV testing facility or have an established relationship with a facility may be more inclined to seek post-test support and linkage to care if they test positive using the HIVST [33, 35].

The WHO HIVST guidelines recommend that programs provide users with full information about using HIVST with emphasis on steps to take after testing and helplines to contact for assistance [14]. Non-intrusive follow-up strategies to provide support, such a text message prompts, can be explored within the Nigerian context. The potential for partner testing was explored in this study and the findings were mixed, with some MSM reporting that HIVST would increase their partners’ awareness about their HIV status and others believing that it will increase trust issues in relationships. Coercion to test using the HIVST kit by parents or partners was also reported as a concern by participants. The ambivalence among MSM regarding the feasibility of HIVST as a tool to encourage partner testing has been reported in other studies [16, 27].

Despite the concerns that participants had about the HIVST, the overall prospect of its use as an HIV testing strategy was positive. The benefits of partner testing notwithstanding, programs must be designed to foster inclusivity and not increase stigma.

Study limitations

The study was based on perceptions about how oral HIVST intervention would work if implemented and participants had never used it but responded based on information provided about the kit they were shown before and during the interviews. There may be slight variations in actual acceptability and uptake. A small purposive sample of MSM was used and may lack broader generalizability. Findings from this research, however, provided critical insights for the design of an acceptability study and provide important guidance as Nigeria rolls out self-testing more broadly.

Conclusion

The majority of the findings about the potential of HIVST to increase uptake of HIV testing among MSM in Nigeria was supportive of HIVST. Privacy and convenience offered by HIVST addresses concerns about stigma and waiting times associated with facility-based testing. Strategies to provide adequate information prior to testing and linkage to care must be developed while planning for HIVST programs to maximize the effectiveness. The implementation of HIVST as an innovative HIV testing tool among MSM using novel distribution models such as peer-to-peer channels that facilitate privacy would potentially increase uptake of HIV testing and repeat testing as important HIV prevention strategies within the HIV care cascade.