This study has identified barriers and enabling factors influencing young people’s testing behaviour.
The barriers to HIV testing
Fear of a positive result came out clearly as a barrier to HIV testing among most young people who responded to this study, mostly those without testing history. According to other studies, the stigma associated with being found HIV positive plays a very significant part in some people bocoming wary of an HIV positive diagnosis 14, hence the decision not to get tested at all. This fear of a positive result is also inherent in issues of disclosure, as most young people fear disclosing their HIV diagnosis to others along the same worries of fear and rejection, stigma and discrimination, and fear of criminalisation, among others 15. It can be argued that all of this plays a part in young people simply opting not to be aware of their status, while the reality is that there is a relatively high risk of HIV infection among adolescents and young adults in Malawi as studies have shown 16, indicating a greater need for interventions aimed at expanding access to testing services for this demographic group.
Poor communication also came out as a barrier at the interpersonal level; a data point that is consistent with the findings of a quantitative study among urban-based young people in Nairobi (Kenya) by Kabiru and others in which only small percentages of respondents indicated that they got an HIV test at the encouragement of either a parent or a partner 17. This negative trend was also evident in the low proportion of those who reported getting encouragement from their peers in the same study; a peer-influence barrier to HIV testing which has also been established by this study at the same interpersonal level.
On cultural norms acting as a community-level barrier to HIV testing among adolescents and young adults, our findings agree with a number of other studies highlighting societal or cultural and religious views as well as conservative parental opinions surrounding HIV and sex that demotivated young people from getting tested 18,19. Apart from hindering HIV testing, poor communication among couples and within families – due to local norms that deter parents from communicating with their children about sexuality – has also been found to contribute to fear of HIV status disclosure among adolescents when they do test positive.20
At the health system level, lack of youth-friendly HIV testing services in particular, as well as youth-friendly health services in general, is the overarching barrier to HIV testing among young people. This barrier involves inadequate staff, lack of space and confidentiality – among others – and our findings are consistent with those of researchers in other settings 21. This barrier needs to be considered in the light of resource constraints facing the Malawian health care system. The YFHS programme in the country started in 2007, and among the key quality aspects required of it are respecting confidentiality, giving choices, and raising awareness of rights 22, all of which seem to be inadequate in the targeted catchment areas, according to the data. In addition, at national leve challenges with the YFHS programme have been evident in Malawi as – by 2014 – less than one third of health facilities had trained providers on the YFHS standards, and studies continued to reveal that adolescents are neither well-received nor comfortable in most government-owned clinics when they go to access various sexual and reproductive health services, as is the standard of care 23,24,25.
The facilitators for HIV testing
At the individual level, perceived susceptibility to HIV infection was cited as one of the key motivators for HIV testing among young people. This motivator was also closely linked to the perceived benefits of knowing one’s HIV status to the individual, indicating a good level of basic knowledge about HIV among the respondents, since it is only with adequate knowledge about HIV can young people admit susceptibility to HIV infection and decide to get tested. This seems to agree with the national picture on HIV related knowledge, as established by the 2015/16 MDHS, which found that over 40% of Malawians aged 15–24 had a comprehensive knowledge about HIV and over 80% in the same age group also acknowledged that a healthy-looking person can have HIV 8. Hence, this level of knowledge may also explain the respondents’ recognition of such a susceptibility to HIV and indicating that knowing one’s status has benefits to an individual.
Perceived consequences of late ART initiation are also a motivator for HIV testing behaviour among some adolescents and young adults, more especially as it relates to how those consequences – such as getting ill – impact one’s dependents. As argued, this is simply consistent with the 90-90-90 strategy which aims at making sure that at least 90% of HIV positive individuals know their status and immediately get initiated on ART because late ART initiation is one of the most prominent hindrances to controlling the HIV/AIDS epidemic for both individuals and entire populations 7,26. Despite this apparent appreciation of the benefits of early ART initiation however, a 2017 doctoral thesis study conducted in Southern Malawi found that young people generally have low ART adherence; largely due to factors such as poor medication self-efficacy, lack of social support and stigma, among others 27.
Among the facilitators identified by this study at the interpersonal level is the presence of partner support. Several studies have identified links between the presence of social reinforcements in a person’s life and that individual’s decisions regarding testing. For instance, in a study of factors that affected HIV testing among the youth in Kenya, researchers found that low social support was most strongly correlated with having no prior HIV testing and vice-versa 28, meaning that the presence of social support in general was a significant predictor of the intention to get tested among the young people who responded. Whether young people trust or view others as helpful – that is whether they view their available social supports as helpful – is a very important factor in help-seeking behaviour29.
Availability of community structures, such as youth clubs where young people engage with each other on issues to do with HIV and AIDS, emerged as a key facilitator to HIV testing among our participants. Research in Mzuzu City (Northern Malawi) showed that the odds of testing in boys living in a community with a functioning HIV/AIDS post-test club, among other facilities, were higher compared to boys from communities without such amenities 19. However, this model of providing HIV testing facilitators requires resources in order to be fully functional, which may explain why such structures were scarce in the sampled catchment areas of our study.
At the health system level, provision of HTC services through outreach clinics has been established as a key driver of HTS uptake among young people. Because the service providers interviewed in this study largely agreed on the issue of distance as a hindering factor to HIV testing among young people, we conclude that outreach clinics would indeed facilitate service uptake by addressing this distance and transport barrier, as has been identified by other studies 14,18.
Our findings may influence health providers to re-evaluate the impact of integrating HIV testing services with other health services in the same setting for all age groups. We observe that such integration negatively affects the utilization of HTS by young people. The findings will also motivate health facilities to prioritize mobile HIV testing activities or outreach clinics incorporating HTS. This is because these have been suggested by both the service providers and the interviewed young people as being helpful in reaching out to young populations with testing because they reduce the costs borne by the clients. This agrees with the findings of a 2018 study carried out in the districts of Blantyre, Machinga, Mwanza and Neno, which established that despite HIV testing services being free in Malawi, users still bear costs through lost income driven by long travel and waiting times at testing facilities. This observation led the reasearchers to recommend the decentralization of testing services beyond static facilities so as to increase uptake.30
Study limitations and gaps
This study’s qualitative approach meant that the strength of the association between the identified factors and HIV testing among the targeted population was not assessed. The study also did not include other key informants, such as parents of the adolescents and other community leaders such as chiefs and religious leaders, in its design. Since some studies have shown that what some of these leaders know and believe about the HIV/AIDS epidemic could make them key players in HIV/AIDS prevention efforts 31, the study may have missed some more views and data on the barriers and facilitators at the interpersonal and community levels.
Areas of further research
Future researchers may consider quantitatively assessing the strength of association between some of the related factors identified and HIV testing behaviour among young people; such as the extent to which fear of a positive result acts as a barrier to HIV testing among adolescents and young adults versus the extent to which perceived susceptibility to HIV infection acts as a facilitator for the same behaviour, for instance. The other area for further research would be an assessment of the effects of factors such as education, one’s general knowledge about HIV/AIDS and testing as well as one’s location of residence as potential influencers of HIV testing choices among young people, because these have also been known to influence the behaviour according to findings by other studies 32,33.