Current Channels for Messaging HIVST Services
For HIVST messaging, the in-person channel was the most reported (85% FSWs and 68% MSM). This trend was followed by social media channels, including Facebook, Twitter, and Instagram (9.4% FSWs and 31.6% MSM). These proportions varied across the study locations. However, the importance of participatory learning and action platforms such as FGDs cannot be overemphasized. FGDs indicated that HIVST was newly introduced to the KP community groups, and integrated with other commodities such as PrEP, condoms, and lubricants, given that they all target the same population groups.
Qualitative data indicated that some MSM reported that they became aware of HIVST initially during peer group discussion and subsequently through NGOs, social media, flyers, emails, and face-to-face with a health care provider. While many of the respondents did not have a good understanding of the workability of the self-testing process, there were selected few who could properly describe the procedures. This finding of the key population's inability to describe procedures for self-testing was not encouraging especially in spite of using some KPs as ambassadors for promoting HIVST services. This might also explain the low access of the KPs to the self-testing services.
"The information I heard is that the HIV self-testing is a kit been used personally in your own convenient time to test yourself either from oral, oral fluids or from blood, so, so that's the information I got from the HIV test” CRS-KII-MSM-07
“Well, because a lot of our community members are not aware of the reason why they should use HIVST - some of those people that we invite usually come for the PrEP services, although the number is not that many, is not that high” LAS-KII-PM-01
Cross-sectional views of the respondents suggested that a variety of channels are being used to encourage wider communication of HIVST information, indicating that there is no one channel for effective delivery of the information.
“We use Facebook, we use WhatsApp, we use Instagram, we use Twitter”. LAS-KII-PM-01
“I belong to a group on Facebook where I get HIV messages from and that is how I got to know of the PrEP we are also talking about it now” CRS-FGD-MSM
In line with the COVID-19 social distancing protocol, program managers reported that the WhatsApp and other social media handles such as Facebook, Instagram, and Twitter handle also act as social support groups which they use to upload videos displaying information and demonstrating how to and how not to conduct self-test for HIV.
Enablers to Acquisition and Use of PrEP and HIVST Messaging among the KPs
Barriers to Acquisition and Use of PrEP and HIVST Messages
Stigma: Findings in this study indicated that stigma includes self and social stigma. The initial self-stigma comes due to the level of literacy required to participate in the social media-based peer session, retrieving messages, and navigating through the platforms. This phenomenon is preponderant among FSWs than MSM and leads to KPs pairing with their friends to receive social media/device-based information on the prevention commodities.
“Some people don't know how to read and write - some of them will choose to join their friends to do it because their friends are doing it. Some will feel ashamed and isolate themselves because they can't read” LAS-KII-FSW-07
From the KPs and program managers’ point of view, there is the tendency that some KPs who test positive for HIV may commit suicide due to social stigma and in a bid to reject the reality of the test results. Also, health provider perspectives indicated that KPs feel stigmatized among their peers for using PrEP.
“You know some persons can be funny. We don't want a situation whereby somebody will test his or herself and commit suicide” LAS-KII-FSW-09
"There are people who may not be comfortable with your sexual orientation and these commodities, because of this kind of situation, you can't hide like that. So, you have to tell the truth" AKS-KII-MSM-04
Discrimination: There is reported discrimination and harassment of KPs by security agencies in Nigeria and the neighbourhood. This is one of the reasons the KPs especially MSM, avoid face-to-face community activities where they could learn about PrEP, HIVST, and other prevention approaches. Discrimination sometimes hinders the MSM group to retain peer discussions and community-related information on their phones due to security personnel interferences to search people's devices.
“When a policeman sees some of us walking like a girl, all you’ll hear is “identify yourself”. And maybe you don't have an ID card, the policeman will go to your phone and before you know it he’ll abuse and infringe into your right just because of your physical appearance". LAS-KII-PM-02
The purported harassment, especially of the MSM community by government authorities was highlighted as one that will require assurance for confidentiality if they must receive face-to-face information.
"Face to face is good but depends on what information you’re sharing. There is something about our community, we need assurance that when they gather another thing will not happen" LAS-FGD-MSM
Fear: The fear of social embarrassment and pain of being associated with the use of ARV for HIV leads to withdrawal, rejection, and missed opportunities to start-up PrEP among the KPs. There is the concern that their partners and the entire society may inflict emotional and social injuries when found with medicines for PrEP. Some KPs opined that they can trade off life instead of taking PrEP.
“It is just fear – you hear KPs say that they don’t want a situation where they will take it because people believe that it is only those that already have HIV infection that supposes to take ARVs- that is their fear" LAS-KII-HCP-01
“Because they will be scared of information, some people believe they should die than knowing it (their status) which will cost them so much” LAS-KII-MSM-05
Privacy: The absence of privacy was found to limit the acquisition of information on PrEP and HIVST services. A significant number of the study participants do not have employment and share accommodation and personal effects with other household members. Therefore, they do not have privacy in keeping and using these essential HIV prevention commodities. Some MSM feel that closed groups such as WhatsApp and Facebook may be abused with gossip and intangible discussions, leading to a lack of willingness of some community members to participate in the discussions.
“The reason, I don't subscribe to this WhatsApp of a thing is, in the beginning, it would be very interesting but at the middle and the end, it's all gossips and stuff that make it boring and uninteresting" LAS-FGD-MSM-P3
Nevertheless, health providers reiterated that KPs tend to be more worried about the confidentiality of the test results, especially when a facility-based confirmatory test is conducted. From the peer educators’ perspective, one major challenge in relaying information on HIVST is the perceived breach of privacy. For example, peer educators have witnessed KPs’ anxieties around how to communicate positive test results to their influencers who may want to refer them to health providers at the facilities for a confirmatory test.
“Even if they take the self-testing kit to their house to test themselves and they come out positive, they will not come out to the facility to tell them you are positive” LAS-KII-PE-01
Also, KPs opined that the challenge of peer sessions is that since it's a group-based event, some KPs may not open up, thinking that there may be information diffusion to wrong personalities.
Limited access to channels of communication: Despite the KPs reporting that logistics was a huge challenge for face-to-face approaches, program managers rather suggested more cost-effective approaches – social media. Although there were positive responses regarding messaging through social media, some KPs complained that they do not have smartphones required to access social media interactions. Some of the FSWs complained about losing the social media handle addresses, mostly Instagram, and Twitter, while some have never been on social media due to lack of smartphones.
“For now, I am not on any social media platform because I don’t have an android phone, because they stole it” LAS-KII-FSW-01
MSM who preferred social media-based channels were of opinion that social media-based communication messages could be misinterpreted, probably due to the inability to correctly interpret the PrEP or HIVST messages. However, KPs recognized that social media benefits them in terms of cost and time savings as well as having to worry less to dress up to attend face-to-face sessions.
Limited electric power supply and internet access: Frequent low phone battery (resulting from limited power supply) and limited internet access were among the potential barriers to effective communication of PrEP and HIVST services among the FSWs especially as it has to do with social media platforms. For those KPs who participate in the social media-based peer sessions, electricity outages and battery discharge sometimes limit their ability to effectively participate and receive information via online peer sessions.
“Access to internet data can be a barrier because when there is no data, I can’t use Facebook or WhatsApp” AKS-KII-FSW-01
“Now when I am talking about WhatsApp or Facebook, the only thing that can hinder me from getting the information might be when I don’t have internet data. If I don’t have data, I cannot participate to get the information” AKS-KII-MSM-09
Language of communication: Some KPs reported that if PrEP and HIVST messages are presented in languages that they are not conversant with, the goal of the communication may be defeated. KPs insisted that those in rural settings should be considered when designing PrEP and HIVST messages in terms of tailoring the languages to a dialect that people would understand.
Socio-economic issues: Several of the MSM are unemployed and depend on their families who may not be able to afford the costs or may not want to pay for PrEP and HIVST services. Poor socio-economic status of KPs may limit attention span during online peer sessions and may lead to inability of the KPs to invest internet data and smartphones to participate in online discussions. Arguably, key influencers need to stay online for longer hours, require data to upload and maintain social media statuses and provide feedback and follow-up services to KPs who may be in need.
From the key influencers' and program managers' point of view, costs associated with participating in peer sessions (including in-person, virtual, and SMS) may hinder the communication of PrEP and HIVST information - these costs are usually indirect and could include costs of refreshment and transportation to the venue. Some KPs argued that the direct cost of PrEP and HIVST may deter KPs from accessing the services, especially for MSM who may be out of a job or depend on the caregivers for support if services are not provided free of charge.
“After approaching them, talking to them and showing them how to use it, the price for getting PrEP and HIVST should not be too high so that people can afford it” LAS-KII-FSW-01
KP influencers reported limited access to health facilities for referral, coupled with a need for follow-up on the use of the kit, especially in circumstances where the client tests negative and needs to be placed on PrEP or positive and requires further HIV care and treatment.
For non-face-to-face peer sessions, money is necessary to purchase a data bundle to enable KPs to receive social media-based PrEP and HIVST information. Some KPs reported that if the distance to the health facility is very far, they may not want to go there all the time due to indirect costs associated with transportation. For key influencers, lack of finance to procure data and other resources was reported as a challenge to relaying PrEP and HIVST information to KPs. Arguably, key influencers need to stay online for longer hours, require internet access to upload and maintain social media statuses and provide feedback and follow-up services to KPs who may be in need.
Program managers think that PrEP and HIVST information dissemination is impeded by the socio-economic status of the KPs. For example, poverty and hunger may limit attention span during peer sessions and may lead to the inability of KPs to purchase data and smartphones to enable them to participate in online discussions. Similarly, key influencers reiterated that the high cost of the commodities limits communication of PrEP and HIVST information to the KPs, especially the MSM community. This is because most MSMs are unemployed and depend on their families who may not be able to afford the costs or may not want to pay for the services. Aside costs, health providers anticipate that lack of incentives impede PrEP and HIVST messaging, arguing that KPs are attracted by non-financial rewards – whether through an online meeting or face-to-face.
“I know that Prep is very expensive, so, it is not easy to get” LAS-KII-HCP-02
Inadequate inclusion of KPs in program planning and implementation: There were also complaints that KPs and their key influencers are excluded from program planning – including initial and evaluation stages. Key influencers think that incorporating KPs and KPIs opinions would enrich the program's success as it relates to increasing awareness for the uptake of preventive services.
But again, there were views that there are not enough champions to drive the awareness campaign for PrEP and HIVST. This is worsened by the prohibition laws in Nigeria which put peer educators at risk of manhandling by the police and hoodlums.
Poor feedback mechanism: Influencers complained that KPs do not always return with the feedback of their HIV self-test results, making it difficult to follow up with further PrEP and other HIV services.
“So, the major challenge with self-test kit is that most often when they access this service, they don’t always come back with feedbacks” LAS-KII-KPI-01
Poor Attitudes of Healthcare Providers: Key informants interviewed indicated that KPs experience disrespect from providers, especially when the provider is not a community member, ranging from emotional abuse to delays, denial of services, and a bridge of confidentiality and privacy. KPs opined that poor interpersonal communication behaviors of health providers can drive them away from accessing PrEP and HIVST services or even from attending or following up with services.
Character, it goes a long way, the way the health providers welcome clients, counsel and interact has a lot to do with health-seeking” CRS-KII-FSW-07
“Sometimes, the health providers talk anyhow to clients. The way you talk to me will make me decide if I want to come back again” CRS-KII-MSM-01
Lack of incentives: KPs often expect financial and other non-financial rewards before participation in information sharing sessions, especially when it involves in-person peer sessions. Non-financial incentives included the provision of free condoms, lubricants, and HIVST kits while financial reward relates to transport fees despite that peer educators visit the KP locations, especially for the FSWs.
"You know here in Nigeria if you want to get somebody's mind, you're supposed to go with something, so there must be something like an incentive to attract them" LAS-KII-HCP-03
“Sometimes, when we come for the meetings (peer sessions), you guys don’t give us condoms or anything at all” CRS-KII-FSW-09
KPs attitudes and perceptions: The indifference of some KPs also limit the acquisition of PrEP and HIVST information, coupled with concerns of why PrEP has to be taken daily and HIVST conducted routinely. These concerns have also led to discontinuations of PrEP use. Among some KPs, there are still doubts about the efficacy of PrEP in protecting an individual, occasioned by advocacy for the combined use of PrEP and condoms for effective protection. KPs reported that this tends to be cumbersome in practice but would rather continue using condoms than PrEP.
Communication Needs of KPs for PrEP and HIVST Services in Nigeria
Receptiveness to future PrEP and HIVST messages: Quantitative data indicated that about 95.5% FSWs and 88.7% MSM indicated that they need to receive PrEP messages in the future. Similarly, 94.2% FSWs and 86.7% MSM were willing to receive HIVST messages in the future. Both FGDs and KIIs elicited reasonable and extreme willingness to receive more information on PrEP and HIVST regardless of the typology of KP. Despite a lack of awareness about PrEP and HIVST, KPs are willing to embrace the messages and are also eager to disseminate PrEP and HIVST information within and across their networks.
“I like it, if they want us to participate, I am ready” LAS-KII-FSW-01
“I need to have more knowledge about it so that I can relate the information to others” AKS-KII-MSM-09
Most KPs want more information on how to take PrEP, eligibility, clarity on the differences between PrEP and PEP, side effects, and pricing for PrEP.
“For now, I don't know anything about the drugs, but if I know more about the drugs (PrEP) I will communicate with my friends and anybody around me. But for now, I don't know anything about it” LAS-KII-FSW-07
Preferences for channels of communication: The preferred channels to receive PrEP and HIVST messages varied across KP typologies. While the FSWs preferred mainly face-to-face, phone calls, and SMS, the MSM group would prefer social media-based channels – mainly WhatsApp, Facebook, Instagram, and Twitter. Also, MSMs advocated for other closed social media channels that only admit community members who are usually introduced by their peers, including Mangam, Tindre, Grindre. The main reason MSM prefers social media approach to face-to-face is because their sexual orientation is criminalized, coupled with stigma and discrimination around it. There may be a high attrition rate in response to the physical meetings. This attribute is complicated by the high mobility of members of the MSM community.
“In our community, we are very mobile, almost every community member you see out there is on social media because that's where you meet new people, that's where we interact, that's where people socialize and meet themselves” LAS-KII-MSM-08
For some of the FSWs, reasons for not preferring social media channels included the unavailability of smartphones for chatting. For KPs who preferred face-to-face channels, the reason was that it offers the opportunity to ask questions, receive instant feedback, and facilitates understanding, while watching non-verbal cues. SMS was also not ranked top priority owing to the assumption that the receiver might decide to ignore the messages for a couple of days or may delete them permanently without reading them. SMS might also be subject to misinterpretation.
“I like WhatsApp. I like Instagram, I like Facebook also”. LAS-KII-FSW-05
“Yea, face to face, at least you will understand better” LAS-KII-MSM-03
“Because it is confidential, so I prefer WhatsApp, nobody has access to my WhatsApp and see what I am chatting” AKS-KII-MSM-09
“Text messages, WhatsApp, face-to-face, Instagram, Facebook, but I prefer text messages". Text messages as most of us don't have smartphones LAS-KII-FSW-06
The expected frequency for receipt of PrEP and HIVST information varied among the respondents, ranging from daily, weekly to monthly basis. There was no consistent pattern and time to receive HIV preventive messages.
Brothel-based FSWs would prefer that their chair ladies act as peer educators, enabled with posters, handbills, and other communication materials that will improve their work. Despite issues of not having a smartphone for social media-based communication, FSWs think that social media or telephone might confuse them and would rather prefer face-to-face interactions to receive PrEP and HIVST messages as this would offer opportunities for clarifications.
“I prefer it because I will be seeing the person explaining it to me, the way he's explaining it on the phone I might be confused, and I might not know what to do so I prefer face to face" LAS-KII-MSM-01
“I will like the person to talk to me, one-on-one interaction because I don't have a smartphone now. Also, I would like to receive text messages on it" LAS-KII-FSW-06
Table 5
Preferred channels of communication for PrEP and HIVST among KPs
|
PrEP
|
HIVST
|
|
FSW
|
MSM
|
FSW
|
MSM
|
Face-to-face
|
67.9
|
59.2
|
67.5
|
47.8
|
WhatsApp
|
8.3
|
17.6
|
9.3
|
20.9
|
Social media
|
0.3
|
1.3
|
5.4
|
24.6
|
SMS
|
20.1
|
12.4
|
24.6
|
20.6
|
Poster/flier
|
0.8
|
1
|
4.8
|
1.8
|
Radio/television
|
1.9
|
1.3
|
6.3
|
3.5
|
Other
|
0.9
|
7.2
|
1.7
|
6.4
|
For MSMs, the most preferred medium for meeting with a health provider is KP-specific platforms and channels, including the one-stop shops (OSS) that are community-driven and friendly.
"But for me, I think I prefer an NGO that deals with the key population, you don't need to be asked unnecessary questions compared to the general hospitals except in terms of STI” CRS-FGD–MSM.
KPs recommended a disaggregated, targeted communication for wider coverage, and also think that PrEP and HIVST information can be disseminated through churches since almost everyone attends religious gatherings. For instance, while those with smartphones can join social media, others without smartphones can be encouraged to attend face-to-face sessions. Face-to-face was repeatedly to better understanding, the opportunity for clarifications, and deeper interaction with the counsellor/peer educator. Consistently among FSWs, there were concerns that social media discourages the active participation of less-educated community members.
Communication with healthcare providers: There was no definite approach to meeting or consulting with health providers identified in this study. Some KPs preferred meeting their health providers face-to-face, though with flexibility for other channels of communication, mainly due to the non-verbal cues that face-to-face channel offers in supporting understanding for sensitive health issues or symptoms. However, there are strong indications for telemedicine among some KPs.
"They can call me on the phone if I need anything, I will tell them to come and meet me here" LAS-KII-FSW-01
“WhatsApp messages are perfect because it's convenient. Not seeing doctors face to face. Even when I travel to the village, I can still get my message via WhatsApp without issues”. LAS-KII-FSW-03
"I prefer face to face because I would be able to ask questions and I will be free to express myself. Like you know, it's just me and you here, people are not much in this place. If people were to be much here, I would not be able to answer all these questions or seat here to gist with you f" AKS-KII-FSW-03
Among the FSWs, preference for health care providers varied - while some FSWs prefer to meet older male health providers, some FSWs prefer to consult middle-aged female health providers who they perceived would maintain confidentiality for the care they provide.
“I need a mature male provider because they can understand. You can never hear your secret from someone else - a mature person can keep your secret” LAS-KII-FSW-03
Expected future content of the PrEP and HIVST messaging: KPs expressed the need for information on how to take PrEP, eligibility, clarification on differences between PrEP and PEP, clarification on any side effects, pricing, for PrEP, price, efficacy, sales point, dosage, available brands. However, Most KPs preferred to received PrEP and HIVST information in multiple languages: English Language or pidgin English, or local dialect.