One of the goals of the revised Nigerian National HIV/AIDS Strategic Framework is to increase demand and uptake of HIV testing among young people in Nigeria [2]. To achieve this goal, it is crucial to understand young people’s preferences for HIV testing options. This will inform developing preference-sensitive, and locally appropriate HIV testing services for young people in the country. This study was conducted to examine youth people’s preferences for different HIV testing options. Specifically, we were interested in understanding preferences for six HIV testing characteristics - location of testing, test administrator, mode of pre-test and post-test counseling, type of HIV test, and cost of HIV test. Overall, the results of the study show that young people have variabilities in their preferences for HIV testing characteristics. This study expands the literature by focusing on Nigerian youth, quantitatively examining HIV testing option preferences, and captured low-income youth.
First, our findings highlight heterogeneity in preferences for HIV testing services among Nigerian youth. These results are consistent with previous literature on young people’s preferences for HIV testing in Malawi, Zimbabwe and South Africa that suggest that one size does not fit all [15, 22]. Many youth preferred HIV self-testing services while others preferred facility-based testing. There were variations in participant’s preferences across the six HIV testing options provided to the participants. This suggests the need for diverse HIV testing service approaches for young people.
Second, most of the participants preferred blood-based HIV self-testing compared to conventional facility-based venipuncture HIV test. Young people’s preferences for blood based HIVST was surprising given the high preference for facility-based HIV testing. This discordance in preference for HIV testing could be because of limited knowledge and understanding of HIVST. Only a small proportion (14%) of the participants had ever heard of HIV self-testing and only one participant had used HIV self-testing. Nonetheless, this is congruent with other evidence which suggests preference for blood-based self-testing compared to facility-based venipuncture HIV test in sub-Saharan Africa [16, 23], Asia [24] and Europe [25]. Our findings also suggest that in addition to increasing knowledge of and awareness of HIV prevention, efforts should be made to integrate information on the full range of testing approaches and prevention tools currently available within Nigeria [2]. This is to ensure that young have people have improved access to and knowledge of HIV testing services in the country.
Third, most of the participants indicated preference for blood-based HIV self-testing compared to oral HIV self-testing. This is similar to the findings in Tanzania [26] and India [27], where participants indicated strong preference for finger prick HIVST compared to oral HIVST due to lack of familiarity and concerns of accuracy with oral HIVST. On the contrary, several other studies in SSA (Malawi, Zimbabwe , Mozambique and Kenya )[15, 28, 29] and the United States of America [30] have largely reported preference for oral HIVST compared to other conventional HIV testing and finger-prick HIVST among study participants. Oral HIVST was preferred because it was easy to use, does not require blood and painless [15, 28]. Given the focus of utilizing HIVST as an innovative and additional approach to increase HIVST among young people in SSA [2, 22], HIVST interventions or programs focused on increasing awareness and uptake of HIVST may need to address some of the concerns around HIVST while highlighting their benefits.
Some youth preferred paying a small amount for HIV testing compared to the majority who wanted HIV testing to be offered free of charge. Similar findings were reported in other studies among young people in SSA (Malawi and Zimbabwe) [15, 31, 32] where young people indicated preference for HIV testing to be free or very low cost due to high financial dependence of young people on their families. High cost attached to HIV testing acts as a barrier to HIV testing among young people [31]. In Nigeria, HIV test is done for free in government clinics and may also explain participants’ preference for free HIV testing [33]. While free HIV testing may not be sustainable for a country like Nigeria that is heavily reliant (95% of funding) on international donors for HIV prevention and management efforts [34], HIV preventions interventions should be cognizant of young people’s aversion to pay for HIV testing. HIV testing interventions or programs should be designed to provide low cost HIV testing options for young people. Also, we found statistically significant association between payment for HV test and some participants characteristics (education level and religion). This suggests that socio-demographic characteristics may influence preferences for paying for HIV test or not. This association can be further explored in future studies to determine to what extent socio-demographic factors may explain young people’s preferences of HIV testing options such as payment for HIV test.
Not surprisingly, as other studies have clearly documented [31, 35], most the participants reported low or no risk perception for HIV. In our study, only fifty-four percent of the participants were sexually active. This could explain the low risk perception among the participants. Nonetheless, it would be important to explore this further in future studies, as low HIV risk perception have been reported as a significant factor that hinder or limit uptake of HIV testing services among young people in other settings [31]. A study in Tanzania for example reported association between self-perceived risk of HIV and voluntary HIV testing and counseling [35]. In the study, participants who reported low self-perceived risk of HIV were less likely to test for HIV [35]. Thus, there is a need to tailor prevention messages correctly so that they reach young people in high sero-prevalence settings in Nigeria, to increase uptake of HIV testing.
The limitations of this study should be kept in mind while interpreting its findings. One limitation is the potential sampling bias. Participants were conveniently recruited from a community youth health fair. Our study participants may be individuals who are already actively engaged towards improving their health. Nonetheless, the characteristics of the study participants are similar to other studies among young people Nigeria. These studies also recorded more female participants to male participants [36-39] and most of the young people had completed at least secondary school education [37, 40]. Another limitation is the social desirability response bias [41] or the possibility that some young people may have provided more socially acceptable responses, thus minimizing reporting their sexual and HIV testing history [42]. This was however mitigated by the anonymous nature of the self-administered survey. Finally, we did not confirm the HIV status of the study participants, which could potentially shape their preferences for HIV testing services [22].
The findings of this study have several implications for the design and implementation of HIV prevention programming, specifically preference-sensitive HIV testing options for young people in Nigeria. First, HIV prevention services should incorporate the needs and preferences of young people to enhance uptake HIV testing. Second, to achieve Nigeria’s HIV strategic objective of fostering an enabling environment where adolescents and young people have improved access to HIV testing services, our findings underscore the need to increase awareness of and access to newer HIV prevention services, including HIV testing options (e.g., free or reduced price or provider-initiated or self-tests). Efforts should also be made to identify ways to increase young people’s familiarity with these novel HIV prevention services to increase likelihood of uptake and/or consistent use. Equally important is working with young people themselves to better understand how and in what contexts these HIV prevention services may be adopted and consistently used [43, 44]. Thus, culturally appropriate interventions will be needed to engage young people in trying these unfamiliar HIV prevention tools. Data on the preferences of young people are also imperative to inform the design of youth-friendly interventions that are acceptable, accessible, and appropriate for all intended users.