Acceptability of Teleconsultation Services for HIV Care in Nigeria: A Mixed Methods Study

Abstract

Introduction:

Access to HIV care remains challenging, especially for patients living in remote areas, despite advances in antiretroviral treatment. The acceptability of teleconsultations for routine HIV care post-COVID is not well-explored. We explored factors influencing teleconsultation acceptability among people living with HIV (PLWH) and attending a tertiary care center in Kano, Nigeria.

Methods:

We used a cross-sectional mixed methods study design. Structured questionnaires were administered to 415 PLWH, supplemented by in-depth interviews with a subsample (n = 20). Logistic regression models and thematic analysis were used for data analyses.

Results:

Of 415 respondents, 55.7% (n = 231) expressed willingness for teleconsultations. Primary motivations included convenience/efficiency (46.7%, n = 194), elimination of travel expenses (31.8%, n = 132), and remote access to specialist care (17.3%, n = 72). Reasons for reluctance included distrust of technology (61.9%, n = 260) and privacy concerns (37.1%, n = 156). Acceptance was higher among males (adjusted odds ratio (aOR) =1.58, 95% confidence interval (CI) = 1.12–3.72), participants with at least secondary education (aOR = 1.47, 95% CI = 1.27–4.97), monthly income ≥30,000 Naira (aOR = 2.16, 95% CI = 1.21–7.31), currently married (aOR = 3.26, 95% CI = 1.16–5.65), and participants without comorbidities (aOR = 2.03, 95% CI = 1.18–4.24). PLWH who self-assessed as being in good health (aOR = 3.77, 95% CI = 1.44–9.94), used the internet regularly (aOR = 3.12, 95% CI = 2.17–5.37), or were aware of telemedicine (aOR = 3.24, 95% CI = 2.45–7.68) were also more accepting of telehealth services. Themes highlighted the need to offer teleconsultation as an optional service.

Conclusion:

Teleconsultation acceptance among PLWH was influenced by sociodemographic, clinical, and technology-related factors. Successful integration of teleconsultation services for PLWH in similar settings necessitates targeted educational interventions and assessment of organizational readiness.

Introduction

The global health challenge posed by the HIV/AIDS pandemic remains significant, especially in sub-Saharan Africa.¹ Nigeria, with an estimated 1.9 million people living with HIV (PLWH),² has made notable progress in enhancing access to antiretroviral therapy (ART) and prevention programs. Despite these efforts, a substantial number of PLWH still face challenges, such as traveling long distances to reach treatment centers, encountering delays caused by staff shortages, and experiencing stigma and discrimination.²

Telemedicine, which leverages telecommunication technology to deliver health care services remotely, has emerged as a promising solution.³ Specifically, teleconsultation, a subset of telemedicine, enables real-time, remote consultations between health care providers and patients through diverse digital communication tools, such as phone calls, video calls, secure social media messaging platforms, and applications.³ The potential of telemedicine goes beyond overcoming geographical barriers; it presents opportunities to bridge gaps in providing effective prevention and care services, particularly in reaching specific populations. Telemedicine could also help mitigate stigma, enhance patient–provider interactions, and improve the continuum of care for PLWH.⁴ Telemedicine constitutes one of the innovative strategies to achieve optimal outcomes across the spectrum of HIV prevention and care, supporting early HIV diagnosis, treatment initiation, sustained viral suppression, prevention of new transmissions, and rapid response to outbreaks.

Teleconsultants, comprising physicians, nurses, and other health professionals, offer remote services to patients or provide referral support for colleagues. Current evidence suggests that teleconsultations are comparable with, or slightly less effective than, in-person consultations, especially in terms of resource management, patient satisfaction, and clinical outcomes.^5,6 Nevertheless, concerns persist regarding service quality and accessibility, particularly for minority groups and in low-resource settings.^7,8

Until recently, telemedicine encountered regulatory and financial challenges in several health care settings.^9,10 However, the COVID-19 pandemic played a transformative role in hastening the global acceptance of telemedicine services, especially in countries such as China, the United Kingdom, and the United States.^11,12 In Nigeria, where the health care system experienced significant strain during the pandemic, telemedicine emerged as a crucial lifeline for PLWH, providing access to essential care while mitigating the risk of COVID-19 exposure.¹³ Despite its pivotal role, the acceptability of teleconsultations for routine HIV care in the post-COVID era remains uncertain, particularly in resource-constrained settings with a high HIV burden, such as Nigeria. In addition, there is a notable lack of evidence regarding the factors influencing attitudes toward teleconsultation for HIV care in these specific settings. Therefore, it is important to investigate the acceptability of teleconsultations for routine HIV care and identify the factors influencing attitudes toward teleconsultations within this subpopulation. This study could address this knowledge gap and provide insights that can inform health care policies and practices in similar resource-limited contexts, contributing valuable data to the growing body of global telemedicine research. This study identified the correlates and motivations influencing the acceptance of teleconsultations for routine HIV care among attendees of a tertiary center in Kano, Nigeria.

Methods

STUDY SITE AND POPULATION

The research was conducted at the S.S. Wali HIV Center in Aminu Kano Teaching Hospital (AKTH) in Kano, Nigeria. AKTH is a 750-bed tertiary hospital with a specialized HIV clinic that operates five days a week, offering a range of free HIV care services, including clinical consultations, laboratory investigations, antiretroviral drugs, patient support groups, counseling and testing, and home-based care.

The study participants consisted of adults (≥18 years old) living with HIV and enrolled in the antiretroviral therapy (ART) program at AKTH. The overwhelming majority of the participants (99%) were from the 44 local government areas of Kano State (Fig. 1). The remaining participants were from the neighboring states, including the Jigawa and Katsina States in northern Nigeria. Trained medical students informed patients about the study’s objectives during their waiting time for appointments, and those providing informed consent were considered eligible for interviews. Individuals deemed too ill for interviews, those with cognitive impairments, and those withholding consent were excluded.

Fig. 1.

Map of Nigeria showing study area.

STUDY DESIGN AND SAMPLING

We used a clinic-based, cross-sectional descriptive study design, utilizing a sequential, explanatory mixed methods data collection strategy. Structured questionnaires were administered to PLWH receiving ART, followed by in-depth interviews with a subsample of 20 survey respondents to provide nuanced explanations for their survey responses. The research team, comprising experts in quantitative, qualitative, and mixed methods research, conducted the study with the assistance of trained medical students who had no clinical responsibilities at the HIV treatment center. The students received training in interview techniques, sampling methods, confidentiality, consent procedures, structured questionnaire administration, as well as ethics and human subjects’ protection.

SAMPLE SIZE DETERMINATION

Sample size determination was based on Fisher’s formula for sampling proportions, assumed 50% acceptability, 95% confidence level, and a tolerable error of 5%.¹⁴ The minimum required sample size was calculated as 372, with an additional 10% added to account for anticipated nonresponses and rounded to 450.

PARTICIPANT RECRUITMENT AND SAMPLING

Participants were recruited while waiting to be seen at the HIV Center. Research assistants informed the patients about an ongoing study related to teleconsultations for routine care. Using the attendance register, a sampling process was used to identify potential participants. Patients whose serial numbers matched the sampling criteria were approached after their consultations. These patients were then provided with detailed information about the study, including its purpose, procedures, potential risks, and benefits. Those who agreed to participate provided informed consent and were invited to a designated room for interviews.

PLWH were systematically sampled, starting with a simple ballot between the first eligible attendee and the attendee whose serial number matched the sampling interval. Subsequent respondents were identified by adding the sampling interval to the previous respondent’s serial number until the desired sample size was achieved. For the qualitative component, a stratified purposive subsample of PLWH (n = 20) who participated in the survey were interviewed to further explore responses regarding the acceptability of telemedicine and teleconsultation. Stratification was based on sociodemographics (sex, age, education, income, residence) and clinical characteristics, including self-assessed health status.

MEASURES AND DATA COLLECTION

Survey questionnaires were adapted from previous studies,¹⁵ covering sociodemographic and HIV-related clinical data, awareness and knowledge of telemedicine and teleconsultations, as well as the acceptability and reasons for acceptance or reluctance, and previous experiences of these services. Qualitative interviews used open-ended questions with probes. All participants provided written or thumb-printed informed consent, with confidentiality assured through the removal of identifiers.

STATISTICAL ANALYSIS

Data were checked, cleaned, and analyzed using SPSS Version 27 (IBM Corp., Armonk, NY). Numerical data were summarized using means and standard deviations or median and range, while categorical variables were presented as frequencies and percentages. The statistical significance of crude associations between sociodemographic variables, clinical characteristics, and treatment with acceptability of teleconsultation was tested with Pearson’s chi-square test or Fisher’s exact test, as appropriate. Type I error was fixed at 5% for all tests.

A binary logistic regression model was developed for the primary outcome (acceptability of teleconsultation). The logistic regression model included independent variables with p < 0.10 at the bivariate level and potential theoretical and empirical confounders. The backward stepwise approach was used to select the most performant model. Adjusted odds ratios (aORs) and their 95% confidence intervals (CIs) were used to measure the strength and direction of the effect on the outcome. Hosmer–Lemeshow statistic and Omnibus tests were used to determine model fitness, with a Hosmer–Lemeshow chi-square p value >0.05 considered a good fit.

QUALITATIVE DATA ANALYSIS

Qualitative interviews were recorded and transcribed verbatim. Thematic analysis, based on the “Framework Approach,” included familiarization, coding, theme generation, code application to transcripts, matrix formation, and interpretation. Findings from both components were integrated.¹⁶

ETHICAL CONSIDERATIONS

The study protocol was approved by the Bayero University Health Research Ethics Committee. Participants were informed that their involvement was voluntary, and informed consent was obtained before the conduct of interviews.

Results

Of the 450 PLWH invited, 415 (92.2%) completed the interviews. Approximately one-third (34.7%, n = 144) were female, with an overall mean age (years) of 40.3 ± 10.29. The majority identified as being of Hausa-Fulani ethnicity (81.2%) and Muslim (86.3%). About two-thirds (65.7%) had at least a secondary education, while 26.0% had no formal education. The median duration of antiretroviral treatment was 8 years (range: 1–34 years). Over one-tenth (13.5%) of the respondents reported comorbid chronic diseases, and 9.2% rated their health status as fair or poor. Regarding internet use, 61.2% reported daily use. One-fifth of respondents (20.9%) accessed the internet rarely or never (20.9%) (Table 1).

Table 1.

Sociodemographic and Clinical Characteristics of People Living with HIV, Kano, Nigeria

CHARACTERISTICS	FREQUENCY NO. (%)
Sex
Male	144 (34.7)
Female	271 (65.3)
Age group
<30	62 (14.9)
30–39	139 (33.5)
40–49	133 (32.0)
≥50	81 (19.5)
Ethnicity
Hausa	264 (63.6)
Fulani	73 (17.6)
Others	78 (18.8)
Religion
Islam	358 (86.3)
Christianity	57 (13.7)
Education
Nonformal	108 (26.0)
Primary	31 (7.5)
Secondary	132 (31.2)
Postsecondary	144 (34.7)
Occupation
Unemployed/student	138 (33.3)
Trading	73 (17.6)
Farming	19 (4.6)
Civil service	58 (14.0)
Business	103 (24.8)
Others	24 (5.8)
Monthly income
<30,000	233 (56.1)
≥30,000	182 (43.9)
Marital status
Single	66 (15.9)
Married	257 (61.9)
Divorced/widowed	92 (22.2)
Number of children
0	72 (17.3)
1–4	198 (47.7)
5–9	125 (30.1)
≥10	20 (4.8)
Respondent’s duration of HIV diagnosis (years)
<5	103 (24.8)
5–9	116 (28.0)
≥10	196 (47.2)
Respondent’s duration on ART (years)
<5	107 (25.8)
5–9	121 (29.2)
≥10	187 (45.1)
Concomitant chronic disease
Yes	56 (13.5)
No	359 (86.5)
Self-perceived health status
Good	377 (90.8)
Fair/poor	38 (9.2)
Internet use
Daily	254 (61.2)
Weekly	57 (13.7)
Monthly	17 (4.1)
Rarely	57 (13.7)
Never	30 (7.2)

AWARENESS AND ACCEPTABILITY OF TELECONSULTATION FOR HIV CARE

Out of 415 respondents, 25.5% (n = 106) reported being aware of telemedicine (Table 2). Specifically, 24.1% associated telemedicine with medical consultations over the phone, 6.0% (n = 25) with remote medical diagnosis and treatment over the internet, 3.6% (n = 15) with medical advice through apps, and 2.4% (n = 10) with video calls between patients and health care providers.

Table 2.

Awareness, Perception, and Acceptability of Teleconsultations for HIV Care, Kano, Nigeria (n = 415)

	FREQUENCY N (%)
Awareness about telemedicine
Heard of telemedicine	106 (25.5)
Perception of telemedicine
Medical consultations over the phone	100 (24.1)
Remote medical diagnosis and treatment over the internet	25 (6.0)
Receiving medical advice through apps	15 (3.6)
Video calls between patients and health care provider	10 (2.4)
Others	2 (0.5)
Digital habits/use of internet
Daily	254 (61.2)
Weekly	57 (13.7)
Monthly	17 (4.1)
Rarely	57 (13.7)
Never	30 (7.2)
Preferred sources of information about telemedicine for HIV care
Health care providers	269 (64.8)
Media	156 (37.6)
Non-governmental organizations	88 (21.2)
Government agencies and organizations	84 (20.2)
Friends and family	17 (4.1)
Acceptability of telemedicine for HIV care
Willing to receive HIV care via teleconsultations	231 (55.7)
Motivations for adoption of telemedicine for HIV care
Convenience, time-saving, flexible appointments	194 (46.7)
Elimination of travel cost	132 (31.8)
Access to specialist care across the world	72 (17.3)
Availability of remote monitoring	44 (10.6)
Assurance of confidentiality/stigma reduction	30 (7.2)
Positive reviews and recommendation of others	6 (1.4)
Reasons for reluctance toward teleconsultations for HIV care
Lack of trust in technology	260 (61.9)
Concerns about privacy and online data security	156 (37.1)
Preference for in-person consultations	59 (14.2)
Lack of technical skills and access to technology	36 (8.7)
Lack of knowledge and fear of technology	11 (2.7)
Perceived challenges of teleconsultations
Will miss face to face interaction	181 (43.6)
Technical difficulties, poor infrastructure, and erratic internet	151 (36.4)
Concerns about confidentiality and data privacy	143 (34.5)
Uncertain quality of care	72 (17.3)
Others	2 (0.5)

ACCEPTABILITY, MOTIVATIONS, AND REASONS FOR RELUCTANCE TO USE TELEMEDICINE

Over one-half (55.7%, n = 231) of respondents expressed willingness to receive HIV care through teleconsultations (Table 2). Primary motivations for acceptance included convenience, time-saving, and flexible appointments (46.7%, n = 194), elimination of travel costs (31.8%, n = 132), access to specialist care (17.3%, n = 72), availability of remote monitoring (10.6%, n = 44), confidentiality and less stigmatizing (7.2%, n = 30), and positive reviews and recommendations from others (1.4%, n = 6).

The main reasons for reluctance included lack of trust in technology (61.9%, n = 260), concerns about privacy and data security (37.1%, n = 156), preference for in-person consultations (14.2%, n = 59), lack of technical skills and limited access to technology (8.7%, n = 36), and unfamiliarity and fear of technology (2.7%, n = 11).

Anticipated challenges with telemedicine included missing face-to-face interaction (43.6%, n = 181), technical difficulties and poor internet connections (36.4%, n = 151), concerns about confidentiality and data privacy (34.5%, n = 143), and uncertainty regarding the quality of care (17.3%, n = 72).

PREDICTORS OF ACCEPTABILITY OF TELECONSULTATION

Male patients had a 58% higher likelihood of accepting teleconsultations compared with their female counterparts (aOR = 1.58, 95% CI = 1.12–3.72) (Table 4). Respondents with secondary and postsecondary education had a 47% (aOR = 1.47, 95% CI = 1.27–4.97) and twofold (aOR = 2.27, 95% CI = 1.24–6.37) increased likelihood, respectively, of accepting telemedicine, in contrast to those with no formal education. Individuals with a monthly income of ≥30,000 Naira were twice as likely to accept teleconsultations for HIV care compared with their counterparts with lower incomes (aOR = 2.16, 95% CI = 1.21–7.31). Regarding marital status, respondents who were currently married had a threefold (aOR = 3.26, 95% CI = 1.16–5.65) increased likelihood of accepting teleconsultation services relative to divorced or widowed respondents. In addition, respondents without comorbidities had twice the likelihood of accepting teleconsultations (aOR = 2.03, 95% CI = 1.18–4.24) compared with those who did not have comorbidities. Similarly, compared with participants who self-assessed their health status as fair or poor, those who reported their health status as good had a fourfold increased likelihood of accepting teleconsultations (aOR = 3.77, 95% CI = 1.44–9.94). In terms of digital habits, respondents who accessed the internet regularly (daily, weekly, or monthly) were three times more likely to accept teleconsultations compared with their internet-naïve counterparts (aOR = 3.12, 95% CI = 2.17–5.37). Lastly, PLWH who were aware of telemedicine demonstrated a threefold increase in the likelihood of accepting teleconsultations (aOR = 3.24, 95% CI = 2.45–7.68).

Table 3.

Summary of Qualitative Findings

THEMES	SUBTHEMES	QUOTES
Thoughts and feelings about teleconsultation	Economic Considerations and Access to Care	“I like it; the concept is good considering the current economic situation... you simply get your recharge card or data, call your healthcare provider, then talk and get prescribed drugs for your care.”-48-year-old male
	Emotional Aspect	“To me, I feel it is very good because it shows that I am being loved and cared for by some people somewhere. Even though there is no physical contact, at least someone will call, ‘hello, am calling from AKTH, how are you doing.’ Seriously, I will be glad.”-40-year-old female
	Preference for Face-to-Face Consultations	“Well, some people think it is easier. For me, I prefer to have an in-person consultation; it is better than that phone call. The difference is if it is in-person, the physician can easily assess you and see things physically, which is not so with tele-consultation.”-38-year-old male
Potential benefits of teleconsultation	Cost Savings and Enhanced Privacy	“The benefits are many; people don’t have to come here; it eliminates transport costs, reduces contact with others, thereby enhancing health and privacy.”-28-year-old male
Potential benefits of teleconsultation	Importance of Face-to-Face Consultations	“Face-to-face consultations are sometimes necessary to allow for a thorough physical examination which is not possible via teleconcultation.”−34-year-old female
Circumstances encouraging teleconsultation	Security, Lockdown, and Convenience	“There are so many factors; insecurity, the COVID-19 or similar lockdowns, and long queues in the clinic. When we first started attending this clinic, we were few, but the number of patients coming to the clinic now per day is too much for the number of healthcare providers.”-48-year-old male
Circumstances encouraging teleconsultation	Travel-Related Situations	“If I travel, instead of missing my clinic appointment, I can choose teleconsultation option because of the distance and continue my medication.”-28-year-old male
Challenges associated with teleconsultation	Telecommunication Issues and Limited Literacy	“There are challenges like telecommunication network; we all know how our network signal is in this country.”-48-year-old male
Challenges associated with teleconsultation	Financial Constraints	“Sometimes there could be telecommunication network problems, there are people with low phone literacy, and financial constraints could also constitute barriers to effective teleconsultation.”−39-year-old male
Factors influencing decision to use teleconsultation	Prompt Responses and Optional Nature	“The only factor that will influence me is if I call, and they respond to me on time... Importantly, teleconsultation should be optional; face-to-face should remain the norm.”-40-year-old female
Factors influencing decision to use teleconsultation	Response Time and Disturbance to Providers	“If the health workers will respond on time and they would not feel we are disturbing them with repeated phone calls. I think this is critical to our adopting teleconsultations.”
Concerns and reservations about teleconsultation	Phone-Related Issues	“There may be concerns if I don’t have the phone or credit and also network difficulties; then I must come to the clinic in-person for consultation.”-30-year-old female
Concerns and reservations about teleconsultation	Teleconsultation Scope	“I am of the view that teleconsultation should be reserved for minor problems such as seeking information or clarification, more serious issues should be tackled during in-person consultations.”−28-year-old male

Table 4.

Logistic Regression Model for Predictors of Acceptability of Teleconsultations for HIV Care, Kano, Nigeria (n = 415)

CHARACTERISTICS	N	THE PROPORTION OF PLWH WILLING TO ACCEPT TELECONSULTATIONS NO. (%)	p VALUE	CRUDE OR (95% CI)	ADJUSTED OR (95% CI)	p VALUE
Sex			<0.001^*
Male	144	101 (70.1)		2.55 (1.66–3.91)	1.58 (1.12–3.72)	0.023^*
Female	271	130 (48.0)		Referent	Referent
Age group			0.99
<30	62	34 (54.8)		Referent	Referent
30–39	139	77 (55.4)		0.98 (0.54–1.78)	0.75 (0.46–1.97)	0.23
40–49	133	74 (55.6)		0.97 (0.53–1.77)	0.69 (0.42–1.92)	0.44
≥50	81	46 (56.8)		0.92 (0.47–1.80)	0.73 (0.27–1.99)	0.25
Ethnicity			0.47
Hausa	264	141 (53.4)
Fulani	73	44 (60.3)
Others	78	46 (59.0)
Religion			0.72
Islam	358	198 (55.3)
Christianity	57	33 (57.9)
Education			<0.001^*
Nonformal	108	48 (44.0)		Referent	Referent
Primary	31	9 (29.0)		0.51 (0.22–1.21)	0.69 (0.39–1.22)	0.37
Secondary	132	70 (53.0)		1.56 (1.18–4.35)	1.47 (1.27–4.97)	0.029^*
Postsecondary	144	104 (72.2)		3.25 (1.92–5.50)	2.27 (1.24–6.37)	0.014^*
Occupation			0.072
Unemployed/student	138	66 (47.8)		Referent	Referent
Trading	73	37 (50.7)		1.50 (0.57–3.96)	1.27 (0.35–2.67)	0.28
Farming	19	11 (57.9)		2.42 (0.27–2.64)	1.54 (0.13–1.67)	0.47
Civil servant	58	40 (69.0)		1.79 (0.66–2.01)	1.46 (0.54–2.14)	0.66
Business	103	64 (62.1)		1.29 (0.54–3.08)	1.16 (0.29–2.87)	0.46
Others	24	13 (54.2)		1.34 (0.48–3.71)	1.27 (0.43–3.21)	0.39
Monthly income (Naira)			<0.001^*
<30,000	233	109 (46.8)		Referent	Referent
≥30,000	182	122 (67.0)		2.31 (1.55–3.46)	2.16 (1.21–7.31)	0.013^*
Marital status			<0.001^*
Single	66	45 (68.2)		1.96 (1.16–4.21)	1.67 (1.36–4.61)	0.027^*
Married	257	154 (59.9)		3.60 (1.22–9.69)	3.26 (1.16–5.65)	0.006^*
Divorced/widowed	92	32 (34.8)		Referent	Referent
Number of children			0.067
0	72	44 (61.1)		Referent	Referent
1–4	198	108 (54.5)		0.76 (0.44–1.32)	0.63 (1.41)	0.57
5–9	125	63 (50.4)		0.65 (0.36–1.17)	0.59 (0.31–1.24)	0.76
≥10	20	16 (80.0)		2.55 (0.77–8.40)	2.13 (0.83–7.43)	0.27
Duration of HIV diagnosis (years)			0.46
<5	103	57 (55.3)
5–9	116	70 (60.3)
≥10	196	104 (53.1)
Duration on ART (years)			0.47
<5	107	58 (54.2)
5–9	121	73 (60.3)
≥10	187	100 (53.5)
Concomitant chronic disease			0.008^*
Yes	56	22 (39.3)		Referent	Referent
No	359	209 (58.2)		2.15 (1.21–3.83)	2.03 (1.18–4.24)	0.029^*
Self-assessed health status			<0.001^*
Good	377	221 (58.6)		3.97 (1.87–8.40)	3.77 (1.44–9.94)	0.013^*
Fair/poor	38	10 (26.3)		Referent	Referent
Internet use			<0.001^*
Daily/weekly/monthly	328	204 (62.2)		3.66 (2.20–6.06)	3.12 (2.17–5.37)	0.024^*
Rarely/never	87	27 (31.0)		Referent	Referent
Aware of telemedicine			<0.001^*
Yes	106	86 (81.1)		4.86 (2.85–8.31)	3.24 (2.45–7.68)	0.033^*
No	309	145 (46.9)		Referent	Referent

The logistic model includes the following variables: Respondent’s sex, age group, education, occupation, monthly income, marital status, number of children, concomitant chronic disease, self-assessed health status, internet use, and awareness of telemedicine.

Hosmer–Lemeshow chi-square = 11.2, p = 0.13.

Significant at p < 0.05.

OR, odds ratio; CI, confidence interval.

Statistically significant at p < 0.05.

QUALITATIVE FINDINGS

Qualitative analysis of interviews with individuals receiving HIV care revealed diverse perspectives on teleconsultation (Table 3). Some participants appreciated its convenience and cost savings, citing economic considerations and improved access to care through simple phone calls. Perceived benefits included enhanced privacy and accessibility, particularly in situations such as insecurity, lockdowns, and long clinic queues.

Challenges associated with teleconsultation were identified, such as telecommunication issues, limited phone literacy, and financial constraints. Participants emphasized the importance of prompt responses from health care providers as a critical factor influencing their decision to adopt teleconsultation.

Concerns were raised about phone-related issues, including low funds and network problems. Some participants suggested reserving teleconsultation for minor issues and face-to-face consultations for more serious matters. Despite positive aspects, participants generally considered face-to-face consultations as the norm, with teleconsultation as an optional and supplementary health care service.

Discussion

We identified the predictors and motivations for the acceptance of teleconsultations for HIV care in Nigeria. We found limited awareness of teleconsultations, with only about one-quarter of respondents having heard about telemedicine. Half of the respondents considered teleconsultations acceptable for HIV care. Predictors of acceptability included sex, education, income, marital status, comorbidities, health status, digital habits, and prior awareness of telemedicine. Qualitative insights highlighted convenience, cost reduction, time-saving, and flexible appointments as key motivators. Conversely, reluctance stemmed from concerns about technology, trust, privacy, a preference for in-person consultations, and perceived technical limitations.

The limited awareness of telemedicine in the sample aligned with studies in parts of Nigeria,^17,18 sub-Saharan Africa,¹⁹ and other low- and middle-income countries,²⁰ but was lower than among PLWH in Brazil^21,22 and the United States.^23,24 Apart from the increased use of telemedicine during the COVID-19 pandemic in higher income settings, these variations could be attributed to diverse population characteristics, methodological approaches, technological penetrance, and digital literacy levels, and emphasize the need for focused research to explore contextual factors.

The acceptance of teleconsultation is in agreement with existing literature, recognizing its advantages, including convenience, cost savings, flexibility, and improved health care access.²⁵ Recent reviews have highlighted the feasibility and acceptability of videoconferencing and video-based interventions. These modalities proved effective in promoting HIV testing, treatment initiation, adherence to medication, and enhancing linkage and retention in treatment for PLWH.²⁶ Telehealth interventions have also demonstrated success in reducing depressive symptoms and improving perceived quality of life.²⁷

The emotional connection with face-to-face consultations described by some participants echoes studies emphasizing patient satisfaction and the human aspect of telemedicine.²⁸ The preference for in-person visits among some respondents is consistent with previous research highlighting the need for patient-centered approaches that accommodate individual preferences when introducing technological innovations to health care.^29
–31 Our identification of circumstances encouraging teleconsultation adds context-specific insights, reinforcing the need for adaptable health care delivery models in the context of HIV care.^32,33

Practices transitioning to telemedicine from traditional in-person clinics reported various benefits, including improved retention in care for patients residing far from clinics and enhanced privacy for those hesitant to attend HIV clinics. However, challenges such as limited access to technology, digital literacy, and privacy concerns for homeless patients were noted.^34
–36 Health care should be tailored to individual patient needs and limitations, especially for those at risk of discontinuation of care.

Challenges related to telecommunication infrastructure, network issues, phone literacy, and financial constraints echoed existing literature.^37
–39 Policy interventions focusing on improving digital infrastructure, enhancing digital literacy, and implementing financial support mechanisms are essential. The preference for prompt responses and the desire for teleconsultation to remain optional underscore the importance of preserving patient choice while integrating telemedicine into HIV care.

The higher acceptance of teleconsultation among male participants hints at potential gender-related disparities in technology adoption within the context of HIV care-seeking behaviors.^40,41 Cultural factors, differential access to education, or variations in health-seeking behaviors between genders may contribute to this distinction.⁴² For instance, in the Islamic practice of purdah, which is common in the study area, physical attendance at clinics could provide women with an opportunity to interact with friends and acquaintances.⁴³ The impact of education and socioeconomic status on teleconsultation acceptance^44,45 underscores the role of education in shaping health literacy, fostering positive perceptions of technology-enabled health care solutions, and enhancing financial capability.^46,47 The latter is often associated with improved access to digital devices, a stable internet connection, and the ability to afford health care services.^48,49 Likewise, the emergence of digital habits, particularly regular internet use as a strong predictor, emphasizes the importance of digital literacy and engagement.⁵⁰ The higher likelihood of acceptance among those with prior awareness of telemedicine also underscores the importance of educational campaigns.

The predictive roles of marital status and perceived health status likely reflect social support structures and the desire for minimal interaction with the health system. Single individuals and those currently married may benefit from robust support systems compared with widows or divorced individuals,^51,52 who may face sanctions or be blamed for introducing HIV into the family.⁵³ Similarly, PLWH in perceived good health may be more receptive to teleconsultations to minimize interactions with the health system and avoid potential stigma.^54,55 Lastly, the qualitative insights provided contextual challenges and opportunities associated with teleconsultation in HIV care, emphasizing the importance of considering both emotional and practical aspects in the development and implementation of telemedicine services.

Telecommunications infrastructure and high data costs can hinder access to teleconsultation services.^13,56 Economic barriers and social status negatively impact the ability to afford necessary technology, while unreliable connectivity can impede digital access for those in remote areas who could benefit most from such services.⁵⁷ Privacy concerns, such as the fear of being overheard during consultations, particularly among women, can also act as barriers to adoption.¹⁰ Maintaining confidentiality is particularly important in environments where HIV-related stigma remains prevalent. The norm of face-to-face clinical consultations and unfamiliarity with telemedicine can also cause resistance.⁵⁸ Women, who often face more substantial barriers to health care access due to cultural and societal norms, might find teleconsultations more appealing if these services can be accessed discreetly from their homes. Men, on the contrary, might be concerned with being perceived as “weak.”⁵⁹ Addressing these challenges requires improving infrastructure, reducing data costs, ensuring secure communication channels, and engaging communities through culturally sensitive education. Tailoring interventions to address gender-specific barriers will further enhance the acceptability and utilization of teleconsultation services.

Overall, addressing disparities in gender, education, income, and health status was deemed important for ensuring equitable access to teleconsultation services. Policymakers and health care providers should collaborate to enhance adoption, addressing critical concerns related to technology trust, privacy, and digital literacy. Targeted educational interventions and strategies, such as implementing teleconsultation as an optional service, ensuring timely responses, and recognizing patient preferences for face-to-face consultations, are recommended for successful integration. Tailored interventions that consider the specific needs and characteristics of different demographic groups can enhance the overall success of telemedicine initiatives in the context of HIV care in Nigeria.

The strengths of this study include the mixed methods design and a large sample size drawn from participants living in a high-burden setting. The limitations include potential biases in self-reported data, the cross-sectional study design restricting causal relationships, and reduced generalizability associated with enrolling participants from a single tertiary referral center. Future research should explore health care provider perspectives and organizational readiness.

In conclusion, this study contributes to our understanding of factors associated with acceptability of telemedicine for HIV care, and provides valuable insights for tailored interventions, policy development, and integration of telemedicine into routine HIV care in similar settings.

Ethical Approvals

Research and regulatory approvals were obtained from the AKTH Ethics Committee (FWA00026225).

Footnotes

Disclosure Statement

The authors declare that they have no competing interests.

Funding Information

This work is supported by the Fogarty International Center (FIC) and the National Institute on Alcohol Abuse and Alcoholism of the U.S. National Institutes of Health (NIH), award number 1D43TW011544. The findings and conclusions are those of the authors and do not necessarily represent the official position of the FIC, NIAAA, NIH, the U.S. Department of Health and Human Services, or the U.S. Government.

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