Abstract
Concerns about stigma and confidentiality limit the uptake of HIV testing and counseling (HTC) among young adults. HIV self-testing has been offered as a youth-friendly alternative to conventional HTC. We conducted a cross-sectional study to assess HTC uptake, willingness to self-test, and their predictors among university students (n = 399) in Kano, Nigeria. Anonymous self-administered questionnaires were provided to participants. Adjusted odd ratios were generated for predictors with logistic regression models. The results showed that only 35.8% (n = 143) of participants had previous HTC.Most respondents (70.4%, n = 281) were willing to self-test. HTC was associated with year of college (500 Level vs. 100 Level), adjusted odds ratio (AOR, [95% Confidence Interval (CI)] = 0.44 (0.19–0.97), campus residence (off- vs. on-campus, AOR = 0.45; 95%CI: 0.28–0.73), sexual activity in the past six months (AOR = 0.39; 95%CI: 0.24–0.64), willingness to self-test (AOR = 0.38; 95%CI: 0.22–0.66), and consistent condom use (AOR = 4.45; 95%CI: 1.41–14.08). Students who were older (≥ 30 vs. <20 years, AOR = 0.20; 95%CI: 0.05–0.90) and female (AOR = 0.56; 95%CI: 0.32–0.98) were less likely to be willing to self-test, whereas students who were more senior (500 Level vs. 100 Level, AOR = 5.24; 95%CI: 1.85–14.84), enrolled in clinical science programs (vs. agriculture, AOR = 4.92; 95%CI: 1.51–16.05) or belonging to “other” ethnic groups (vs. Hausa–Fulani, AOR = 2.40; 95%CI: 1.11–5.19) were more willing to self-test. Overall HTC uptake was low, but acceptability of self-testing was high. College seniority, age, ethnicity, and program of study were associated with willingness to self-test. Our findings support the feasibility of scaling up HIV self-testing among university students in Nigeria.
Introduction
HIV testing and counseling (HTC) has increased access to antiretroviral therapy, yet nearly one in five persons living with HIV are unaware of their status. 1 These numbers are even lower in West and Central Africa—at the end of 2018, less than two-thirds (64%) of people living with HIV in the sub-region knew their HIV status, compared to 85% in East and Southern Africa. 1 Although East and Southern Africa is the most affected sub-region (adult prevalence of 7%), the HIV response there has been more effective, with improved availability of HIV testing and access to antiretroviral treatment (67%) compared to West and Central Africa, where the adult HIV prevalence is 1.5% with only 53% of HIV-infected persons accessing antiretroviral treatment. 1
HIV self-testing (HIVST), the performance and interpretation of a rapid diagnostic test on one’s own oral fluid or blood sample in private, is an additional approach to increasing uptake of HIV testing services. 2 However, HIVST has its drawbacks, including requiring confirmation, risk of self-harm and partner violence, and missed opportunities for counseling and prompt linkage to care. 3 Nevertheless, in some settings, HIVST has doubled the uptake and frequency of HIV testing uptake, with minimal risk. 4 The reported acceptability of HIVST among young adults in some African countries range from 60.3% to 96.4%,5–7 while among students it ranged from 81.4% to 87.1%.8–14
Nigeria is Africa’s most populated country, with a population of ∼200 million, half of whom are young adults. The national HIV prevalence in Nigeria is 1.4%, with a three-fold higher prevalence (1.3%) among young women aged 20–24 years, compared to men of the same age group (0.4%). 15 University students are at increased risk of contracting HIV and other sexually transmitted infections, due to increased opportunities for sexual experimentation and risky sexual activities associated with new-found social freedoms. 16 The cultural milieu in northern Nigeria also encourages early marriage, intergenerational marriage, and concurrent sexual partnerships. Furthermore, child labor, female genital cutting, divorce, re-marriage, low pre-marital HIV screening, and low condom use increase the risk among young adults. 17
Despite their increased risk, HIV testing rates among young Nigerians is very low—in 2017, only 9.5% of males aged 15–24 years and 12.1% of females of the same age in Nigeria reported having tested for HIV in the prior year and received the results of their test. 18 The World Health Organization (WHO) has encouraged the adoption of HIVST, 19 yet little country-specific research has focused on university students in Nigeria. Variable HIVST acceptance rates have been reported in sub-Saharan Africa,8–10,20,21 but to our knowledge, none of these studies was conducted among students in Nigeria. Being the most educated cohort, university students could serve as peer educators and link youths to treatment, thereby enabling the achievement of the 95–95–95 target of ending the AIDS epidemic by 2030. 1
Objective
The objective of this study is to examine the acceptability of HIVST and identify factors associated with the uptake of HIVST services among university students in Kano, Nigeria. Improved understanding of HIV testing history and attitudes toward HIVST among university students could inform the development of targeted programs, facilitate HIVST, and expand access to HIV prevention and treatment services.
Materials and methods
Study area and population
The study was conducted on the two campuses of Bayero University and its affiliated teaching hospital. Bayero University is located in Kano, northern Nigeria, and has two colleges, two schools, and 19 faculties with an undergraduate student population of 21,682. 22 The majority of students are from Kano and neighboring states, but a sizeable proportion come from other parts of Nigeria and West Africa. 22 The study population consisted of registered undergraduate students. We excluded postgraduate students, students on postings outside Kano, on sick leave, and those who withheld consent.
Study design and sampling
The study was cross-sectional in design. The sample size was obtained using Fisher’s formula for a single proportion, 23 with the confidence level set at 95%, and a tolerable error of 5%. We assumed that half of the 21,682 students would be willing to self-test, as a prior stakeholder survey reported that about half of the students (54.8%) supported the introduction of HIVST, and a p = 0.50 minimizes sampling error and provides maximum sample size. 24 The sample size (n = 384) was increased by 10% to account for non-response, giving a final sample size of 427.
A multistage sampling method was used. In the first stage, 25% of the faculties/courses of study were selected using a one-time ballot. Pieces of paper with serial numbers were mixed in a box and five picked, representing the sampled faculties. In the second stage, one department was selected from each sampled faculty/course of study using the same method. In the third stage, proportionate numbers were allocated to each department and level. Students were systematically recruited from each level.
Ethical clearance was obtained from the Aminu Kano Teaching Hospital Ethics Review Committee (approval number NHREC/21/08/2008/AKTH/EC/2512). Informed consent was obtained after providing detailed information about the study to potential participants. Students were informed that participation was voluntary and that non-participation had no consequences. No incentives were provided. Students who required counseling or health services were referred to the University health services. Questionnaires were anonymous and participants were identified by unique serial numbers in the database.
Data collection and measures
Data were collected using a structured questionnaire adapted from a previous study. 25 The first section had 12 items eliciting participants’ socio-demographic characteristics, including age, marital status, religion, ethnicity, faculty/course of study, and level of study and residence. The second section consisted of 17 items that inquired about previous HIV counseling and testing, place, frequency, motivations for testing, and reasons for not testing. The questionnaire also assessed awareness of self-testing for HIV. The third section ascertained participant’s willingness to self-test. The final section centered on previous HIVST, self-reported sexual activity, and risk behavior, including the number of sexual partners and condom use.
The questionnaire was pre-tested for clarity and cultural sensitivity on 40 students of Maitama Sule University, another university located in Kano, Nigeria. The test–retest correlation was used. The questionnaire was administered among the same participants three weeks after the first assessment. Content validity was ascertained by infectious disease specialists and community physicians at Aminu Kano Teaching Hospital. Reliability estimates were based on Cronbach’s alpha values. The sections on HIV testing history, willingness to self-test, and risky sexual behavior had Cronbach’s alpha values of 0.83, 0.88, and 0.82, respectively.
The two main outcomes of this study were: (1) previous HIV counseling and testing and (2) willingness to self-test for HIV. Previous HIV counseling and testing was determined using the question “Were you ever counseled and tested for HIV?”, with two options: “Yes”, coded as “1”, and “No”, coded as “0”. Similarly, willingness to self-test for HIV was assessed using “Are you willing to test yourself with HIV self-test kit?”, with two choices: “Yes”, coded “1”, and “No”, coded as ‘0’.
The explanatory variables for the two outcomes included socio-demographics (gender, age, ethnic group, religion, state of origin), faculty/course of study, and level of study, residence, sexual activity, and risk behavior (number of sexual partners, condom use). Willingness to self-test for HIV was included as an independent variable in the model for previous HIV counseling and testing, while previous HIV counseling and testing was included as an independent variable for willingness to self-test.
Procedures
Students were informed of the study through union and department representatives and fliers/posters. Trained research assistants provided self-completed questionnaires to sampled students during lunch break and retrieved it after completion. All questionnaires were checked for completeness and data were double-entered independently by clerks into a password-protected database at the Centre for Infectious Diseases Research.
Data analysis
Data were coded, sorted, and processed using SPSS software version 22 (IBM Corp., Armonk, NY). 26 After data cleaning, continuous data were summarized using means with standard deviation or median with range. Categorical data were presented as frequencies and percentages. At the bivariate level, Pearson’s chi-square was used for comparison of the frequencies, while Fisher’s exact test was used when the validity conditions of the latter test were not verified. 27 Multicollinearity was checked between independent variables using collinearity statistics, with a tolerance value cut off of <0.2. The criteria used for multicollinearity was tolerance and it’s reciprocal, the variance inflation factor (VIF). If the value of tolerance was less than 0.2 and the value of VIF was 10 and greater, then the multicollinearity was considered problematic, and only one of the variables is included in the model. 28 However, none of the variables reached the threshold for elimination. Variables with p < 0.10 at the bivariate level and those that were contextually important were entered into a multivariate logistic regression model.29–31 Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were computed using the stepwise approach for each of the two main outcomes (“Previous HIV counseling and testing” and “willingness to self-test for HIV”). Hosmer–Lemeshow statistic and Omnibus tests were conducted to determine model fitness, with a Hosmer–Lemeshow chi-squared yielding p-value of >0.05 indicating a good fit. 32
Results
Socio-demographic and behavioral characteristics
Of 427 students recruited, 399 (93.4%) completed the questionnaires. Reasons for non-response included “I am too busy” (n = 12, 2.8%), “I have other appointments (n = 7, 1.7%)”, and “It would take too much time” (n = 9, 2.1%). Participants were mostly young (mean age ± SD, 23.3 ± 0.18 years), male (60.0%, n = 239), and single (87.5%, n = 349). Majority were of Hausa/Fulani ethnic group (84.5%, n = 337) and Muslim (96.0%, n = 383). Half of the respondents were in their fifth or sixth year of study and two-thirds resided off-campus. Over a quarter of participants were sexually active. Among those sexually active, a third had multiple sex partners, and 18.3% used condoms at their last sexual encounter (Table 1).
Socio-demographic characteristics of University students, Kano, Nigeria.
aOthers = Igbo, Yoruba, Tiv, Egbira, Kanuri, and Nupe.
bOthers = Other Nigerian states.
cOnly for sexually active respondents.
HIV counseling and testing, motivations, and reasons for not testing
Only 143 participants (35.8%) had previously been tested for HIV. Of these, 59.4% (n = 85) received HIV testing once. The most frequent motivations for HIV testing were to meet physical examination requirements for university admission (28.0%, n = 40), due to recommendations from a health provider (16.8%, n = 24), or in response to suggestions from a friend or family member (13.3%, n = 19). About a quarter (24.5%, n = 35) of the respondents last tested in the preceding 12 months. Testing was mostly at the university clinic (16.5%, n = 66) or a HTC center (10.3%, n = 41). The common reasons for not testing included: “I don’t think I have HIV” (47.3%, n = 121), “I would have liked to, but did not have the opportunity” (20.0%, n = 51), and “There is no reason for testing” (16.8%, n = 43, Table 2). At the bivariate level, prior HTC was more prevalent among older, non-Hausa–Fulani students, and among first and final year students and those that were willing to self-test. Higher previous testing rates were observed among sexually active students engaged in risky behavior and campus residents (p < 0.05, Table 3).
HIV testing history and willingness to self-test among University students, Kano, Nigeria (N = 399).
aWet nurse requirement, NGO Health campaign, and as part of the practical course.
bPharmacy shop/chemist shop, and private hospital/clinic.
HIVST: HIV self-testing.
Prior HIV testing and willingness to self-test by respondent characteristics, Kano, Nigeria (n = 399).
bOnly for sexually active respondents.a statistically significant at P<0.05
Awareness and willingness to self-test for HIV
Slightly more than half (55.9%, n = 223) of the respondents had heard about HIVST prior to the study. Only 9.0% (n = 36) of respondents reported previous HIVST. The overwhelming majority of participants were willing to self-test (70.4%, n = 281) and to pay for the test kits (55.9%, n = 223). Over half (61.4%, n = 245) of the respondents were willing to self-test with a sexual partner. At the bivariate level, willingness to self-test was consistently high across gender, age, ethnic, religion, state, and marital categories (p > 0.05, Table 3).
Predictors of HTC
The independent predictors of previous HTC included level of study, residence, sexual activity, condom use, and willingness to self-test. Students in the second to sixth year of study were 72–74% less likely to have had HTC compared to first-year students. Compared to campus residents, students living off-campus were 55% less likely to have had prior HTC (AOR = 0.45 (95%CI: 0.28–0.73)). Similarly, students who were not sexually active were 61% less likely to have tested for HIV compared to their sexually active peers (AOR = 0.39, 95%CI: 0.24–0.64). Occasional and regular condom users were respectively six and four times as likely to have tested for HIV compared to never users. Respondents who were unwilling to self-test for HIV were 62% less likely to have had HTC compared to those who were willing (AOR = 0.38, 95%CI: 0.22–0.66)). The logistic regression model was a good fit (Hosmer–Lemeshow Goodness-of-fit test x 2 = 3.54, p = 0.90).
Predictors of willingness to undergo HIVST
Willingness to self-test for HIV was predicted by respondents’ gender, age, ethnicity, faculty/course of study, and level of study (Table 4). Females were 44% less likely to be willing to self-test for HIV compared to males (AOR = 0.56, 95% CI: 0.32–0.98). Similarly, older respondents (≥30 years) were 80% less likely to be willing to self-test for HIV compared to their younger counterparts, age <20 years (AOR = 0.20, 95%CI: 0.05–0.90). Non-Hausa–Fulani students were twice as likely to self-test for HIV compared to their Hausa–Fulani colleagues (AOR = 2.40, 95%CI: 1.11–5.19). Furthermore, students of the faculty of clinical science had nearly five-fold increased likelihood to be willing to self-test for HIV compared to those in the faculty of agriculture (AOR = 4.92, 95%CI: 1.51–16.05). Students in their fifth year of study or later were five times as likely to be willing to self-test for HIV relative to first-year students (AOR = 5.24, 95%CI: 1.85–14.84). Finally, students with no history of prior HTC were 57% less likely to be willing to self-test for HIV (AOR = 0.43, 95%CI: 0.24–0.79). The model was a good fit (Hosmer–Lemeshow Goodness-of-fit test x 2 =6.77, p = 0.56).
Logistic regression model for predictors of previous HIV counseling and testing and willingness to self-test for HIV among University students, Kano, Nigeria (n = 399).
aLogistic model includes the following variables: gender, age group, ethnicity, religion, marital status, faculty/course of study, level of study, residence, sexual activity, condom use, and willingness to self-test.
bLogistic model includes the following variables: gender, age group, ethnicity, religion, marital status, faculty/course of study, level of study, residence, and sexual activity.
cSignificant at p < 0.05.
CI: confidence interval.
Discussion
Recognizing the complementary role of HIVST in access to prevention, treatment, and care, the WHO encouraged countries to generate evidence for its adoption. It was against this background that we documented HTC uptake, willingness to self-test for HIV, and their correlates among undergraduates. We found low uptake of HTC, but most students were willing to self-test. HTC uptake was associated with level of study, residence, sexual activity, condom use, and willingness to self-test, whereas respondents’ age, gender, ethnicity, faculty/course of study, and level of study predicted willingness to self-test.
The proportion of sexually active students in our sample (28.8%) was lower than reports from other Nigerian (48.6%),33,34 and African (51.8–80.9%) institutions.8,9 However, multiple sex partnership (33.0%) was similar to other Nigerian institutions,33,34 and elsewhere in Africa (33.3% and 33.9%).8,9 In contrast, reported condom use among our participants (18.3%) was lower than among their contemporaries in other Nigerian (68%)33,35 and African institutions (33.5–66.5%).8,9 This finding suggests a lower prevalence of sexual risk behavior among our respondents. Cultural factors, the burden and intensity of HIV interventions, variations in study populations, methods, and measurements could explain these differences. For instance, early marriage, intergenerational marriage, and concurrent sexual partnerships are common in northern Nigeria, thereby increasing HIV transmission risk. 17 Similarly, comprehensive knowledge was found in only 43% of young women and 34% of young men aged 15–24 years. 36 In the referenced study, “comprehensive knowledge” was defined as knowledge that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner could reduce the chance of getting HIV, that a healthy-looking person could have HIV, and rejection of the two most common local misconceptions about HIV transmission or prevention (i.e. HIV can be transmitted by mosquito bites and by sharing food with person who has HIV). 36 The figures could be lower in northern Nigeria considering disparities in education. 36 Furthermore, variations in measurement could occur between self-report and HTC records, as interviews are prone to social desirability bias.
The uptake of HTC documented in our study (35.8%) was higher than in some Nigerian institutions (16–30.4%),34,37,38 but lower than in other institutions within the country (44.2–58.5%),39–42 parts of Africa (43.3–98.5%),8,10,43,44 and the rest of the world (41.9–87%).21,45 In 2018, 67% of those living with HIV in Nigeria were aware of their status. Globally, HIV testing levels were lowest in the Middle East and North Africa (47%), and in west and central Africa (65%). Western Europe, Central Europe, and North America (88%) were closest to achieving 90% testing coverage, followed by East and Southern Africa (85%). 1 Apart from variations in the study population and study methods, disparities in HIV risk perception and access to voluntary counseling and testing services could also account for the differences.
The reasons given by our participants for avoiding HTC were similar to some previous reports, 42 but not others.8,46 For instance, the proportion of respondents who did not perceive any risk of HIV acquisition (16.8%) was lower than in other African countries (22.7–23.5%).8,42 Similarly, the proportion of our respondents who attributed inability to undergo HTC to lack of opportunity (20.0%) was two-fold higher than in Ethiopia (9.1%). 42 Furthermore, the proportion of participants who expressed anxiety regarding positive results (1.0%) was much lower than in other Nigerian universities (39.1–82.7%).41,47,48
Compared to our study population (55.9%), similar proportions (46.2–54.5%) of students in other African institutions knew about HIVST.8,9 However, the acceptability of HIVST (70.0%) was lower than in other parts of Africa (81.4–87.1%)8–14 and Canada (81%). 24 While the reasons for the high awareness and acceptability are consistent with other studies that identified convenience, confidentiality, and promptness as the main advantages of HIVST, 49 the lower acceptance of HIVST among our respondents could be due to variations in culture, the burden, and intensity of HIV interventions across Africa. 17
Willingness to pay for test kits was higher among our participants (55.9%) than in other Nigerian institutions (50%), but lower than in other African institutions (72.8–78.4%)8–10 and Canada (74%). 24 Other studies reported that the proportion of students willing to self-test could change if out-of-pocket costs were eliminated.11,50 Furthermore, compared with our respondents (61.4%), a higher proportion (68.4–84%) of their peers in other African countries would self-test with their partners.8,9 This could potentially double the uptake of self-testing, and facilitate protection and treatment of partners.
Most of the predictors of prior HTC except residence have been reported elsewhere.8,11,12,28,44 The predictive role of sexual activity is not surprising, since sexual activity is the dominant route of HIV infection in sub-Saharan Africa. Sexually active and regular condom users are likely motivated by the need to protect themselves from contracting HIV. They are, therefore, more likely to test for HIV. The predictive effects of level of study on uptake of HTC have been reported in other studies,44,51 where senior students were less likely to undergo HTC. Our finding could be explained by the inclusion of HTC as part of pre-admission medical examination in most Nigerian tertiary institutions. Pre-admission exams are an opportunity for new students to get tested, while senior students could have been admitted before the implementation of the policy. Likewise, campus residents have the advantage of easier access to HTC services in university clinics (can schedule visits more easily). Finally, it seems logical to expect those who had HTC to be willing to self-test.
The predictors of willingness to self-test in our study differs from previous studies.8,9 The high acceptance of HIVST among senior students suggest increased risk perception among mature and sexually active students. It is conceivable that increased institutional efforts targeting freshmen with HIV/AIDS messages during orientation programs could partly explain the willingness of first year students to self-test. The reasons for disparity in attitudes among students in their second to fifth years is however, not as easily deduced. This finding should be explored in future studies using qualitative or mixed methods research.
On the differences by gender, another study in Africa found higher acceptance of HIVST among males. 20 This finding could be due to gender variations in risk behavior. Similarly, the effect of ethnicity on willingness to self-test could be related to cultural practices that increase the risk of HIV. The willingness of clinical students to self-test has been reported elsewhere 52 and could be due to better knowledge, skills, 53 and perception of risk of sexual exposure.
Given the large testing gap and the willingness of the participants to use self-testing as an alternative, policymakers should pilot HIVST adoption to facilitate diagnosis and access to prevention, care, and treatment among this sub-population. A critical mass of these young people should be trained and motivated to support their peers. In addition, test kits, counseling services, and linkage to campus health facilities are essential. Future studies could compare testing skills and interpretation among students and health care workers.
Our study has limitations. First, interviewing a cross-section of students in one university in northern Nigeria introduces selection bias, as our sample may not be representative of all Nigerian universities. Even within northern Nigeria, there are variations in cultural practices. It is therefore, necessary to exercise caution when extrapolating our findings to other institutions. The use of a probability sampling method, however, increases the likelihood of our participants being representative of students of other institutions. Second, responses were self-reported and subject to social desirability bias. However, detailed explanation about the study objectives, assurance of confidentiality, and self-completion of the questionnaires could have reduced this possibility. Finally, when confronted with the reality of HIV testing, some respondents who were keen on self-testing could change their minds. Nonetheless, this proportion is unlikely to be large enough to alter the programmatic utility of our results. The strengths of our study include the large sample size, high response rate (93.4%), the use of a validated questionnaire, and the application of multivariate regression analyses, which controlled for potential confounders.
Conclusion
We found HTC uptake to be low among a sample of university students in northern Nigeria, but the majority of university students were willing to self-test for HIV. We recommend measures that will enable increased uptake of HTC services, including training of peer educators, establishment of counseling hotlines, reliable supply of subsidized test kits, and strengthening of linkages with university health services.
Key messages
Uptake of HTC services is low among university students in northern Nigeria, but the majority of university students were willing to self-test for HIV. Willingness to undergo HIV-self testing was associated with college seniority, age, ethnicity, and program of study. Our findings support the feasibility of scaling up HIVST among university students in northern Nigeria.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
