HEALTH EDUCATION RESEARCH Vol.35 no.

6 2020
Pages 524–537
Advance Access published 3 September 2020

‘I will welcome this one 101%, I will so embrace it’:

a qualitative exploration of the feasibility and
acceptability of HIV self-testing among men who have

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sex with men (MSM) in Lagos, Nigeria

Osasuyi Dirisu1*, Adekemi Sekoni2, Lung Vu3, Sylvia Adebajo1,

Jean Njab1, Elizabeth Shoyemi4, Sade Ogunsola2 and Waimar Tun3
1
HIV and AIDS Program, Population Council, Utako 900108, Abuja, Nigeria, 2College of Medicine, University of Lagos,
Akoka 100213, Lagos, Nigeria, 3HIV and AIDS Program, Population Council, Washington, DC 20008, USA and 4HIV and
AIDS Program, Population Council, Yaba 100001, Lagos, Nigeria
*Correspondence to: O. Dirisu. E-mail: osasuyidirisu@gmail.com
Received on Jul 29, 2020; editorial decision on Jul 28, 2020; accepted on Aug 4, 2020

Abstract would improve access to HIV testing among

Men who have sex with men (MSM) are dispro-
portionately affected by HIV in Nigeria. A key
strategy in reducing transmission is to increase
HIV testing uptake and linkage to treatment for
those who test positive. HIV self-testing (HIVST)
is an innovative strategy with the potential to in-
crease uptake of HIV testing among key popula-
tions at higher risk for HIV. We conducted 23
in-depth-interviews with MSM and two focus
group discussions with key opinion leaders to ex-
plore perceptions about the feasibility and ac-
ceptability of oral HIVST among MSM in
Lagos, Nigeria. HIVST was highly acceptable
because it was considered convenient to use,
painless, private and addressed concerns about
stigma. Concerns cited by participants included
comprehensibility of instructions to perform
and interpret results correctly, as well as lack of
support mechanisms to facilitate post-test fol-
low-up and linkage to care. Provision of ad-
equate pre-test information was considered vital
as part of the kit distribution process to ensure
seamless use of HIVST kits. One-on-one peer-to-
peer distribution strategies and retail outlets
that facilitate anonymous pick-up are potential
distribution channels identified in this study.
Overall, our findings suggest that an HIVST
program that incorporates these considerations
MSM in Nigeria.
Introduction
Men who have sex with men (MSM) are dispropor-
tionately affected by HIV in Nigeria and findings
from the Integrated Biological and Behavioural
Surveillance Surveys (IBBSS) showed that the
prevalence among MSM increased from 17.2% in
2010 to 22.9% in 2014, while the prevalence
declined for other key population groups such as fe-
male sex workers [1, 2]. Population-based studies in
various cities in Nigeria have shown HIV preva-
lence estimates among MSM to range from 23% in
Lagos to 35% in Abuja, which is up to 10 times
higher than the HIV prevalence among the general
population of adult males (3.3%) [3–5]. MSM con-
stitute a hidden population in Nigeria because of
prohibitive laws that criminalize same-sex sexual
relationships and high levels of homophobia,
stigma, discrimination and ostracism [3, 6–8]. This
often results in poor access to HIV and sexual health
services among MSM. For example, only 65% of
MSM ever had an HIV test according to the IBBSS
2014 [2].
Increasing uptake of HIV testing is an important
HIV prevention strategy. Challenges with facility-
based HIV testing include stigma associated with

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the HIV testing process, long waiting times and
privacy concerns [9]. Innovative HIV testing strat-
egies that maximize confidentiality, privacy and
stigma reduction are key to bridging the disparities
in increasing the uptake of HIV testing and linking
HIV positive MSM to care and treatment. HIV self-
testing (HIVST) is an HIV testing option that has
the potential to address barriers to uptake of HIV
testing because it can be performed by conducting
an oral fluid- or blood-based test in the privacy of a
person’s home using a simple kit. HIVST as a
screening test is performed in private and provides
information that the user needs to act upon to re-
ceive additional support, such as confirmatory test-
ing, counseling and treatment [10]. Thus, HIVST is
a rapid screening test and reactive test results require
further testing and linkage to care. There is a large
body of evidence indicating that HIVST addresses
privacy and confidentiality issues associated with
facility-based testing [9, 11–13]. In addition,
HIVST could increase testing frequency, which is
recommended for higher risk groups, including
MSM [14, 15]. The acceptability and feasibility,
however, varies by context, and this needs to be
established prior to adopting specific access or dis-
tribution strategies, particularly for a population like
MSM in an environment with high levels of stigma
and discrimination [9, 10, 16]. Key issues that need
to be contextualized include: the process for obtain-
ing the kit; providing adequate information about
the use of the kit and strategies to ensure linkage to
care if HIV positive [10].
Nigeria has achieved milestones in testing and
approving oral-based HIVST products for use.
National guidelines for HIVST in Nigeria have been
developed and launched; no approach has, however,
been identified for distribution of HIVST kits in
Nigeria. HIVST is reported to be available over the
counter at retail pharmacies but it is unclear about
utilization or linkage to post-test services. This for-
mative study explored MSM perceptions of oral
HIVST and potential barriers to and facilitators of
HIVST use. In addition, it sought to identify oper-
ational and contextual issues that might affect the
distribution of HIVST kits to MSM in the Nigerian
context and the potential for linkage to care. This
Feasibility and acceptability of HIV self-testing
HIVST implementation science project is one of the
first to be implemented among MSM in Nigeria and
is a particularly important contribution to Nigeria’s
HIVST guidelines [17].
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Methods
Study design
This qualitative descriptive study was conducted as
part of the formative phase of a multiphase study to
explore the perceptions of MSM regarding the ac-
ceptability of oral HIVST for HIV testing and the
feasibility of using MSM key opinion leaders
(KOLs) to deliver HIVST kits to MSM. In this for-
mative phase, semi-structured in-depth interviews
(IDIs) with MSM and focus group discussions
(FGDs) with KOLs were conducted.
Theoretical framework for the study
The information–motivation–behavioral (IMB)
skills model was used as the conceptual approach
to understand the considerations of MSM about
adopting HIVST as shown in Fig. 1 [18]. The
model posits that HIV prevention IMB skills
as well as the self-efficacy to act increases the
likelihood of uptake of HIV prevention behavior
[18–20]. The model guided the exploration of in-
formation needs of clients, motivations and be-
havioral skills supporting HIVST uptake.
Elements of the ecology model were adapted to
understand health systems and structural barriers
to linkage to care.
Study site
The study was conducted in November 2016 in
Lagos state, South-West Nigeria. Lagos state is the
smallest state by size but has 27.4% of the urban
population of Nigeria. In 2015, Lagos state was esti-
mated to have a population of 24.6 million people;
metropolitan Lagos is the most populous city in
Africa with 20 000 people per square kilometer
[21]. Over 60% of country’s commercial and indus-
trial investments take place in Lagos and it is
regarded as the financial hub of Nigeria. Lagos is
525
O. Dirisu et al.
Fig. 1. Theoretical framework for HIVST acceptability and uptake.
one of the most ethnically diverse states in Nigeria
as a result of increasing rural urban migration.
Lagos has a large population of MSM and a high
HIV burden among MSM [3]. A mapping and char-
acterization exercise conducted by Lagos state gov-
ernment in 2015 estimated the population of MSM in
the state to be 4828. Findings from the IBBSS show
that HIV prevalence among MSM in Lagos
increased from 25.4% in 2007 to 41.4% in 2014 and
this was the highest in Nigeria [1, 2]. The HIV preva-
lence in Lagos state among the general population is
1.4% [4]. The study was conducted at the Population
Council’s community health center (CHC) in Lagos,
Nigeria. The CHC is staffed by trained sensitized
staff and provides a safe space for confidential KP-
friendly clinical and community services.
Study participants and data collection
procedure
As HIVST programs had not been implemented in
Nigeria at the time of this study, it was conducted to
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understand preferred channels for obtaining and
using the HIVST kits as well as potential barriers for
follow-up or linkage to care. IDIs were used to ex-
plore the acceptability of oral HIVST and barriers to
utilization among MSM. FGDs with KOLs explored
contextual narratives about the feasibility of using
KOLs as a distribution strategy for oral HIVST kits.
In-depth interviews
KOLs referred MSM within their network for the
study. Twenty-three MSM who met the eligibility
criteria were recruited to participate in this study.
Participants had to be aged 16 and above, be cisgen-
der male, have had anal intercourse (receptive or
insertive) with another man in the past 6 months,
and self-report being HIV negative or of unknown
HIV status during the past 3 months. To ensure that
perspectives of MSM who had previously tested
negative for HIV and those who had never tested
was adequately explore, the sample was diversified
based on HIV testing history. KOLs recruited

participants from their own large social networks of
MSM. Interested participants were invited to an
MSM-friendly drop-in clinic operated by the
Population Council, screened for eligibility, and if eli-
gible, consent was taken and interviews were con-
ducted in private consulting rooms. Before the
interviews, MSM participants were shown an actual
HIVST kit (OraQuick Rapid HIV 1=2 Antibody Test,
OraSure Technologies) and a video to explain the pro-
cedures for testing. Trained interviewers conducted
the IDIs in Pidgin English using a semi-structured
interview guide and focused on capturing information
on opinions of the HIVST kits, how it can be distrib-
uted to MSM in Nigeria, and what mechanisms need
to be in place to ensure safe and appropriate distribu-
tion and use of the test kits. Nigerian Pidgin English
was used because it is a widely spoken language spo-
ken across Nigeria especially in Metropolitan areas
such as Lagos and among young people.
Focus group discussions
Two FGDs were conducted with a total of 12 KOLs
(6 per group) to investigate the feasibility and oper-
ational aspects of using KOLs to distribute HIVST
kits. The KOLs who participated in the FGDs were
selected from a pool of KOLs trained by the
Population Council as HIV Counselors and peer
educators for an MSM-friendly program at the CHC
in Lagos, Nigeria. The KOLs were respected mem-
bers of the MSM community who were successful
in referring peers to the CHC, they had to be at least
18 years of age, completed secondary school and
had real-time information about at least 10 physical
and virtual MSM hotspots. The KOLs have also pre-
viously worked with the drop-in clinic operated by
Population Council. FGDs explored KOL’s per-
spectives on the distribution of HIVST kits, recom-
mendations for how tools and instructional
materials can facilitate accurate use of HIVST kits,
and strategies to provide post-test counseling and
linkages to care for HIVST users.
Ethical considerations
The study protocol received ethical approvals from
the Population Council Institutional Review Board
Feasibility and acceptability of HIV self-testing
and the Health Research Ethics Committee of the
College of Medicine at the University of Lagos. All
procedures performed in studies involving human
participants were in accordance with the ethical
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standards of the Population Council Institutional
Review Board and the Health Research Ethics
Committee of the College of Medicine of the
University of Lagos and with the 1964 Helsinki dec-
laration and its later amendments or comparable
ethical standards. Informed consent was obtained
from all individual participants included in the
study. All participants except KOLs received a
1500-naira ($7.50) reimbursement for their time and
travel.
Data analysis
The interviews were recorded digitally, transcribed
verbatim, reviewed by the lead author and trans-
ferred to NVivo 11 software for analysis. The re-
search team consisted of the Study Investigator and
three experienced qualitative researchers who read
all transcribed IDIs and FGDs to familiarize them-
selves with the data and the coding process was
guided by themes emerging from the data as well as
priori codes. The researchers coded the same tran-
scripts to ensure consistent application of the codes,
discussed discrepancies and contributed to the devel-
opment of a thematic framework of codes through
consensus. The analytical strategy was thematic ana-
lysis, and this was used to explore emergent patterns
and themes within the data [22, 23]. The coders
understood the local context and one of them was
involved in conducting the interviews. Their under-
standing of the local context enhanced the interpret-
ation of the data to reflect participants views;
iterative discussions mitigated the risk of coders rep-
resenting their perceptions of the data and increasing
the trustworthiness of the analysis process. The re-
search team hosted community meetings after the
study to present findings and receive feedback.
Results
Two-thirds of the IDI participants were between 16
and 24 years of age, and almost all had completed at
527
O. Dirisu et al.

Table I. Characteristics of MSM IDI participants (N ¼ 23)

Demographic features Number of MSMs (N ¼ 23)

Age group 16–24 years 17

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25 and above 6
Highest educational level Certificate/trade school 1
Completed secondary school 13
Tertiary education 9
Marital status Single and living with male sex partner 6
Single, not living with male sex partner 14
Married to a woman 3
Sexual orientation Gay/attracted to men only 12
Bisexual 9
Straight/heterosexual 2
Status of HIV testing Never tested 10
Tested/most recent test result was negative 13
FGD (n ¼ 12)
Age group 16–24 years 7
25 and above 5
Marital status Single 12
Highest educational level Certificate/trade school 4
Completed secondary school 2
Tertiary education 6
Years of experience as a KOL <12 months 9
12–24 months 0
>24 months 3

least secondary education (Table I). The majority
was single, 12 of the participants self-identified as
gay and 9 as bisexual; about half had never tested
for HIV. Overall, the majority of the participants
reported they were willing to use the oral HIVST be-
cause it addressed critical barriers to HIV testing
among MSM.
Findings are discussed along five thematic areas:
perceived facilitators, perceived barriers, partner
testing, preferred distribution channels and consid-
erations for linkage to care (Table II). The quotes
are labeled ‘PT’ to represent participants that previ-
ously tested and ‘NT’ to represent never tested. Age
is separated into two categories: <25 (participants
under 25 years) and 25þ (participants 25 years and
above).
Perceived facilitators of oral HIVST
Convenient
There was consensus across the interviews that oral
HIVST is convenient because there is no need to
wait in long queues at the health facilities. Several
KOL participants acknowledged the potential for
HIVST to increase uptake of HIV testing and facili-
tate regular testing, especially for working class
MSM who were only available to test during the
weekend when test centers are closed. Some partici-
pants were impressed by the fact that HIVST could
be used anytime and anywhere they felt comfort-
able. The potential for HIVST to improve regular
HIV testing among those who had previously tested
and facilitate testing among those who had never
tested was acknowledged by many who reported
that HIVST could be conveniently worked into their
everyday lives.
This is an improvement on what has been be-
fore; now people don’t have to get pricked
with the needle . . . this is very easy, so many
people will welcome this new initiative . . .
more confidentiality with it and reduced
waiting time at HIV testing facilities. (IDI,
25þ, PT)

528

Table II. Facilitators and barriers of oral HIVST uptake
Perceived facilitators of oral HIVST
Perceived barriers of oral HIVST (information needs)
Preferred distribution channels
Barriers to linkage to care
Easy to use and pain-free
The easy to use, pain-free HIV testing process of
oral HIVST was an attraction for the majority of
respondents who reported that they dreaded
repeated needle pricks from conventional HIV
testing.
I think, with what I have seen, it’s easier, it’s
confidential and there is no fear of you being
pierced to get the HIV test done. (IDI, 25þ,
PT)
I will welcome this one 101%, I will so em-
brace it, because I won’t have the fear of
pricking anymore. (IDI, 25þ, PT)
Interviewer: So can you tell me why you have
never tested for HIV?
R14: Well . . . when it comes to that, I’m al-
ways scared because of the needle. This HIV
self-test kit I have just seen, is okay by me be-
cause a lot of people outside there, they
are always scared like me, they won’t be
scared again if they know about this one.
(IDI, 25þ, NT)
HIVST addresses concerns of privacy and
stigma related to facility-based HIV testing
Privacy concerns were critical in deciding whether
to seek HIV testing, which underpinned the decision
not to test among many participants, particularly
those who had never tested. Participants expressed
Feasibility and acceptability of HIV self-testing
Convenient
Easy to use
Pain-free
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Addresses issues of privacy and stigma
Low literacy and poor comprehensibility of instructions
Misconceptions about mode of HIV transmission
One-on-one distribution through KOLs
Peer-to-peer distribution
Pharmacies/retail outlets
Denial of a positive HIV test result
Perception of HIV as a death sentence
Belief in religious/traditional healers
Lack of information about follow-up services
concerns that they were reluctant to visit conven-
tional HIV testing centers because they feared that
confidentiality could be breached by counselors dis-
closing their HIV status to other MSM or family
members, or that they could be seen by other com-
munity members. MSM participants mentioned that
the MSM community is closely networked, imply-
ing that information sharing occurred very easily
through social media and during community activ-
ities. Most participants reported that HIVST had the
potential to address stigma and privacy concerns
associated with visiting HIV testing centers or other
HIV testing venues.
The MSM community is a very small and
close-knit community and . . . when it is a
member of the community that is testing
them, they believe the tester already knows
their status, the tester knows who they know.
Though as a counselor tester, you shouldn’t
disclose people’s status to other people, but
this client already has that mentality that
once the tester knows, other people within
my circle know . . .. (IDI, 25þ, PT)
I would have gone for HIV like last year or
so, but I wasn’t feeling comfortable around
the area, it was in an open place with people
. . . I was not comfortable enough because
people were there and maybe when they give
you your result, your expression will show
you are HIV positive. (IDI, 25þ, NT)
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O. Dirisu et al.
Perceived barriers to HIVST
Information needs and comprehensibility of
the instructions
Several KOL participants flagged that a large pro-
portion of the MSM community members they
catered to were not literate enough to comprehend
written instructions. As correct use of the oral
HIVST kit is hinged on clear comprehension of the
written instructions, the risk of errors resulting from
incorrect use of the kits was viewed as a significant
barrier to use. There was consensus that the instruc-
tional manual of the oral HIVST kit should use for-
mats that can be understood at different literacy
levels to be considerate of the information needs of
potential users. Some participants reported that
MSM who had literacy issues would benefit from
videos, pictorial instructions and translation of writ-
ten instructions into local languages.
We have the lower [socio-economic] class
MSM, those who cannot read, the illiterates
. . . those people who cannot read and write
. . . they don’t know how to do it [HIVST].
(FGD [KOL], 25þ, PT)
In addition, there were some misunderstandings
about the oral HIVST kit among participants. Some
MSM participants inferred that because the oral
HIVST collects a sample from the mouth, there
must be HIV in the saliva and mouth and that saliva
could be a mode of transmission for HIV. They rec-
ommended that explicit information related to how
the virus is not present in saliva needs to be included
in the HIVST information leaflet.
You have to really educate people that there
is not enough HIV in the mouth to transmit
the virus, just knowing that the virus is there
in the mouth. (FGD [KOL], <25, NT)
Potential for coercive testing
The risk of coercion to use the self-test kits (e.g.
parents coercing their children and sex partners
coercing their partner) was articulated by both KOL
and MSM participants. This was a concern because
of the ease of administering the test at home. There
530
were significant concerns that parents could force
their children to test for HIV, thereby prompting
MSM to be more hidden and increasing the risk of
stigma and ostracism.
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. . . there are ways people can use it in a harm-
ful way, just like whereby you have a family
member or may be a community member
that is sick and you are forcing him or her to
use the test kit, it is harmful, like forcing
them to use it against their own wish . . ..
(FGD [KOL], 25þ, PT)
. . . the only disadvantages I am seeing, be-
cause for parents to sit their children down
and carry the test on them and know their sta-
tus, they might be discriminating and shout-
ing that how do you come to contract this
(HIV), that is the only disadvantages I see.
(IDI, <25, NT)
One of the most mentioned perceived barriers
was the potential for poor linkage to HIV care and
treatment upon receiving an HIV positive self-test
result. This is discussed in a later section specifically
on linkage to care and treatment.
Distribution channels
Privacy in obtaining and using the kits
The most important concern with regard to obtain-
ing the HIVST kits was related to how privately
MSM can receive the kits. While they acknowl-
edged that the HIVST process affords them privacy,
participants pointed out that uptake would likely be
low if the kits were only accessible at venues that
compromised their anonymity. They favored distri-
bution channels that were private and reduced
stigma associated with being seen collecting an
HIVST kit. Such channels included sessions with
peer educators or KOLs, community dialogs within
the MSM networks and through friends.
If the kit is placed in the market for people to
get, the stigma around HIV will not let people
say that they want to go and buy it because
even those people, they will feel that I am
buying it . . . because I already have it (HIV)

just because of the stigma. (FGD [KOL],
25þ, PT)
We would like to get it hidden, yes hidden,
because some people will like to behave like
saints, they wouldn’t want to get such things,
they will be concerned about ‘how will this
person see me?’ So, I believe hidden because
the other person doesn’t know I got it. (IDI,
<25, PT)
One-on-one distribution through KOLs and
peer-to-peer distribution
We explained to participants how KOLs would dis-
tribute the HIVST kits to their large peer groups as
part of the upcoming pilot distribution intervention
and were asked to react to the intervention.
Participants indicated that they considered KOLs to
be respected members of the MSM community with
the capacity to reach their peers through face-to-
face interactions, social media and social events.
Participants also indicated that they would prefer if
the KOL had experience using the self-test kit on
themselves so that the KOL would be knowledge-
able about every aspect of HIVST.
In our community, there are certain people
that command respect and attention. By their
charisma, they can easily gather community
members. Those are such persons we should
engage with distribution, because they will
know how to reach their peers. (FGD [KOL],
25þ, PT)
I would want it to come from somebody that
have passed through it, I would rather take it
from somebody I know, that have used it.
(IDI, 25þ, PT)
Some KOLs reported that their capacity to reach
different types of MSM during conventional HIV
testing sessions (peer sessions, community dialogs)
was limited because some MSM do not want the
KOL to know their HIV status, given the close-knit
nature of the MSM community. Consequently,
KOLs embraced HIVST because they could provide
information to their peers about the kit and give their
Feasibility and acceptability of HIV self-testing
peers the kits to test privately. For KOLs distributing
kits to be a viable strategy, the KOLs would have to
maintain confidentiality in their interaction with
their peers and let their peers know that they do not
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have to tell their test result to the KOL.
Like going for an MSM outreach, going to
test MSM people in the party and a lot of
them will say they don’t want to do test be-
cause they know your face, because you are
their friend . . . they don’t want you to know
their status and because of that they don’t
want to do the test . . .. So, I think this will
really help them, if we can introduce this, for
them to do it by their self. (FGD [KOL],
25þ, PT)
The MSM community was described as highly di-
verse in terms of age, socio-economic status, sexual
identity and marital status. Married MSM and young
MSM were more inclined to receive the kits discreet-
ly to keep the HIV testing process hidden from their
spouses and parents, respectively. Peer-to-peer chan-
nels from trusted MSM within their demographic
groups were preferred by some participants.
Talking of the high class MSM . . . they call
them ‘red bulls’ on the island, if you want to
reach them, you have to go to their house,
they don’t even need your money, they will
host you . . . let the younger ones go for
younger ones, then let the middle class go for
the middle class and let the upper class go for
the upper class . . .. (FGD [KOL], 25þ, PT)
Married men definitely will want to be hid-
den about it, you have to explain to your wife
why you are testing for HIV. People in the
lower class what if they are dependent on
their parents; younger people, teenagers,
minors . . . you’d have to be very discrete
about the kit. So, that would affect the way
they easily access it. (IDI, <25, NT)
Other distribution channels
While the majority of MSM participants was in
favor of peer distribution by KOLs, a few others
531
O. Dirisu et al.
preferred to obtain the kits from a wide variety of
places. The preference for a variety of places was
based on the perceived convenience of obtaining the
self-test kit whenever it was needed as opposed to
being restricted to KOLs or peers. Party venues
were also considered important distribution chan-
nels and they were preferred over pharmacies and
retail outlets because MSM could pick up an
HIVST kit anonymously. Another issue identified
with picking up HIVST kits from retail outlets, such
as pharmacies, was that the personnel would be
poorly equipped to provide counseling services.
Yes, like I said earlier we should be able to
get it, maybe anywhere, in the hospital,
chemist, SHOPRITE, shopping malls. (IDI,
<25, PT)
As an MSM, the only place I will like to re-
ceive this kit, or accept it, is where I know it’s
confidential, and in the party, I know that
everybody is collecting his kit. (IDI, <25, PT)
Partner testing
There were mixed accounts about the potential of
oral HIVST to increase uptake of HIV testing
among partners of MSM. While some participants
opined that the use of the kit would increase part-
ners’ awareness about their status and risk, others
believed it would increase conflicts and mistrust
within the relationship. There was consensus, how-
ever, that partners would be more receptive to use
the kit if MSM shared positive experiences about
using the kits, presented information about using the
kits in a suggestive manner and allowed their part-
ners to use the kit privately. Testing in relationships
was recognized as a defining issue for the future of
the relationship because knowing partners’ status
was identified as key to personal health. The nega-
tive aspects of partner testing, as mentioned by par-
ticipants, included damaging their relationship and
difficulties around disclosure after testing if one
partner tests positive.
. . . you can give your partner but it is not a
must that your partner . . . will do it in your
532
front, is a private something. So a partner can
decide to do it at his or her own will. (IDI,
25þ, PT)
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If one person turns to be reactive, it will cause
so much damage . . . it could lead to a break-
up, it could lead (someone to say). ‘You are
the person that infected me, how come?’
(FGD [KOL], 25þ, PT)
Barriers to linkage to care
One of the biggest concerns raised by both MSM
and KOL participants was that because self-testers
would be testing on their own, they would not be
receiving assistance and counseling on how to ac-
cess HIV care and treatment if they self-tested posi-
tive. This section highlights the various perceptions
and beliefs held by MSM that prevent them from
seeking HIV care and treatment and cannot be
addressed through post-test support since self-
testers are testing without the immediate support of
any providers.
Denial of a positive HIV test result
Because self-testers would be testing alone, MSM
participants were concerned that many MSM would
be in denial of their HIV positive test result and ul-
timately not seek HIV treatment. Participants spoke
about the difficulty of accepting an HIV positive sta-
tus and the fear of living with HIV.
There is this anxiety and sometimes fear . . .
before running the test . . . Denial! Some peo-
ple even when they are positive don’t believe
it, they need time to process it and sadly,
there’s little one can do . . .. But then, with
the self-test kit people might not know and it
will just be with the person battling it, inside
him or herself. (IDI, 25þ, PT)
I thought of it like it is private, if one is posi-
tive, they might not want to come out, I don’t
know I thought of it also, since it is a private
thing, the person might be positive, and they
still have this idea that I am not positive . . ..
(IDI, 25þ, PT)

Perception of HIV as a death sentence
Lack of linkage to post-test support for follow-up
was flagged as a potential disadvantage to using
HIVST. Many MSM have a strongly held belief that
a positive HIV test result was synonymous with a
‘death sentence’ reinforced by stigma and discrim-
ination from family and society. Many participants
perceived that although HIVST increased privacy,
some people may not reach out for counseling or
support after conducting the HIVST.
I remembered someone who tested positive
and he was looking for where he could com-
mit suicide, the counselor gave him advise
before he could calm down . . .. (IDI, <25,
PT)
. . . some people are always scared going to
know their HIV status because they think that
anyone that is HIV positive is close to his or
her death, like the person is going to die very
soon. (IDI, <25, NT)
Stigma as barrier to HIV treatment
Stigma associated with being identified as MSM
was a major barrier to accessing post-test counseling
services and commencing antiretroviral treatment
for those who self-test HIV positive.
Number one is self-discrimination, in the
sense that since the normal pre-test counsel-
ing is not there before he did the test, the oral
test for himself, when the result is out, the
thought of how did I get this thing will cover
his mind, because no pre-test counseling, so
that is number one and number two, who is
he going meet or how is he going to tell them
that this is what is wrong with me, that is the
referral part of it . . . how will he refer himself
to the facility. (FGD [KOL], 25þ, PT).
Belief in traditional/religious healers as
barriers to HIV treatment
Participants explained that some people were
inclined to seek ‘divine healing’ for HIV in Nigeria.
Feasibility and acceptability of HIV self-testing
The belief in faith healing or traditional herbs was
viewed by KOLs as a barrier to HIV treatment after
HIV testing reveals a positive result.
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Nigerians now we believe so much in all
those thing, religious parol (slang) that T. B.
Joshua will heal me or my pastor will heal
me, and everything! or they have all those
herbs, herbs! They believe the religious set-
ting. (IDI, 25þ, NT)
When we go out for the normal HIV test . . .
and they are reactive, you find it hard to bring
them to care because . . . they don’t believe,
some of them believe in faith healing while
others because of the stigma, they don’t want
to accept the fact that they are positive. (FGD
[KOL], 25þ, PT)
Information about follow-up
One of the most important points highlighted
throughout the interviews about facilitating linkage
to care was providing adequate information before
the kit was given to MSM. Providing information
about the steps involved in the testing process, hot-
line numbers for guidance and information about
HIV testing centers was considered vital. Most par-
ticipants considered it useful for HIV program imple-
menters to identify accessible HIV testing centers
that adopt a non-judgmental approach to MSM and
committed to protecting their confidentiality.
Places where they are welcomed . . . not ran-
dom hospital were you are not free to tell the
doctor about your sex life so that you can tai-
lor their services to one’s needs . . . where
one will feel at home and at ease to access
care. (IDI, 25þ, PT)
There are some communities where you can’t
easily find HIV walk in centers where people
can go to access care. So those kinds of peo-
ple are the lower rank of the society that can
barely feed him or herself to find it get money
to go to the center, because what he is think-
ing as of that time is how to live to the next
day. (IDI, 25þ, PT)
533
O. Dirisu et al.
Discussion
This was one of the first studies to explore the ac-
ceptability and feasibility of HIVST among MSM
in Nigeria, a population that still needs increased
coverage of and experience great barriers to HIV
testing. We found that the oral HIVST was consid-
ered highly acceptable among MSM because it
addressed key concerns: privacy, convenience of
testing and a pain-free testing experience. Privacy
offered by the HIVST addresses issues related to
stigma and discrimination which is a major barrier
to uptake of facility-based HIV testing. These find-
ings are consistent with other studies that docu-
mented ease of testing, painless testing,
convenience and privacy of testing as facilitators of
oral HIVST [14, 24–29]. In addition to encouraging
MSM who have never tested to get tested for the
first time, HIVST could facilitate regular testing and
increase testing frequency.
Concerns related to comprehensibility of HIVST
instructions, privacy in obtaining the kits and support
mechanisms for post-test follow-up and linkage to
care are similar to challenges of HIVST documented
in other studies [30, 31]. Comprehensibility of
HIVST user instructions across different literacy lev-
els is an important consideration in a developing
country like Nigeria to ensure that potential users are
not excluded because of their level of literacy. The
use of instructional videos, pictorial illustrations and
translation of written instructions into local lan-
guages is useful strategies in a country like Nigeria
with different dialects [29, 32, 33]. The WHO guide-
lines on HIVST recommend varied approaches, such
as directly assisted HIVST (trained providers demon-
strate the use of the kit while HIVST is being per-
formed) and unassisted HIVST (users follow the
instructions and test themselves) [14]. A hybrid of
both approaches may be beneficial for MSM who
are illiterate by enabling them to understand correct
use of the kit through demonstration and subsequent-
ly using the kit privately with helplines they can call
for additional support.
Participants suggested that uptake of the HIVST
may be low if MSM perceive that the process of
534
obtaining the kit compromised their privacy and
would stigmatize them. One-on-one peer-to-peer
distribution strategies and retail outlets that facilitate
anonymous pick-up are potential channels for
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HIVST pick-up among MSM identified in this
study. Findings from the follow-up survey compo-
nent of this implementation science project using a
KOL distribution strategy to reach 319 MSM with
HIVST kits showed that the most acceptable chan-
nels to receive HIVST kits were from community-
based organizations and peers/KOL [34].
Distribution strategies for HIVST kits should also
reflect the diverse needs of MSM across different
demographic groups. Maintaining privacy in the
process of obtaining self-test kits was reported as a
critical factor in facilitating uptake of oral HIVST in
a previous acceptability study [12].
We found that the fear of knowing one’s status
was reinforced by stigma and perceived lack of sup-
port for those who test HIV positive. The fear of
knowing one’s status expressed by some partici-
pants as a reason why MSM may not be inclined to
test for HIV is not specific to HIVST but may com-
pound issues with linkage to care if they test positive
and do not seek post-test support. Fear has been
identified as a major barrier to uptake of HIV testing
and linkage to care [24, 28]. The limitations of
HIVST in reaching people who are not inclined to
test because of the fear of testing HIV positive has
been documented [32]. HIVST kit distribution pro-
grams should be linked with strategies that provide
information about the benefits of testing in general.
Provision of adequate pre-test information as part of
the kit distribution process can be useful in address-
ing misconceptions that may arise about HIV trans-
mission mechanisms and the use of HIVST.
The HIVST procedures rely heavily on the user’s
decision and action to seek help [10]. Linkage to
care has been identified as the most critical consid-
eration for providing HIV support services for those
who self-test HIV positive [13]. A vital strategy for
facilitating linkage to care discussed by participants
was for program planners to identify upfront access-
ible referral centers that provide MSM-friendly
services and provide information about these centers

during HIVST kit distribution. This strategy will
help MSM who utilize HIVST to view it as part of a
process and may avert delays in decision making
about follow-up testing and linkage to care for those
who test positive. Findings from other studies sug-
gest that MSM who know about an HIV testing fa-
cility or have an established relationship with a
facility may be more inclined to seek post-test sup-
port and linkage to care if they test positive using
the HIVST [33, 35].
The WHO HIVST guidelines recommend that
programs provide users with full information about
using HIVST with emphasis on steps to take after
testing and helplines to contact for assistance [14].
Non-intrusive follow-up strategies to provide sup-
port, such a text message prompts, can be explored
within the Nigerian context. The potential for part-
ner testing was explored in this study and the find-
ings were mixed, with some MSM reporting that
HIVST would increase their partners’ awareness
about their HIV status and others believing that it
will increase trust issues in relationships. Coercion
to test using the HIVST kit by parents or partners
was also reported as a concern by participants. The
ambivalence among MSM regarding the feasibility
of HIVST as a tool to encourage partner testing has
been reported in other studies [16, 27].
Despite the concerns that participants had
about the HIVST, the overall prospect of its use as an
HIV testing strategy was positive. The benefits of
partner testing notwithstanding, programs must be
designed to foster inclusivity and not increase stigma.
Study limitations
The study was based on perceptions about how oral
HIVST intervention would work if implemented
and participants had never used it but responded
based on information provided about the kit they
were shown before and during the interviews. There
may be slight variations in actual acceptability and
uptake. A small purposive sample of MSM was
used and may lack broader generalizability.
Findings from this research, however, provided crit-
ical insights for the design of an acceptability study
Feasibility and acceptability of HIV self-testing
and provide important guidance as Nigeria rolls out
self-testing more broadly.
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Conclusion
The majority of the findings about the potential of
HIVST to increase uptake of HIV testing among
MSM in Nigeria was supportive of HIVST. Privacy
and convenience offered by HIVST addresses con-
cerns about stigma and waiting times associated
with facility-based testing. Strategies to provide ad-
equate information prior to testing and linkage to
care must be developed while planning for HIVST
programs to maximize the effectiveness. The im-
plementation of HIVST as an innovative HIV test-
ing tool among MSM using novel distribution
models such as peer-to-peer channels that facilitate
privacy would potentially increase uptake of HIV
testing and repeat testing as important HIV preven-
tion strategies within the HIV care cascade.
Acknowledgments
The authors thank Lanre Osakue, Efe Ekperigin
and Ebunoluwa Taiwo for overseeing the smooth
implementation of data collection and managing
staff. Most importantly, we thank the participants
without whom this study would not have been pos-
sible. The authors also thank the dedicated staff of
the Community Health Center and the key opinion
leaders and the research assistants who helped with
the implementation of this study.
Funding
National Institutes of Health (1R21AI124409-01).
Conflict of interest statement
None declared.
References
1. Federal Ministry of Health, Nigeria. Integrated Biological
and Behavioural Surveillance Survey (IBBSS). 2010.
535
O. Dirisu et al.
Available at: https://naca.gov.ng/final-nigeria-ibbss-2010-re
port/. Accessed: 28 May 2020.
2. Federal MInistry of Health, Nigeria. Integrated Biological
and Behavioural Surveillance Survey (IBBSS). 2014.
Available at: https://naca.gov.ng/final-nigeria-ibbss-2014-re
port/. Accessed: 28 May 2020.
3. Vu L, Adebajo S, Tun W et al. High HIV prevalence among
men who have sex with men in Nigeria: implications for
combination prevention. J Acquir Immune Defic Syndr 2013;
63: 221–7.
4. Federal Ministry of Health,Nigeria. National HIV&AIDS
and Reproductive Health Survey (NARHS Plus II, 2012).
2012. Available at: https://naca.gov.ng/wp-content/uploads/
2016/11/NARHS-Plus-2012-Final-18112013.pdf. Accessed:
28 May 2020.
5. Awofala AA, Ogundele OE. HIV epidemiology in Nigeria.
Saudi J Biol Sci [Internet] 2018; 25: 697–703.
6. Adebajo SB, Eluwa GI, Ahonsi BA et al. Prevalence of inter-
nalized homophobia and HIV associated risks among men
who have sex with men in Nigeria. Afr J Reprod Health
2012; 16: 21–8.
7. Abrahams N, Jewkes R. Managing and resisting stigma:
a qualitative study among people living with HIV in
South Africa. J Int AIDS Soc 2012; 15: 10.7448/IAS.15.2.17330.
8. Schwartz SR, Nowak RG, Orazulike I et al. The immediate
effect of the Same-Sex Marriage Prohibition Act on stigma,
discrimination, and engagement on HIV prevention and
treatment services in men who have sex with men in Nigeria:
analysis of prospective data from the TRUST cohort. Lancet
HIV 2015; 2: e299–306.
9. Pai NP, Behlim T, Abrahams L et al. Will an unsupervised
self-testing strategy for HIV work in health care workers of
South Africa? A cross sectional pilot feasibility study. PLoS
One 2013; 8: e79772.
10. World Health Organization. Report on the first international
symposium on self-testing for HIV: the legal, ethical, gender,
human rights and public health implications of HIV self-test-
ing scale-up. Geneva, Switzerland, 2013.
11. Wright AA, Katz IT. Home testing for HIV. N Engl J Med
2006; 354: 437–40.
12. Young SD, Daniels J, Chiu CJ et al. Acceptability of
using electronic vending machines to deliver oral rapid HIV
self-testing kits: a qualitative study. PLoS One 2014; 9:
e103790.
13. Walensky RP, Paltiel AD. Rapid HIV testing at home: does
it solve a problem or create one? Ann Intern Med 2006; 145:
459–62.
14. World Health Organization. Guidelines on HIV Self-testing
and Partner Notification: Supplement to Consolidated
Guidelines on HIV Testing Services, 2016. Available at:
https://www.who.int/hiv/pub/vct/hiv-self-testing-guidelines/
en/. Accessed: 28 May 2020.
15. Witzel TC, Weatherburn P, Rodger AJ et al. Risk, reassur-
ance and routine: a qualitative study of narrative understand-
ings of the potential for HIV self-testing among men who
have sex with men in England. BMC Public Health 2017;
17: 491.
16. Figueroa C, Johnson C, Verster A et al. Attitudes and accept-
ability on HIV self-testing among key populations: a litera-
ture review. AIDS Behav 2015; 19: 1949–65.
536
17. Federal Ministry of Health Nigeria. Operational Guidelines
for the Delivery of HIV Self Testing in Nigeria. HIV Self
Testing, 2018. Available at: https://fmic.gov.ng/federal-gov
ernment-launches-operational-guidelines-for-hiv-self-test
ing-kit/. Accessed May 28, 2020
Downloaded from https://academic.oup.com/her/article/35/6/524/5900854 by University of Ghana, Legon user on 01 March 2021
18. Fisher JD, Fisher WA. The information-motivation-
behavioral skills model. Emerg Theor Health Promot Pract
Res Strateg Improv Public Health 2002; 1: 40–70.
19. Fisher JD, Fisher WA, Williams SS et al. Empirical tests of
an information-motivation-behavioral skills model of AIDS-
preventive behavior with gay men and heterosexual univer-
sity students. Health Psychol 1994; 13: 238–50.
20. Chang S J, Choi S, Kim S-A, Song M. Intervention
Strategies Based on Information-Motivation-Behavioral
Skills Model for Health Behavior Change: A Systematic
Review. Asian Nursing Res 2014; 8: 172–81.
21. Lagos State Government . The Official Website of Lagos
State: Population [Internet], vol. 2015. 2011. Available at:
http://www.lagosstate.gov.ng/pagelinks.php? p¼6.
Accessed: 28 May 2020.
22. Braun V, Clarke V. Using thematic analysis in psychology.
Qual Res Psychol [Internet] 2006; 3: 77–101.
23. Braun V, Clarke V. Frequently Asked Questions, Thematic
Analysis [Internet]. 2015. Available at: http://www.psych.
auckland.ac.nz/en/about/our-research/research-groups/the
matic-analysis/frequently-asked-questions-8.html. Accessed:
28 May 2020.
24. Hussen SA, Stephenson R, Del Rio C et al. HIV testing pat-
terns among Black men who have sex with men: a qualitative
typology. PLoS One 2013; 8: e75382.
25. Wirtz AL, Clouse E, Veronese V et al. New HIV testing
technologies in the context of a concentrated epidemic and
evolving HIV prevention: qualitative research on HIV self-
testing among men who have sex with men and transgender
women in Yangon, Myanmar. J Int AIDS Soc 2017; 20:
21796.
26. Katz DA, Golden M, Hughes J et al. Acceptability and ease
of use of home self-testing for HIV among men who have
sex with men. In: 19th Conference on Retroviruses and
Opportunistic Infections. Seattle, WA, 2012. Available at:
https://forumresearch.org/storage/documents/_
2012NationalSummit_Posting/a_044_katz.pdf
27. Pérez GM, Cox V, Ellman T et al. ‘I know that I do have
HIV but nobody saw me’: oral HIV self-testing in an infor-
mal settlement in South Africa. PLoS One 2016; 11:
e0152653.
28. Witzel TC, Rodger AJ, Burns FM et al. HIV self-testing
among men who have sex with men (MSM) in the UK: a
qualitative study of barriers and facilitators, intervention
preferences and perceived impacts. PLoS One 2016; 11:
e0162713.
29. Stevens DR, Vrana CJ, Dlin RE et al. A global review of
HIV self-testing: themes and implications. AIDS Behav
2018; 22: 497–512.
30. Freeman AE, Sullivan P, Higa D et al. Perceptions of HIV self-
testing among men who have sex with men in the United
States: a qualitative analysis. AIDS Educ Prev 2018; 30: 47–62.
31. Krause J, Subklew-Sehume F, Kenyon C et al. Acceptability
of HIV self-testing: a systematic literature review. BMC
Public Health 2013; 13: 735.

32. Indravudh PP, Choko AT, Corbett EL. Scaling up HIV
self-testing in sub-Saharan Africa: a review of technol-
ogy, policy and evidence. Curr Opin Infect Dis 2018; 31:
14–24.
33. Schnall R, John RM, Carballo-Dieguez A. Do high-risk
young adults use the HIV self-test appropriately?
Observations from a think-aloud study. AIDS Behav 2016;
20: 939–48.
Feasibility and acceptability of HIV self-testing
34. Tun W, Vu L, Dirisu O et al. Uptake of HIV self-testing and
linkage to treatment among men who have sex with men
(MSM) in Nigeria: a pilot programme using key opinion
leaders to reach MSM. J Int AIDS Soc 2018; 21: e25124.
35. Paz-Bailey G, Pham H, Oster AM et al. Engagement in
Downloaded from https://academic.oup.com/her/article/35/6/524/5900854 by University of Ghana, Legon user on 01 March 2021
HIV care among HIV-positive men who have sex with men
from 21 cities in the United States. AIDS Behav 2014; 18:
348–58.
537