‘I no longer fear testing’: investigating young people’s experiences of and preferences for oral HIV–self testing programs on college campuses in Zimbabwe

Abstract

Background Adolescents and young people face social, structural, and systems-level barriers which prevent them from accessing facility-based HIV testing, leading to delays in knowledge of HIV diagnosis and subsequent linkage to care. The World Health Organization (WHO) recommends oral mucosal transudate HIV self-testing to augment HIV testing services, and it may serve as an entry point for young people to engage with the HIV prevention and care cascade. However, presently young people across sub-Saharan Africa lack access to HIV self-test kits, which are available only at facility-based testing sites, through piloted distribution, or for purchase at prohibitive costs in private pharmacies. Youth-friendly distribution models for HIV self-testing are required. This study assessed 1) young people’s experiences of, and preferences for, campus-based HIV self-test distribution at tertiary level colleges in Zimbabwe; and 2) provider perceptions of the feasibility of scaled campus-based HIV self-test distribution across Zimbabwean tertiary schools. Methods In depth interviews (n=26) and focus group discussions (n=4) were conducted with adolescents and young people (n=52), and key informant interviews (n=5) and focus group discussions (n=1) were conducted with nurses (n=14). Participants were recruited from nine universities and technical vocational colleges in Harare, Bindura, Masvingo, and Gweru, Zimbabwe. Data was recorded, transcribed, and coded for emergent themes using NVIVO 12 qualitative data analysis software package. Results Overall, campus-based delivery of HIV self-tests was highly accepted by young people at tertiary level colleges. Participants reported enhanced feelings of privacy, confidentiality, autonomy, and empowerment with campus-based self-testing compared to facility-based self-testing. They found that the public nature of the campaign-style testing station generated a social acceptance of HIV testing amongst students on campus. Participants raised concerns about experiencing social coercion to test, lack of emotional support when testing alone, and adequate linkage to care systems. Participants agreed that campus-based HIV self-test distribution programs should be led by lay counselors, offer both on-site and off-site testing, provide links to prevention services including VMMC and PrEP, integrate comprehensive sexual and reproductive health education, and have continuous post-test counseling. Nurses cited limited human resources, clinic licensure, and low uptake of campus clinic services as factors affecting the feasibility of scaling campus-based HIVST distribution in tertiary schools across Zimbabwe.