Knowledge, attitudes and perceptions about HIV self-testing amongst college students in Namibia

Introduction

The introduction of Highly Active Antiretroviral Therapy (HAART) in the mid-1990s, has been applauded for its significant reduction of AIDS-related morbidity and mortality (Iloeje et al., 2005). Administration of HAART brought about a tremendous and profound reduction in the rate of immunodeficiency-related opportunistic infections (Iloeje et al., 2005). As well as, the most important stage in the initiation of an HIV positive individual into the care and treatment cascade remains a conclusive HIV diagnostic test (Omondi, Mbogo and Luboobi, 2018). The Joint United Nations Programme on HIV/AIDS (UNAIDS) targets to have reached at least 73% viral suppression in people living with HIV/AIDS (PLWH) by the end of the year 2020 which in turn will make it possible to end AIDS by the year 2030 (Celum and Barnabas, 2019). This ambitious goal is only possible if at least 90% of PLWH are diagnosed and linked to care. Previously, facility-based HIV testing has targeted volunteers, who were mostly women. However, with this strategy; a significant number of men and youth are missed, as they are not as forthcoming as women with regards to testing, and therefore, contribute disproportionately to testing gaps (Kumwenda et al., 2019; Dzinamarira et al., 2020).

Various centers in the Northern region of Namibia offer HIV testing through voluntary counseling and testing (VCT) where individuals initiate testing and the provider-initiated testing counseling (PITC), where HIV testing is offered to clients who would have visited health centers to access medical services (Jong et al., 2013). The World Health Organisation (WHO) introduced PITC as a way of increasing testing and counseling services uptake (Kennedy et al., 2013). With the setting of 90-90-90 vision 2020 by UNAIDS the government of Namibia through the Ministry of Health and Social Services (MoHSS) increased ways to scale up HIV testing services (HTS) all over the country to reach underserved populations such as young adults and men (Indravudh et al., 2019). All these strategies have seen successes in ensuring universal testing. However, despite these efforts, gaps in meeting the UNAIDS 90-90-90 have been identified by the recent Namibia population-based HIV impact assessment (NAMPHIA) which found that 86 % of PLWH in the age group 15-64 years knew their status with 79.6 % of the males and 89.5 % of females (MoHSS, 2018). In Namibia, HTS has been offered through traditional facility-based testing (MoHSS, 2011), which is considered to lack privacy, delays clients whilst waiting in line for their turn, associated with stigma, inconveniences of distance, and total costs involved (Wood, Ballenger and Stekler, 2014). There has been global progress in the promotion of HIV status awareness even though approximately 50% of PLWH do not know their status (UNAIDS, 2019). To attain the first 90 of the UNAIDS vision 2020 90-90-90 target in young adults, urgent and innovative ways of scaling up HTS are needed to improve the epidemic control as a substantive number of these young adults are unaware of their status in East and Southern Africa (UNAIDS, 2019).

There is a need for urgent action, as only approximately 10% of the young males and 15% of females, are aware of their HIV serostatus in East and Southern Africa. For this action, innovation is needed to increase HIV testing. Extending HTS out of the immovable facilities might be the solution especially in a country like Namibia where 5% of females and 11% of males are reported to have sex before the age of 15 (Gumede and Sibiya, 2018; UNAIDS, 2019). It is of paramount importance that in the process of scaling up HTS the decision for someone to get tested should not compromise their autonomy (Wurm et al., 2019). This is why it is important to acquaint young adults with HIV self-testing (HIVST).

HIV self-screening tests could help in increasing the number of individuals who have been tested and are aware of their HIV status (Dzinamarira and Mashamba-Thompson, 2019). With HIVST, the individual is accorded with convenience and privacy, as testing can be done in the comfort of one’s home residence. It further adds empowering options for care at the same time, offering means of fast-tracking, pre-screening, and triaging out those who have self-tested negative (Dzinamarira, 2019; Dzinamarira et al., 2020). HIVST will therefore help in closing the existing testing gap between women and young adults, as it can scale up HIV testing coverage and frequency. This will allow health systems to focus only on those who would require further assistance concerning counseling, HIV confirmatory testing, and initiation into the treatment and care cascade. Generally, studies have shown knowledge and acceptance of, and positive attitudes towards HIVST in key populations (Harichund and Moshabela, 2018; Tun et al., 2018; Dzinamarira, Pierre and Rujeni, 2019; Hatzold et al., 2019).

Behaviour change is difficult and complex as it is based on a comprehensive understanding of the factors that influence the uptake and implementation of specific health behaviours. The theoretical domains framework incorporates a range of factors that influence the extent to which a behaviour change can be enacted, such as knowledge, social influences, and emotions among others (Cane, O’Connor and Michie, 2012). This study is based upon the theoretical domains framework as the ability and urge to self-test is dependent on the knowledge, attitudes, and perceptions of an individual. In November 2018, the MoHSS started allowing and urging the citizens of Namibia to make use of HIVST. However, not everyone is versed with this new strategy so there is a need to explore awareness and acceptance through studying how knowledgeable young adults are about this topic, and what their perceptions of and attitudes towards HIVST are. This will help in identifying gaps in scaling up HIVST among potential young adult self-testers in Namibia.

Methods

The study was conducted at Elite Tutorial College in Ondangwa. Elite Tutorial College is a tertiary institution located in Ondangwa town in the Oshana region, which is in the Northern part of Namibia located 60km from the Angola border.

To calculate the sample size, Cochran’s formula was used.

Where:

n is the sample size.

Z is the z-value at the 95% level of significance (1.96).

p is the (estimated) proportion of the population with the attribute in question. In this case the attribute was knowledge of HIVST which according to Dzinamarira et al. 2019 is 21%. The proportion of knowledge was used in this case as knowledge precedes acceptability and perceptions.

q is 1-p

e is the desired level of precision; i.e., the margin of error which was set at 0.05 in this study.

Using Cochran’s formula, a sample size of 255 was calculated. However, the total number of students at Elite college is 1000, and this sample size is more than 5% of the population hence a finite population correction had to be factored in to calculate the final sample size. Therefore, a modification to Cochran’s sample size for small populations was used to calculate the new sample size. The following formula was used:

Where:

n₁ is the new adjusted sample size.

n₀ is the initial calculated sample size (255 calculated above).

N is the size of the population.

After adjusting for the population size, a new sample size of 203 was calculated. However, due to the covid restrictions prevailing at the time the study was conducted the researchers conveniently restricted the sample size to 106 after considering school attendance patterns. Only 96 students finally took part in the study. This still represents more than 5% of the target population hence the results of this study have enough power to infer to the sample population.

The study used a self-administered structured questionnaire adapted from (Gumede and Sibiya, 2018; Dzinamarira et al., 2020). The questionnaire comprised of 65 questions and used the language of instruction in the College, which is English. The study was approved by the Stellenbosch University Research Ethics Committee (REC): Social, Behavioural and Education Research (SBER) under protocol number HIV-2020-18539. Written informed consent for participation and for publication of the participants’ details was obtained from all participants.

For this survey, we included four main sections to assess their socio-demographic characteristics, their sexual health, and their health-seeking behaviour, knowledge about HIVST, attitudes, and perceptions towards HIVST and HIV positive status disclosure. We validated the questionnaire through a pilot study at Credential College with a sample of 10 students. The comments from the respondents in the pilot project were used to amend some of the questions in the questionnaire.

Results

Knowledge of HIV self-testing

Knowledge of HIVST was very limited in this sample of respondents with the majority of respondents (76.29%) confirming that they do not know what HIVST is all about. The same proportion of respondents reported that they had never heard about HIVST, while a slightly higher proportion (79.38%) said they had never read about HIVST. Despite this, more than 90% of the respondents confirmed that they had never used an HIVST kit, and at least more than half of them (51.04%) were aware that HIVST kits are legally allowed to be used in Namibia. Most participants were aware of the existence of HIVST kits in private pharmacies (78.35%), while only 44.33% were aware that HIV test kits were available on the internet platforms. The majority of respondents indicated that HIVST is done using blood (89.69%) with less indicating that saliva can also be used as a sample for HIVST (22.68%). Table 3 is a summary of the findings on the knowledge of HIVST by respondents.

Table 3. Knowledge of HIV Self-testing.

Variable	Frequency n (%)
Know what HIV self-testing is
Yes	23 (23.71)
No	74 (76.29)
Heard about HIV self-testing
Yes	23 (23.71)
No	74 (76.29)
Read about HIV self-testing
Yes	20 (20.62)
No	77 (79.38)
Ever seen a HIV self-testing kit
Yes	21 (21.65)
No	76 (78.35)
Ever used an HIV self-testing kit
Yes	9 (9.28)
No	88 (90.72)
Is it legal to use a HIV self-testing kit in Namibia?
Yes	49 (51.04)
No	47 (48.96)
HIV self-testing kits are available in private pharmacies
Yes	76 (78.35)
No	21 (21.65)
HIV self-testing kits are available in government clinics and hospitals
Yes	73 (75.26)
No	24 (24.74)
HIV self-testing kits are available on the internet
Yes	43 (44.33)
No	54 (55.67)
HIV self-testing can be done using blood
Yes	87 (89.69)
No	10 (10.31)
HIV self-testing can be done using saliva from the mouth
Yes	22 (22.68)
No	75 (77.32)
A person can perform HIV self-testing on himself/herself
Yes	56 (57.73)
No	41 (42.27)
It takes 20 to 40 minutes to get results from the HIV self-testing process
Yes	63 (64.95)
No	34 (35.05)
The HIV self-testing result can be negative if the HIV infection is less than 3 months old
Yes	52 (53.61)
No	45 (46.39)
The person needs to retest after 3 months if the test is negative
Yes	77 (79.38)
No	20 (20.62)
There is need for an HIV counselor before taking the HIV self-test
Yes	81 (83.51)
No	16 (16.49)

In cross-tabulations, there is no existence of a significant difference in knowledge of HIV self-testing between males and females (p > 0.05) in all the attributes except for the need to have a retest after 3 months when the test is negative (p = 0.009), as shown in Figure 1 below. A higher proportion of females (86.57%) were more knowledgeable compared to their male counterparts in this attribute.

Figure 1. Cross tabulation by gender.

Discussion

The study’s main aim was to explore how knowledgeable young adults in Ondangwa are to HIVST, their attitudes, perceptions, and acceptability of home-based approaches to HIV testing. This study brought up vital findings; firstly, young adults lack knowledge on HIVST as only 23% revealed knowing about HIVST; secondly, this study showed a positive attitude towards HIVST as they agreed that it was a good idea. The participants showed positive perceptions about HIVST offering privacy, allowing positive people to get treatment before they get sicker but issues of regulation, suicide, and abuse by family members and employers. Demographics revealed that the study predominantly consisted of females with 69% of the participants being female and 31% being male. Of those who took part in this study, 89% spoke Oshiwambo with few representations from other ethnic groups. A recent population and housing census conducted by the Namibian Statistics Agency, found that the Oshana region is home to approximately 91% Oshiwambo speaking (NSA, 2017) which is in line with the findings of this present study.

The study found out that only 23% were aware of HIVST and had heard about it whilst 68% of the participants found it acceptable. Of importance to this study is the focus by the republic of Namibia in the 2017/2018 – 2021/2022 HIV and AIDS strategic framework. The HTS section of the AIDS strategic framework seeks to improve HTS uptake among young adolescents (MoHSS, 2017) as a vital step in meeting the 90-90-90 UNAIDS and ending HIV/AIDS by 2030. Studies have reported that HIVST offers the capacity to close the testing gap (Freeman et al., 2018; UNAIDS, 2019). In this study, the reports about condom usage during the first sexual encounter, late sex debut (sex after 18 years), knowledge of HIVST, and positive attitude towards HIVST and HIV risk perception were found to be factors associated with HIVST awareness. The present study further found that health-seeking behaviour, knowledge of HIVST, and positive attitude towards HIVST to be factors associated with acceptability of HIVST. The results from the present study corroborate previous calls to find solutions to poor sexual reproductive health-seeking behaviour by young adults and men (Ekouevi et al., 2020). Due to lack of knowledge, use was also minimal as only 9% reported having self-tested before, with 76 % reporting they knew that HIVST kits existed in private pharmacies. This corroborates with what Greacan et al. recommended in their study in 2016 that free HIVST kits be made available in medical centers and other public institutions (Greacen et al., 2016).

Approximately 60% of the participants in this study preferred to test alone and this has been evidenced as well in a study by Young and colleagues in 2014 (Young et al., 2014). The participants unanimously (87.6%) agreed that they would seek medical help with a positive HIV test result. Previous studies (Kalibala et al., 2014; van Rooyen et al., 2015; Gumede and Sibiya, 2018) agree with these results. Despite participants indicating positively that they would follow up with health professionals after a positive HIV self-test result, Peate (2015) raised concerns about the lack of linkage to care of HIVST citing that, contacting a health professional is an individual responsibility (Peate, 2015). Concerns about confidentiality in HIVST were raised by 78% of the participants agreeing on secrecy regarding the HIV positive test and 55% disagreeing to disclose a HIVST positive result to their sexual partners; this corroborates with studies by Dzinamarira and colleagues and that by Gumede and colleague (Dzinamarira et al., 2020; Gumede and Sibiya, 2018).

Despite participants agreeing to HIVST as part of the HIV/AIDS epidemic control, 67.7 % of participants fear incorrect readings and poor interpretation of the test results, which may lead to either false positives or false negatives. Furthermore, 64.9 % agreed that testing instructions could be wrongly read and interpreted. These fears have also been of concern in past studies (Ng et al., 2012; Choko et al., 2015; Martínez Pérez et al., 2016; Sarkar et al., 2016; Gumede and Sibiya, 2018). Regulation of HIVST kits sale has not yet been enacted in Namibia both online and in pharmacies and in this study, 56.6 percent agreed that if not regulated by the government, chances of illegal HIVST kits flooding the streets are high. This drawback has been of concern in past studies (Koutentakis et al., 2016; Williams et al., 2017; Gumede and Sibiya, 2018). The findings of this study revealed low awareness of HIVST at 23 percent and high acceptability of 68 percent among young adults attending Elite tutorial college in Ondangwa. Previous studies done in different subpopulations revealed similar patterns; for example, a study in Kigali Rwanda among men by Dzinamarira and colleagues revealed an awareness of 21 % and acceptability as high as 74 % (Dzinamarira, 2020); whilst another study among bisexual men in Australia revealed that 41.9 % were aware of HIVST (Dean et al., 2019). A South African study done in the district of eThekwini in KwaZulu Natal showed higher levels of awareness at 69.9 % (Gumede and Sibiya, 2018). The similarity of the study in eThekwini to this present study is that they both had an almost similar representation of (males 30.1 % females 68.8), and (males, 30.9 % females 67.7 %) respectively. Other studies that were done in Peru and Brazil also revealed awareness at high levels of 97 % among men (Volk et al., 2016). In addition, the low levels of awareness may be due to HIVST being a new intervention that many people are not aware of and it is still in its inception stages.

The findings of this study found HIVST acceptability at 68.8%. Acceptability slightly lower than this of 56.2% was found among Australian MSM (men who have sex with men) and bisexual men (Dean et al., 2019). In a study among Chinese MSM 43.8 % found HIVST to be acceptable (Wong et al, 2015). Attributes to variations in acceptability also vary according to differences in the sampled populations. In both Dean et al. and Wong et al., the sampled populations were MSM (Dean et al., 2019; Wong et al, 2015). A study among 3662 South African students showed acceptability of 75% with around 43.4% of the sample being males (Mpata Mokgatle and Madiba, 2017). High acceptability of this magnitude was also found out in a Kenyan study (Kalibala et al., 2014). Results of this survey corroborate findings from a systematic review carried out by Krause and colleagues in 2013 (Krause et al., 2013). The findings from this study are also in tandem with findings from literature reviews by Figueroa and colleagues (Figueroa et al., 2018) and Pant Pai and colleagues (Pant Pai et al., 2013). Acceptability of HIVST in SSA has been found out to range from 22% to 94% with a biased pattern where men benefit more than women from HIVST interventions (Kurth et al., 2016; Maheswaran et al., 2016). In comparison, studies that have men only reported high acceptability rates of around 70 to 94% whilst those that include women as the present study ferry around 22 to 64% (Dyk, 2013; Kurth et al., 2016; Gumede and Sibiya, 2018; Vara et al., 2020). The highlights of this study are that key factors such as knowledge of HIVST and health-seeking behaviour influence the acceptability of HIVST. This is similar to findings from another study by Izizag and colleagues (Izizag et al., 2018).

Conclusion

The findings from this current study revealed low levels of HIVST knowledge but the young adults in this study showed high acceptability of HIVST. These findings accentuate the importance of advancing awareness programmes for HIVST as an alternative strategy of scaling uptake of HTS among young adults in Namibia.

Data availability

The data that support the findings of this study cannot be made openly available due to security risks. The data will be made available to researchers upon reasonable request by emailing the corresponding author.