Correlates of uptake of HIV testing among children and young adolescents in Akwa-Ibom state, Nigeria: a secondary data analysis of the Akwa-Ibom aids indicator survey, 2017

HIV remains one of the public health challenges of our time; responsible for morbidity and mortality across different age group [1]. It is estimated that there are about 37,900,000 people living with HIV globally [2]. Of these, 36.2 million were adults and 1.7 million were children less than 15 years old [2]. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 1.7 million individuals worldwide became newly infected with HIV in 2018; 160,000 new infections among children ages 0–14 [3]. In 2018, only 79% of people with HIV globally knew their HIV status [2]. Although new HIV infections have declined by an estimated 16%, from 2.1 million in 2010 to 1.7 million in 2018, around 770,000 deaths were recorded from AIDS-related illnesses worldwide in 2018 [2].

Globally, mother-to-child transmission of HIV accounts for more than 90% of all new paediatric HIV infections and may occur during pregnancy, labor, delivery or breastfeeding [4]. The risk of mother to child transmission during pregnancy ranges from 20 to 45%. However, with specific interventions, this risk can be reduced to less than 2% [5]. Without testing and treatment, 50% of HIV-positive infants die by age 2 years and 75% by age 5 years. For children who became infected through vertical transmission or other means such as unsafe blood transfusions, the best protection against dying from AIDS is HIV testing and diagnosis followed by prompt ARV treatment [6].

About 1.9 million Nigerians are living with HIV, giving a national prevalence of 1.4% [7]. This makes Nigeria the country with the second highest burden of HIV globally [8]. The Nigeria HIV/AIDS Indicator and Impact survey in 2018 estimated the prevalence among children aged 0–14 years to be 0.2%. HIV prevalence varied by zone across Nigeria, with the highest in South-South Zone (3.1%) and Akwa-Ibom state recording the highest in the country- 5.5% [7]. Reports from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) also showed that only 40% of women who gave birth since January 1, 2015 knew their HIV status despite the investment in safe and cost effective prevention of mother to child transmission (PMTCT) interventions for HIV in the country [7]. This limits the identification of HIV exposed children and proportion of those accessing HIV testing services which is the basis for timely initiation of antiretroviral therapy [9]. As a PMTCT priority state [10], the identification of correlates of testing behaviour is extremely important. This can be used to improve HIV testing campaigns by refining messages that target individuals at highest risk of infection [11].

Both individual and institutional factors have been found to affect uptake of testing services in sub Saharan Africa [12]. Individual factors were mainly related to parents or guardians of the children and included demographic (e.g., gender, age, marital status) and socioeconomic factors (e.g., income, urban/rural residence, education attainment) [12‐15]. The institutional factors were mainly inadequate human resources, supplies and weak infrastructure [12, 16].

Given that there is still no cure for HIV, prevention continues to be a main thrust of HIV control efforts. HIV testing and counselling is central to these efforts. It presents valuable opportunities to identify new infections, increase awareness of HIV status, and addresses the HIV related health disparities [17]. In addition, it alleviates anxiety, promotes behavioural change and facilitates early referral to care and support, including access to antiretroviral (ARV) drug therapy [18]. By implementing focused, high-impact prevention and accelerated HIV testing, it is expected that 95% of people living with HIV should know their HIV status by 2030 [19]. This would mark the end of the AIDS epidemic as a public health threat and reduce drastically the number of people acquiring new HIV infection [20‐22].

Many studies have assessed knowledge, perception and factors influencing HIV testing among adult but there is a dearth of studies on the correlates of factors influencing testing amongst children and young adolescents. This will help inform public health policy to develop a more holistically targeted and context specific HIV testing program for children and young adolescents as an important HIV prevention and treatment strategy. Such knowledge will also help combat the factors that may mitigate uptake of testing services [23]. Ending the AIDS epidemic is an opportunity to lay the foundation for a healthier world for future generations [24]. It will be impossible to end the epidemic without bringing HIV treatment to all who need it. Testing helps identify those to be treated. This study therefore aims to determine the correlates of HIV testing amongst children and young adolescents in Akwa-Ibom State, Nigeria using data collected as part of the Akwa-Ibom AIDS indicator survey (AKAIS) (a population based cross-sectional survey that offered household-based HIV testing, conducted between April and June 2017).

Only 14.2% (568) of a total 4037 children and young adolescents who participated in this study have ever been tested for HIV. This is slightly lower compared with result from a population-based survey done in Kenya where 16.4% of children less than 15 years had ever tested for HIV [25]. Contrary to result from this study, more children (34.7%) in a facility based study done in Cameroon had previously been tested for HIV [26]. In achieving population-level viral suppression and epidemic control in a state with the highest prevalence of HIV in Nigeria, a widespread coverage through targeted HIV testing is essential [20]. Although testing for HIV is the cornerstone of ultimate prevention, most children and young adolescents are still unaware of their status [27]. Testing uptake is higher among adults compared to children as evidenced from the 2017 Multiple Indicators Cluster survey [28]. There is evidence that HIV negative women seroconvert during the breast feeding period [29, 30]. These children are usually not considered exposed because their mothers were negative during antenatal resulting in missed opportunities. While there is evidence of mother to child transmission due to the high prevalence of HIV in Akwa-Ibom state [7], testing of exposed children has not been optimal [2]. Risky sexual behavior among young adolescents also make them vulnerable to HIV infection. This low prevalence of testing uptake can be attributed to less autonomy and decision-making power including health-seeking behaviour associated with this age group. It further buttresses the lack of evidence for HIV Testing Service approaches targeted towards children and adolescents [31]. The study sample is made up of 50.8% male (2048) and 49.2% females (1989). The ratio of males to females is about 1:1 which indicates that approximately, equal number of males and females were involved in the study. This is similar to the census held in Nigeria in 2006 [32]. The study was done on children and young adolescent from 0 to 14 years because Akwa-Ibom has the highest prevalence of HIV in Nigeria [7] with an increased risk of mother-to-child transmission. Also, the increase in risky behaviour associated with adolescents globally [33], makes it necessary to determine if they have ever been tested as well as understanding the correlates of testing uptake among them.

The mean age of the children and adolescents was 6.20 ± 3.91. Result showed approximately 15.0% of children less than 10 years and only 10.4% of adolescents aged 10-14 years have ever been tested for HIV. Although adolescents are at a greater risk of being infected, the testing rate is still low. In a similar study to assess the prevalence and correlates of HIV testing in Uganda, it was discovered that only 10.7% of adolescents aged 10–14 years had ever been tested for HIV [15]. Results of this study showed sex and age of the children and adolescents were not significantly associated with uptake of HIV testing. This was found to be consistent with a study from Western Kenya which showed the sex and age of a child had no significant association with acceptance of HIV testing [34].

Despite the higher percentage of children and young adolescent in urban area (18.3% vs. 12.2%) ever testing for HIV, location was not significantly associated with uptake of HIV testing in this study. This was inconsistent with a facility based cross-sectional study in Tanzania where mothers or caregivers who resided in the urban region were four times more likely to send their children for HIV test compared to their counterparts in the rural communities [35]. The result from this study may be due to the presence of primary health care facilities and community health care workers in both rural and urban parts of Akwa-Ibom.

Although more children enrolled in school had been tested for HIV, this was not significant in the study. However, Ssebunya et al. reported that adolescents with higher educational status were more likely to have been tested for HIV [15]. The study by Ssebunya et al. included adolescents up to 19 years who needed no parental consent before getting tested for HIV [15]. Although less common, transfusion of contaminated blood remains a very important cause of paediatric HIV infection in developing countries [36]. However, due to the screening of donated blood for evidence of HIV infection, the risk of acquiring HIV from blood transfusions is extremely low. From the result, 46.1% of children and young adolescents who have been transfused have been tested. This was found to be a significant correlate of uptake of HIV testing. Those who have been transfused were 5.3 times more likely to have been tested. This can be explained with the fact that blood recipients are also screened for HIV before being transfused due to medico-legal reasons.

Age as well as the sex of the caregiver were not significant in the multiple logistic regression model. Contrary to the result of this study, Makau, Okwara & Oyore in 2015 discovered that caregiver’s age was a significant predictor of testing uptake [37]. A similar study done in Cameroon identified the sex of a caregiver as a significant correlate as women were more likely to take their children for HIV testing services [26]. This could be due to the study being facility-based considering the feminization of uptake of HIV services in Cameroon [26, 38]. The association between caregivers’ educational level and testing uptake is consistent with other studies. Children of caregivers with no education had less chance to have been tested compared to children of caregivers with tertiary education. Higher education attainment was a strong correlate of testing uptake, which is in accordance with positive role of education in promoting general health status [16]. This finding suggests that educated caregivers may be more knowledgeable about the risk of HIV and understand the benefits of testing for HIV in both children and young adolescents. This finding reaffirms the results from Zambia showing that caregivers with higher level of education were likely to be more knowledgeable about mother-to-child transmission [39] and will be more willing to present their children for testing. In a cross sectional facility based study done in Tanzania, higher chances to access testing services were observed among children whose caregivers had attained high education level [40].

Caregivers’ knowledge of HIV was not significant in the uptake of HIV testing in children and young adolescents. This might be due to the high level of stigmatization associated with HIV. Despite the adequate knowledge of HIV, caregivers might prefer to remain unaware of the status of their children for fear of stigmatization if the result turns out positive. Contrary to results from this study, Makau et al. reported in their study on factors influencing uptake of EID among mothers in Kenya that good maternal knowledge is a significant predictor of EID uptake [37]. Samson et al. also discovered a significant association as having adequate knowledge was associated with an increase in uptake of HIV testing [35]. Results indicates that 23.5% of children whose caregivers knew their status have been tested for HIV. This was significant as those who had been previously tested were 8.3 times more likely to have been tested for HIV compared to those who have not. Vreeman et al. in 2010 stated that children were less likely to be tested for HIV if their mother/caregiver had an unknown HIV status [34]. According to Bwana et al., a mother’s ignorance of her status is a significant predictor of missed opportunity to access HIV testing services [40]. Children of HIV infected mothers/caregiver were more likely to get tested due to the knowledge they have acquired about HIV and the willingness to prevent their children from contracting the virus.

The limitation of AKAIS is mainly the cross-sectional nature of the survey, which only provides a snapshot of the HIV prevalence in Akwa Ibom state. The generalizability of the study findings is limited to the region under study. The study only assessed information on children and young adolescents aged 0-14 years, therefore, the findings may not be generalizable to adolescents above 14 years. However, the large sample size of 4037 among children aged 0–14 years helps provide important insights about HIV testing in children. Collecting accurate information about sensitive topics is difficult, particularly topics pertaining to HIV testing. Respondents may have provided socially desirable answers rather than provide answers that accurately reflect their experiences. Respondents may not readily disclose whether they have previously tested for HIV, for fear of being identified as HIV positive.

This study has demonstrated that uptake of HIV testing among children and young adolescents in Akwa-Ibom state is low. There is a need for HIV interventions to be targeted towards this age group. Scaling up HIV testing services through provider initiated testing and counseling and family index testing will help increase the uptake of testing services among children and young adolescents. Addressing the knowledge gap amongst caregivers especially in rural areas is crucial towards improving the effectiveness of HIV interventions. Community-based health education and testing will also increase access to HIV services. This will have a positive effect towards ending the AIDS epidemic by 2030.