Key informants included: one (1) HIV expert at the national level, three (3) HIV experts at the regional level, three (3) HIV experts at the district level, one (1) VCT counselors, two (2) clinicians (1 in a public facility; 1 in a private facility) four (4) influential leaders (1 = Imam; 1 = HIV NGO representative; 1 = local leader; and 1 = chairperson of community advisory board), three (3) tourist experts, and one (1) bar worker. All KIs who were invited to attend the interviews did participate. We did note some differences in accounts of attitudes, perceived norms, and personal agency related to HIVST, and HIV testing experiences between FBWs and MCPs, whereby female participants contributed more information compared to their male counterparts.
Attitude about HIVST
According to the IBM model, attitude towards a behavior refers to experiential attitude (emotional response to the idea of engaging in a behavior), and instrumental attitude (beliefs about the outcomes of the behavior). In this study, participants expressed both experiential attitudes and instrumental attitudes towards HIVST.
Experiential attitudes
Male participants’ emotional responses related to the uptake of HIVST, including enjoying the freedom to test after deciding to test for HIV. This was well illustrated in the following quote from a male participant: “I would prefer self-testing because I will have the freedom to test myself, once I have decided to test for HIV” (FGD participant, in his 30’s).
Most female participants expressed anticipated relief to avoid needle pricks by using an oral-fluid self-test, and fear of seeing blood. This observation was well described by a female participant who said: “By using this [oral-HIVST] … you do not need to prick yourself to get a blood sample but you collect a sample from the mouth to test for HIV. I will prefer it [oral-HIVST] because I dislike seeing blood and I also fear needle pricks” (FGD participant, in her mid 30’s).
Instrumental attitudes
Female participants expressed that their ability to self- test for HIV would increase their trust and acceptability of their test result:
“First, I will have the ability to test myself. Secondly, I will trust my HIV self-test results because I am the one who has done the test, which is different from if someone would have taken my blood or a sample from the mouth and go to test for HIV. So if I test myself whatever the test result may be I will accept it” (FGD participant, in her 20’s).
Other positive consequences of HIVST that were anticipated by both female and male participants included privacy during testing, avoidance of long queues, reduced time spent traveling to and from health facilities, reduced time spent waiting for test results, a reduced counselor’s workload, and reduced indirect costs related to transporting to facilities. Male participants particularly valued the privacy and convenience that they anticipated was a consequence of being able to test:
“First, I will test in the privacy of my house, and this [HIVST], will reduce the costs of transport of going to the health facility to test for HIV. Secondly, I will avoid the long queues in the health facilities, while waiting for testing services. Thirdly, it will reduce the time I would use to go to the health facility and also I will use less time to test and get my results” (FGD participant, in his late 40’s).
Anticipated positive consequences particularly valued by female participants were reduced transport costs to visit a testing point. This was well explained by a middle-aged female participant who said: “If I buy this kit [self-test], and test myself at home, I will reduce the cost of transport to go to test at a health facility or stand-alone clinic” (FGD participant, in her 30’s).
Additionally, a counselor observed that HIVST might free counselors’ time previously spent on testing HIV-negative individuals and hence reduce their workload: “[…] from our side [counselors] we will have fewer clients to attend, which will reduce the workload ”(IDI participant 12, in her 50’s).
Perceived norms about HIVST
It is theorized that injunctive norms (beliefs about what significant others think one should do regarding a behavior) and descriptive norms (individual’s perception about the extent to, which significant others will perform the recommended behavior) about HIVST will influence the intention to perform HIVST. Most participants expressed perceived norms that were supportive of HIVST. None mentioned norms that were not supportive of HIVST.
Injunctive norms
Participants expressed a belief that people in their social environment, such as parents and peers, would approve their uptake of HIVST. The belief supportive of HIVST was well illustrated in the following quote: “I know my mother would approve I should use HIVST to test for HIV. She always insists that I should be careful with my health because we work in a very risky environment for HIV infection” (FGD participant, in her mid 20’s).
Subjective norms
Some female respondents expressed a belief that significant people such as relatives or friends would accept and take up HIVST. This positive belief was illustrated in the following quote: “I think relatives or friends will see it [HIVST] as an additional approach that may increase testing options, which is easy to use and needs less time to know their HIV status” (FGD participant, in her mid 20’s).
Personal agency toward HIVST
Personal agency refers to perceived control (environment facilitates or impedes behavior) and self-efficacy (confidence a person has in their ability to perform the behavior).
Control belief
Most male participants agreed that testing for HIV on their own would facilitate the uptake of HIVST. Men felt that taking control of their testing, and making positive choices derived from using the HIVST kits was a positive feature of HIVST and a first step to know one’s HIV status:
“HIVST is very important to me because it will empower me to test for HIV whenever I decide to test. This could be like the first step to know my HIV status before I decide to go to test for HIV at a health facility or testing centers” (FGD participant, in his 20’s).
Some key informants perceived that the introduction of HIVST would be likely to minimize the stigma associated with HIV testing, and this would facilitate uptake: “I think HIVST will reduce stigma in the community because my results will remain my secret. I am sure no one will know my HIV status unless I decide to disclose my results” (IDI participant 11, in his mid 40’s).
Interestingly, a male informant observed that young people may be likely motivated to use HIVST, because of lack of counseling since they have no time to wait: “Some people may be motivated to use HIVST because of lack of counseling, particularly young people who have no time to wait” (IDI participant 14, in his mid 50’s).
Some key informants believed that monetary incentives and the availability of social support for those who test HIV positive would facilitate acceptance of HIV testing. A male informant said: “[…] for example provide incentives [monetary] for those who will agree to test for HIV. Also, there should be social support for those who will be HIV positives, such as diet, financial assistance, and counseling” (IDI participant 1, in his 40’s).
Conversely, a male HIV expert mentioned monetary incentives as a potential impediment:
“Initially, incentives may work to motivate people to use HIVST kits to know their HIV status. However, this may not be sustainable in the long run, if you consider the issue of ART adherence for example. What I believe is that clients should know that HIV testing is beneficial to their overall health status, and they would proactively seek care and treatment” (IDI participant 15, in his late 50’s).
Beliefs about the facilitators for performance
Some key informants believed that the features of oral-fluid HIV self-testing that would facilitate uptake were that it would be easy to use, painless and less invasive compared with finger prick for blood-based testing. A male participant, however, perceived that the stated preference of oral-fluid test might hinder uptake of HIVST because of concerns around accuracy:
“My concern here will be the accuracy of the results from these two samples. I am not sure if the results will be the same or different. However, from our clients' perspectives, I think most will believe the results from the blood compared with the results from a sample from the mouth (oral-fluid sample). The reason is simple- the current rapid test that we are using we collect a blood sample for testing, so clients are used to that. Another reason is their understanding that the viruses are in the blood and not in the oral-fluids! If we introduce taking a sample from the mouth (oral-fluid sample) to test for HIV, it will take time and effort to convince clients that it is possible to test HIV from a sample taken from the mouth” (IDI participant 15, in his late 50’s).
Most female participants mentioned that features of an HIVST distribution strategy that would facilitate uptake the availability of accessible locations for distribution, interventions to advocate for HIVST and make people aware of it, and interventions to ensure and linkage from HIVST to HIV prevention, treatment, and care.
Female participants believed that easy access of HIVST kits, and disclosure of a negative HIV test result, has a positive effect in performing HIVST: “I do not think at the hospital it will be easy. I think at the drug shop or pharmacy is much easier because I will go there at any time and buy my kit and go back home to test” (FGD participant, in her late 20’s).
Another female participant observed: “[…]once you test and find that you are HIV negative, then you disclose your test results to your male partner, and he would be motivated to do self-testing” (FGD participant, in her 30’s).
Most female participants perceived the results of the self-test might facilitate linkage to care. A female discussant stated: “If I find that I am HIV positive, I will go to the health facility to confirm my test results” (FGD participant, in her 30’s).
Most female participants commonly cited pharmacies, or drug shops, and workplaces as appropriate locations for distribution of HIVST that might facilitate the uptake of HIVST. A young woman explained: “I think the appropriate place should be in pharmacies or drug shops or chemists, etc.” (FGD participant, in her mid 20’s).
Some key informants perceived that the availability of appropriate locations for, and strategies of distribution of HIVST kits would facilitate uptake of HIVST and that these included community-based distributors, integration into existing services and outreach community-based interventions, and vending machines and kiosks.
A male HIV expert elaborated: "For HIV self-test to retain its true meaning, services must be available close to residential areas […], so delivery could be door-to-door. We have the home-based care service (HBC), and the home-based care attendants can move from house to house to supply the self-test kits" (IDI participant 8, in his late 30’s).
Conversely, a clinician perceived that public distribution of HIVST kits may negatively impact on the uptake of HIVST:
“What is important I think is how the HIVST kits will be distributed. If the HIVST kits will be distributed in public places where there is a possibility of other people seeing the collection of the kits, no one will be willing to come forward to collect the kits” (IDI participant 7, in his late 50’s).
Key informants perceived that strategies for advocacy and raising awareness of HIVST, including the use of influential leaders, use of existing peer networks, and effective communication, might positively impact on the uptake of HIVST. Key informants cited the role of influential leaders in raising awareness of HIVST. A woman informant explained:
“The community leaders should be the first group of people to be trained on HIVST in the community. The community leaders would include priests, pastors, sheiks, politicians, and the so-called: ‘influential people' –people who are respected in the community. Once they [influential leaders] are aware of the HIVST they will play a very important role in creating awareness in the community because they have many followers who trust them [influential leaders]” (IDI participant 3, in her 60’s).
Finally, key informants mentioned a variety of strategies that may facilitate linkage to HIV prevention, treatment, and care following HIVST. The strategies were well described by a female HIV expert in the following quote:
“[…]if we involve community health workers in the distribution of the HIVST test kits, then it will be easy for the same community health workers to follow-up clients who have requested for the test kits and ask them if they have tested and if they have sought care. Another alternative could be to ask clients to return the self-test kits to the pharmacy or drug shop after a certain period, for example, 3 days and recorded in a register. Another alternative could be the use of mobile applications or services such as phone calls or text messages to monitor clients and link them to HIV prevention, care, and treatment services” (IDI participant 9, in her 50’s).
Beliefs about barriers to performance
A common impediment to the uptake of HIVST cited by most female participants was the cost of buying the self-test kits. A young woman explained: “[…] most people in rural settings are poor. Therefore, if these [self-testing kits] will be sold in pharmacies, it may be difficult for most people to afford” (FGD participant, in her 20’s).
Most key informants suggested no-cost or very low cost through government subsidies or health schemes to circumvent the cost of buying the self-test kits. A male informant explained: “I think health insurance schemes could cover for the cost of buying the HIVST kits. For example, most porters are covered by a health insurance scheme called: Micro Health Initiative, which pays for their treatment when they fall sick” (IDI participant 1, in his 40’s).
Another impediment to the uptake of HIVST, mentioned by some female participants was the cost-benefit of buying self-test kits or food. A woman participant said: ‘I don’t want a high-cost self-test kit, [....]. So would I be willing to buy a kit instead of food? If that is the choice the question is what will I choose? Will I choose to buy the self-test kit or a loaf of bread?’ (FGD participant, in her mid 20’s).
Participants mentioned other constraints that may hinder the uptake of HIVST, including illiteracy, physical disabilities such as poor eyesight, and fear of HIV positive results. A young man explained: ‘Most people, particularly in the rural areas are illiterate; they cannot read a newspaper. How could they be able to read and follow the instructions of how to perform self-testing?’ (FGD participant, in his 20’s).
Another male participant added: ‘[…] the problem will be to people, who have eyesight problems, then it will be difficult for them to perform HIVST, and they may need assistance’ (FGD participant, in his 20’s).
A male participant cited fear of HIV positive results:
'Fear of HIV positive results is what makes most people not to test for HIV. The main reason for this fear is anticipated-stigma-whereby people think that if they are diagnosed HIV positive, other people will know and isolate them either at the workplace or in their community' (IDI participant 14, in his 50’s).
Key informants perceived lack of policy on HIVST might hinder uptake. A male HIV expert had this to say: ‘[…] lack of policy on HIVST may be a barrier to self-testing’ (IDI participant 15, in his late 50’s).
Male participants raised concerns regarding the quality of HIVST kits because of a lack of regulatory mechanisms and past experiences of buying fake drugs: ‘We have experiences of buying fake drugs from some drug shops / or pharmacies. What will prevent them not to sell fake self-testing kits?’ (FGD participant, in his 30’s).
Most HIV testing experts perceived lack of counseling, and linkage to care as another constraint to the uptake of HIVST, leading to missing or delayed initiation to treatment: ‘[…], I anticipate lack of linkage to care, particularly for those who will test HIV positive, if there will be no follow-up mechanisms. This may lead to missing or delayed initiation of treatment’ (IDI participant 9, in her 50’s).
A female HIV testing expert expressed her concern related to the limitations of HIVST as a screening test, and a follow-up visit to a health facility for a confirmatory test in case of a reactive result:
"My concern is the fact that HIV self-testing is a screening procedure. If my test result is reactive, then I need to go to the health facility again for a confirmatory test. My other concern is that HIVST tests like any other rapid HIV tests have a limitation of not detecting acute HIV infection during the window period" (IDI participant 13, in her 50’s).
Self-efficacy towards HIVST
Most men were confident in their capacity to use the HIVST kits. Some male participants stated their preference for face-to-face counseling with a trained counselor to clear doubts about an individual’s performance with HIVST kits. A male participant explained: “Wherever the self-test kits would be available, clients must receive counseling and a demonstration on how to use the self-test kits before they buy the kits and test for HIV. Once clients receive all the necessary information, self-testing correctly for HIV is possible” (FGD participant, in his mid 20’s).
However, some female participants were less confident in their capacity to use the HIVST kits correctly when alone. Their lack of confidence in their capacity to use the kits may lead to potential mistakes, which would reduce their trust in the self-test results:
“ I will not be confident to test myself as if I will go to ANGAZA (a stand-alone VCT site)…that the instrument [HIVST] has shown correctly the results…maybe I have made a certain mistake or there may be something which I have done wrong…” (FGD participant, in her 30’s).