Introduction

HIV testing is a crucial entry point for uptake of HIV prevention and treatment services [1]. To meet the UNAIDS’ 95-95-95 targets for ending AIDS by 2030, 95% of people living with HIV (PLWHV) should be diagnosed, 95% of those diagnosed should be taking antiretroviral therapy (ART), and 95% of those on ART should be virally suppressed. Yet two decades of global health programming that expanded HIV testing at community- and facility-based sites achieved only 79% global diagnostic coverage, according to UNAIDS 2019 estimates [2]. This gap in diagnostic coverage reflects considerable heterogeneity across age group and geographic region. Youth (ages 15–24) are less likely to access HIV testing than adults (ages 25–49) [3], and they are disproportionately affected by HIV; in 2018, an estimated one third of all new infections occurred in the 15–24 age group [4], with 73% of new infections among youth occurring in Africa [5]. HIV self-testing (HIVST) may increase the uptake and frequency of testing for youth and others unlikely to test [6–8], and has shown to be an acceptable method to learn one’s HIV status without risk of self or social harm [9].

In Zimbabwe, despite strong gains made to increase diagnostic coverage over the last decade, approximately half of youth had tested for HIV according to a 2015–2016 Zimbabwe population-based survey (ZIMPHIA) [10]. Young people do not access HIV testing due to perceived or actual barriers of accessibility, perceptions of limited support from social networks, concerns over confidentiality and fear of stigma from healthcare providers [11–13]. They want to see convenient, non-judgmental, free HIV testing services prioritized and made available in spaces easily accessible to them [14, 15]. Youth-friendly delivery options for HIV testing are needed to improve knowledge of serostatus and reduce new infections among youth [16].

In 2015, Zimbabwe developed a national policy on HIVST and initiated large-scale implementation under the HIV Self-Testing Africa (STAR) initiative. Results from the STAR trial demonstrate how targeted roll-out of HIVST across multiple distribution models can increase coverage of HIV testing and contribute to case finding among populations unlikely to test, including youth [6]. While HIVST is available in a number of private clinics and pharmacies across Zimbabwe, offering HIVST and counseling in venues primarily frequented by youth may provide more accessible, less stigmatizing opportunities for them to test.

Delivery of HIVST on tertiary school campuses is one such option. In South Africa, where similarly to Zimbabwe youth account for a disproportionate number of new HIV infections but are less likely to test than adults [4, 17], a study investigating the acceptability of HIVST distribution on college campuses found the delivery of unsupervised HIVST was highly accepted by students [18]. A similar study in the Democratic Republic of Congo found that both supervised and unsupervised HIVST was favored among university students [19]. More research is needed to understand the factors that impact acceptability and uptake of HIVST at tertiary-level schools, so youth-focused testing strategies can be improved. Here, we describe Zimbabwean young adults’ (ages 18–24) [20] acceptability of a lay counselor-led campus-based distribution of HIVST, and their recommendations for future implementation.

Methods

We conducted qualitative research within the Feasibility and Acceptability of HIV Self-Testing study (FAST), an interventional study that evaluated HIVST uptake among young adults at tertiary educational institutions in Zimbabwe. The qualitative sub-study was implemented concurrently with the FAST study, and it was conducted in accordance with the consolidated criteria for reporting qualitative research (see S1 File) [21].

Participants and recruitment

The qualitative research team consisted of lead qualitative researcher (ALK), research assistant (DM), and the FAST principal investigator (GM). In total, we recruited 52 young adults from 10 FAST distribution sites in Harare, Bindura, and Masvingo, Zimbabwe (see S1 Table). For IDIs, 26 individuals were purposively sampled from a list of participants who approached the distribution table to learn more about the study, opted in or out of HIVST, and consented to undertake a qualitative interview. We used a maximum variation approach [23] and intentionally varied the demographic attributes of participants by gender and testing selection (self-tested on-site, off-site, or opted not to test) in order to maximize a broad representation of participant types within each selected category (see Table 1).

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Table 1. Purposive sampling framework of IDI participants.

https://doi.org/10.1371/journal.pone.0253745.t001

We conveniently sampled 26 participants to participate in four FGDs. DM approached potential participants at the distribution sites; if they met the participant eligibility criteria and provided informed consent, they were scheduled to participate in a mixed-gender FGD.

Results

In total, 52 young adults took part in our study (Table 2); across 10 colleges and universities. Of the total sample, four individuals had reactive self-test results which were confirmed positive with blood-based testing, and 41 had non-reactive results. One individual had a false-reactive result, which was later confirmed negative with blood-based testing. Participants cited various reasons for accessing HIVST on campus, including: recent risky sexual experience, curiosity to try a new diagnostic technology, and a desire to follow preventative health guidelines and ‘know one’s status’. Six participants opted out of campus-based HIVST, i.e., they approached the distribution team to learn more about the study, did not proceed to HIVST, but agreed to undertake a qualitative interview.

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Table 2. Participant demographics.

https://doi.org/10.1371/journal.pone.0253745.t002

Of all IDI participants (n = 26), 61.5% (n = 16) reported previously testing for HIV, 81% (n = 13) of whom had accessed facility-based testing. Of participants who took a HIVST (22/26), 30% (n = 6) reported testing for the first time, with four of these first-time testers opting to test onsite. Questions related to personal history of HIV testing were not asked of FGD participants to safeguard their privacy.

Themes in the data emerged within two broad categories: acceptability of and concerns with campus-based HIVST. Factors that contributed participants’ acceptance of this distribution modality were a perceived increase in autonomy and convenience. Additionally, some participants felt that campus-based distribution of HIVST created an environment of social acceptability around HIV testing more broadly. Factors that contributed to participants’ concerns with campus-based HIVST distribution were a perceived lack of privacy and insufficient post-test counseling, as well as experiences of socially coerced testing.

Discussion

The results of our study indicate that campus-based delivery of HIVST is highly acceptable among tertiary-level students. Students favored this distribution model because it enabled them to circumvent aspects of facility-based testing they viewed as barriers, including lack of privacy, confidentiality, convenience, and autonomy. Participants who tested on-site were primarily first-time testers and favored the ‘supported, but autonomous’ experience of testing in or near the campus-based distribution booths. The majority of participants who tested off-site reported previously testing for HIV, and were comfortable taking their kit to another location for use. The flexibility of campus-based distribution enabled multiple forms of engagement, empowering participants to assess their individual needs while deciding when, where, and with whom to test. Taking charge of one’s own health motivates young adults to test for HIV [12, 27]; this resonates with our findings that a youth-friendly campus-based HIVST delivery option enabled participants to more easily access testing.

However, while many participants benefitted from the flexibility of campus-based distribution of HIVST, there were some participants who did not feel the distribution model provided sufficient privacy to comfortably test themselves for HIVST. Several participants who opted not to HIVST reported that the act of approaching the campus distribution booth in front of their peers diminished their privacy. Interestingly, this contrasts with the experience of other participants who felt that testing amongst their peers in a familiar environment generated a sense of social acceptability, projected the image of broad student buy-in, and reduced their experience of anticipated stigma. More research is needed to understand the nuances in perceptions of privacy and HIV testing for young adults.

Despite the positive reception of campus-based HIVST, participants raised several concerns. First, there were concerns about socially coerced testing. Given the social nature of the distribution sites, students approached the recruitment table in large or small groups. Often, participants decided to test on-site but did not want to wait in line to use the private testing booths, and opted to conduct their test on the grounds near the distribution campaign station. In cases such as these, several participants reported feeling subtly coerced by their friends to disclose their status after completing their self-test. It is important to note that coercive or mandatory HIV testing is never advised, but can occur inadvertently, including with HIVST [28]. It is imperative that non-facility based HIVST delivery models, including campus-based testing, develop clear protocols and communication materials so lay distributors can effectively sensitize self-testers against coercing partners, friends, or other social contacts into using HIVST.

Other notable concerns raised by participants included the lack of in-person support with campus-delivered HIVST, particularly for those who tested alone or received reactive results. Participants’ perceptions around the value of privacy while testing ranged from the desire for total privacy with no support from staff, to partial privacy with easily accessible in-person support close on hand. Participants who opted to test on-site reported that their decision was motivated by a fear of conducting the self-test improperly, and the anxiety that testing positive while alone could lead to suicide or other self-harm. The HIV Self-Testing Africa (STAR) trial found no evidence of suicides or deaths related to uptake of HIVST across six HIVST implementation studies conducted in Malawi from 2011 to 2017 [9, 29]; however, the fear of suicidal ideation associated with testing alone is consistent with findings from previous research on HIVST acceptability in both adults and young adults [30–32]. Both on-site and off-site testers recommended increasing in-person support for first-time testers, and expanding post-test counselling options for couples in newly serodiscordant relationships and those with reactive test results.

Despite varying levels of need for staff support while testing, participants agreed that HIVST distributors should be young adult lay counselors, preferably from outside the school community. This finding differs from recent studies among young adults in Nigeria and Uganda that showed participants favored peer-to-peer distribution of HIVST, where they could access self-tests from a trusted leader of a social network within their community such as a savings group or girls club [33, 34]. This difference could be due to the highly networked nature of student communities within schools. A young adult counselor who is relatable, but not part of the school community, may be an attractive feature for participants wanting to easily access testing while maintaining privacy.

Participants also recommended that future campus-based HIVST delivery offer secondary distribution kits for partners, friends, or family members. Female participants in particular discussed how partner-delivery of HIVST would be a valuable extension to campus-based programming, as it would offer them an empowering tool to negotiate testing with their male partners. In 2019, the WHO recommended social-network based testing as part of an updated package of partner services among key populations [35]; index testing and secondary HIVST kit distribution were among novel testing approaches cited for consideration within these communities. While early evidence suggests they may increase HIV diagnoses, identify additional PLWHV, and increase acceptability of partner HIV services among key populations [35, 36], there is limited research that examines the efficacy of these modalities among young adults. A recent study examining social harms incurred from partner-delivered HIVST found that coercion to test between adult partners in established relationships was seen as well-intentioned and socially appropriate [9]; however, currently it is unclear if coercion to test would be similarly interpreted during partner-delivered HIVST between young adults. More research is required to understand the acceptability and possible risks of these novel recruitment methods among young adults, as well as the feasibility of incorporating these methods into campus-based HIVST distribution.

This study is not without its limitations. The study focused primarily on participants attending technical vocational colleges, the majority of which were located in Harare. This may reduce the breadth of our findings. In addition, our relatively small sample size and non-randomized sampling methods reduces the generalizability of the study. However, our findings are consistent with those from two campus-based HIVST distribution studies in South Africa and Democratic Republic of Congo [18, 19], and they further contribute to our understanding of young adults’ acceptability and preferences of campus-based, youth-friendly HIVST distribution.

Conclusions

As more PLWHV become aware of their status, innovative testing strategies are required to reach the first of the UNAIDS 95-95-95 goals by 2030. As a screening tool, HIVST is consistent with PEPFAR recommendations for scaling up efficient strategies that test fewer people but identify higher numbers of positive cases [37]; however, HIVST distribution methods need to be strategically designed to reach distinct subpopulations. Our findings indicate that campus-based delivery of HIVST at tertiary-level schools in Zimbabwe is highly acceptable among young adults, and that uptake of HIVST through this distribution model is most promising if young adult lay counselors distribute self-tests, continuous counseling options are improved, and information sensitizing young people about socially coerced testing is provided alongside testing services. Implementing campus-based HIVST, alongside a combination of targeted HIVST strategies such as facility, community, and social network-based testing approaches will likely be necessary to close the gap in diagnostic coverage for young adults in Zimbabwe.

Supporting information

Acknowledgments

The authors would like to acknowledge all of the young adults who agreed to participate in the study, and share their experiences of HIV self-testing.