Exploring attitudes towards HIV self-testing among men at Katurura Hospital in Windhoek, Namibia: A Constructivist Inquiry

Ligamena Nambili Kakoma
International University of Management, Windhoek, Namibia

Mwakanyadzeni Abigail Chipare
International University of Management, Windhoek, Namibia

DOI: https://doi.org/10.55320/mjz.51.2.460

Keywords:Attitudes, Constructivist Approach, HIV Self-Testing (HIVST), men, Namibia

Background: In the context of Katutura Hospital's outpatient departments in Namibia, this qualitative study explores men's attitudes towards HIV Self-Testing (HIVST). Embracing a constructivist philosophical stance, the research aims to comprehend the subjective construction of reality by individuals concerning HIVST. The adoption of purposive sampling facilitates the selection of participants capable of offering diverse perspectives on HIVST.

Methods: Purposive sampling is employed to select participants capable of providing diverse perspectives on HIVST. In-depth interviews are conducted at Katutura Hospital's outpatient departments to collect data. Thematic analysis serves as the methodological approach to analyse interview transcripts, enabling the identification of key themes and patterns in participants' attitudes towards HIVST.

Results: The study reveals a spectrum of attitudes among participants, ranging from positive acceptance to scepticism and reluctance towards HIVST. Positive attitudes predominantly stem from perceived convenience, privacy, and accessibility of self-testing kits. However, concerns about accuracy, counselling, and linkage to care also emerge among participants, indicating potential barriers to widespread adoption of HIVST.

Conclusion: The study underscores the complexity of attitudes towards HIVST among men in Namibia. By elucidating the factors influencing these attitudes, the findings offer valuable insights for developing targeted interventions aimed at promoting HIV testing uptake and reducing treatment delays among men in the country. Tailored awareness campaigns and interventions addressing knowledge gaps and misconceptions surrounding HIVST are deemed crucial for effectively promoting its adoption.

The prevalence of the Human Immunodeficiency Virus (HIV) in Namibia presents significant public health challenges, with the country experiencing a high burden of HIV-related morbidity and mortality. Despite advancements in HIV prevention and treatment, Namibia continues to struggle with one of the highest HIV prevalence rates globally, with an estimated 220,000 people living with HIV^[1] . This persistent epidemic places immense strain on the healthcare system and poses substantial developmental obstacles for the country.

To combat the HIV crisis, the Joint United Nations Programme on HIV/AIDS (UNAIDS) introduced the 95-95-95 global targets, aiming to control and ultimately end the epidemic by 2030. These targets emphasise that 95% of individuals living with HIV should be aware of their status, 95% of those diagnosed should receive sustained antiretroviral therapy (ART), and 95% of those on ART should achieve viral suppression. Despite efforts to implement strategies to meet these targets, Namibia, like many other regions, faces challenges in achieving the first 95 target, particularly in ensuring widespread HIV testing coverage.

Research indicates that regular HIV testing is crucial for achieving the first 95 target, as individuals unaware of their HIV status contribute significantly to new infections^[2] . However, men in Namibia exhibit lower healthcare-seeking behaviour compared to women^[3] . This might be attributed to them encountering barriers such as masculinity norms, confidentiality concerns, HIV stigma, fear of test results, long waiting times, and perceived unwelcoming conventional HIV Testing Services (HTS)^[4,5] .

Recent advancements in HIV testing include the introduction of HIV self-testing (HIVST), recommended by the World Health Organization (WHO) as an additional approach to HIV testing. HIVST, although not diagnostic, screens for the presence of antibodies and has been deemed safe, reliable, and accurate, providing an opportunity to empower individuals reluctant to test, enabling early treatment, and linkage to care^[6,7] .

While several countries, including Namibia, have responded to HIVST guidelines, with approximately 28 countries implementing them and more than 59 countries developing policies, the attitudes of specific populations, especially men, towards HIVST remain relatively unexplored. Understanding these attitudes is crucial for designing targeted interventions to increase HIV testing uptake and ultimately mitigate the impact of the HIV epidemic in Namibia. This study, therefore sought to understand the subjective construction of reality by men attending outpatient services at Katutura Hospital in Namibia regarding HIVST.

This qualitative study was underpinned by a constructivist philosophical stance, recognizing the subjective construction of reality by individuals^[8] . This approach was chosen to delve deeply into the multifaceted attitudes and perceptions of men (n=25) regarding HIV Self-Testing (HIVST), acknowledging the importance of understanding their lived experiences.

A constructivist philosophical perspective is rooted in the belief that people construct their own subjective realities through their lives or experiences they are exposed to, their everyday interactions, and varied interpretations of their environment^[9] . This approach emphasises the idea that reality may not necessarily be an objective truth, but rather a product of a person's perceptions and interpretations. In this study, adopting a constructivist stance meant acknowledging and exploring the multiple, diverse realities that men construct around the issue of HIVST. Further, a qualitative research design was employed to allow for an in-depth exploration of participants' attitudes towards HIVST. This methodological choice aimed to capture the richness and complexity of participants' perspectives, offering insights into the factors influencing their attitudes and behaviours.

Purposive sampling was utilised to select participants who could provide diverse and insightful perspectives on HIVST. Sampling continued until data saturation was reached, ensuring that a comprehensive understanding of the phenomenon under investigation was achieved.

Data collection occurred through in-depth interviews conducted by LNK, a female postgraduate student at Katutura Hospital’s outpatient departments, providing a natural setting for engaging with participants. The hospital was purposively selected as it caters for a diverse population within a black township in Windhoek, Namibia. Through open-ended questioning, participants were encouraged to share their thoughts, feelings, and experiences related to HIVST. Audio recording of interviews ensured accuracy and fidelity in data collection. The data analysis process involved a systematic approach to organizing, coding, and interpreting interview transcripts. Themes and patterns emerged from the data, providing valuable insights into the underlying factors shaping participants' attitudes towards HIVST.

Ethical considerations were central to the research process, with approval obtained from the institutional ethical committee of the International University of Management, Windhoek, Namibia and the Ministry of Health and Social Services (Ref 17/3/3 LNK). Written informed consent was obtained from all participants, and measures were implemented to safeguard their confidentiality and anonymity throughout the study.

In summary, the study employed rigorous qualitative research methods to explore the attitudes of men towards HIVST. By embracing a constructivist philosophical stance and employing a qualitative research design, the study aimed to uncover rich insights into the lived experiences of participants in relation to HIVST.

In the demographic breakdown, 25 male individuals took part in this study, spanning an age spectrum from 18 to 50 years. Among them, the prevailing marital status varied, encompassing both married and unmarried individuals. Notably, each participant demonstrated fluency in the English language.

Attitudes of HIV Self-Testing
Two distinct attitudes toward HIV self-testing emerged from the data: positive and negative. Participants expressed positive attitudes by highlighting the benefits of HIV self-testing, often comparing it to traditional HIV testing methods. Conversely, negative attitudes centred on various concerns and reservations regarding self-testing.

Positive Attitudes:
Approximately half of the participants expressed a strong inclination towards using HIV self-testing kits or recommending them to others. Several reasons were cited to support this preference. This was exemplified by one participant who said:

"The first reason….(is) was that men’s health-seeking behaviour is pretty limited compared to that of women. For this reason, they would prefer to buy an HIV self-testing kit, over having to come to hospitals and get tested all at once."
Participant 5, aged 46.

Another line of thought that emerged was the premise of having to come to get counselling coupled with healthcare workers intervening in personal space and so on. Further, some participants noted that self-testing necessitated the elimination of long queues as one stated:

“I’d rather buy the HIV self-test kit and test myself than come stand in these lines."
Participant 4, age 27.

The other emergent notion was that of stigma, yes; data revealed that stigma is still cemented in the communities. One participant remarked:

‘Yes, number one, you know, when HIV started, if you follow the history, it was like an abominable disease or just a shame we just had that understanding that if you have HIV, you feel discriminated against and people are not comfortable to be around you."
Participant 1, aged 38.

Negative Attitudes:

A significant portion of participants expressed reservations about recommending HIV self-testing. Some participants cited a lack of trust in the accuracy of self-testing kits or expressed discomfort with the idea of testing themselves.

“But for me, from my understanding, I don’t trust HIV self-testing….I don’t like it and I don’t like the idea of testing myself." Participant 1, aged 38

"It’s not that I do not trust myself, but I would like to be in the presence of a professional, you understand? I myself I am capable of doing the test, but still, I want to have that confidence, you know, confidence in results is actually very important." Participant 8, aged 22.

"Well, I can see that the doctors are more equipped with knowledge unlike of you doing the test by yourself maybe you can mess up during the process so I think it’s best to see a doctor." Participant 5, aged 46. Participant 9, aged 50

A few participants also showed unwillingness to utilise HIV self-testing by arguing that although most people are willing to self-test and get their results, not all who test positive will be willing to come to the hospital and be initiated on treatment.

"Because now if I buy that kit, there’s not also on books that know Namibia’s having ten people are HIV positive or less because there is no record for us in the country. How many people are HIV positive or not? Because I tested, it’s negative, but if it’s positive it's only me who knows. Not even the pharmacists." Participant 9, aged 50

This study aimed to investigate the perspectives of male attendees at the outpatient departments of Katutura Hospital and male healthcare workers in Namibia. Specifically, it sought to understand their attitudes towards HIV self-testing, assessing whether they would personally use it or suggest it to others. The findings revealed a mixed range of responses, contrasting both positively and negatively with conventional HIV testing services.

Approximately half of the participants expressed a favourable inclination towards HIV self-testing, stating their willingness to utilise it themselves or recommend it to acquaintances. The primary reasons cited for this interest were the convenience and privacy afforded by self-testing. Notably, most men expressed a preference for purchasing HIV self-testing kits over visiting a hospital for testing. This inclination was motivated by a desire to avoid discomfort associated with pre- and post-counselling sessions, long wait times, and concerns about encountering stigma.

The above findings conform to several studies including, Njau and colleagues who reported that positive attitudes towards HIVST were associated with privacy and convenience of choice ^[10] . Taken together, these findings indicate that HIV self-testing can be an acceptable tool for gearing an increase in HIV testing uptake among men.

As far as negative attitudes towards HIV self-testing are concerned, just over half of the participants could not recommend or show an interest in HIV self-testing. While some participants indicated that they do not trust HIV self-testing in general, others are more concerned about kits accuracy and ultimately false and inconclusive results. Some participants on the other hand do not like the idea of testing themselves. The above could be attributed to misconceptions around HIV self-testing, lack of expertise coupled with having more confidence in healthcare professionals than the self^[11,12] . A few participants also argued that although HIV self-testing might be a good tool, and most people might be willing to use it, not all those with positive cases would be willing to be linked to treatment and care. Moreover, there was also a sense among some participants that HIV self-testing interferes with HIV statistics and data surveillance. With this notion in mind, it seems more appealing, especially for those testing for the first time, to test for HIV at healthcare facilities, where a social worker could be helpful. These observations corroborate previous studies on issues related to HIV self-testing^[4,10] .

Despite positive attitudes towards HIV self-testing, concerns regarding linkage to care, accuracy, and potential misuse were evident. These findings echo previous literature^[4,10,13] and underscore the importance of addressing these issues through informed education and targeted interventions.

Study limitations

The study's limited generalizability due to its context-specific findings at Katutura Hospital underscores the need for caution when extrapolating results to broader populations or different healthcare facilities in Namibia. Moreover, potential biases in participant selection, despite efforts to ensure diversity through purposive sampling, may have led to the underrepresentation or exclusion of certain groups, thus compromising the study's comprehensiveness. To address these limitations, future research endeavours should consider diversified sampling strategies, incorporating participants from various outpatient settings, rural areas, and demographic groups to enhance representativeness. Additionally, conducting longitudinal studies could provide deeper insights into the dynamics of attitudes towards HIV self-testing among men over time, while integrating mixed-methods approaches could offer a more comprehensive understanding by combining qualitative insights with quantitative data to explore correlations with demographic or socio-economic factors.

Tailoring HIV self-testing initiatives to suit men's preferences requires multifaceted approaches. Based on the study findings, the authors posit that the Namibian government could include subsidies or free distribution of testing kits to enhance accessibility, alongside decentralized distribution channels. Integration of counselling into testing processes and practical demonstrations at the point of purchase can address literacy and usability concerns. Additionally, leveraging peer influence and women's involvement can enhance awareness and encourage uptake among men. Mobile outreach programmes, community engagement, and multimedia campaigns should be employed to disseminate information effectively. While positive attitudes towards HIV self-testing were evident, concerns remain, emphasising the need for ongoing education and research to optimise delivery and uptake. This study therefore lays the groundwork for future investigations into improving HIV self-testing initiatives tailored to men's needs.

What is already known on this topic:

• Men in Namibia exhibit lower healthcare-seeking behaviour compared to women.
• HIV Self-Testing (HIVST) has been recommended by the World Health Organization (WHO) as an additional approach to HIV testing.
• Previous research indicates that regular HIV testing is crucial for achieving the first 95 target of the 95-95-95 global targets.

What this study adds:

• Exploration of attitudes towards HIV self-testing among men at Katutura Hospital in Windhoek, Namibia.
• Utilization of a constructivist inquiry approach to understand the subjective construction of reality by individuals regarding HIVST.
• Identification of a spectrum of attitudes among participants, ranging from positive acceptance to scepticism and reluctance towards HIVS/T.

Acknowledgements – The authors acknowledge Dr. James January for his insightful comments on the manuscript.

Competing interest – The authors declare no competing interests, financial or otherwise.

Authors' contributions - Both NLK and MAC conceptualized the data, NLK was involved in data collection and both NLK and MAC were involved in coding, data analysis, preparing and finalizing the manuscript. Both authors approved the final version for publication.

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Medical Journal of Zambia, Vol 51, 2

The Medical Journal of Zambia, ISSN 0047-651X, is published by the Zambia Medical Association.
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