Improving HIV Prevention for Key Populations in Nigeria: Insights on Access, Barriers, Stigma, and Service Utilization

Design and Procedure

This cross-sectional study was conducted in 2023, involving data collection from KPs in nightclubs and brothels across three LGAs in Kano, Nigeria. These LGAs were specifically selected due to their high concentration of KPs. Participants underwent HIV testing using self-test kits, and those who tested positive were promptly linked to treatment services. To encourage the participation of participants in this sensitive study, the research team approached potential participants respectfully, explaining the study’s purpose and emphasizing confidentiality, privacy, and the importance of HIV awareness and treatment. They provided brief counseling in private spaces within the venues, ensuring participants felt comfortable and informed about the process, benefits, and voluntary nature of HIV self-testing. Sexually active participants in this study refer to an individual who has engaged in any form of sexual activity (vaginal, anal, or oral sex). Ethical considerations were thoroughly addressed, and support services were readily available for any follow-up needs. Additionally, the study assessed the willingness of KPs to access HIV services using a well-structured 17-item questionnaire. A willingness threshold was set at 75%.

Population and Sampling

This study was conducted in three LGAs: Gwale, Fagge, and Tarauni in Kano State, Northern Nigeria, with a population of Fagge (1,282,500), Gwale (588,500), and Tarauni (364,900).^[15] In order to minimize potential selection bias, the study utilized snowball sampling to recruit participants, enhancing reach within the target population. However, FSWs unwilling to participate were excluded, and eligibility was restricted to those proficient in English or Pidgin. Individuals who could not communicate in either language were ineligible to participate. KPs aged 18 and above residing in the selected LGAs in Kano State were included in the study, while those below 18 years were excluded.

This study used a quantitative research approach to ensure comprehensive data collection and analysis. The snowball sampling technique was employed; the participants were recruited to participate in the survey from the brothels and clubs across the three LGAs in Kano State with referrals from initial participants. The initial participant selection was based on key informants familiar with the target locations within the three LGAs in Kano State. These informants identified individuals who frequented or worked in brothels and clubs, facilitating the recruitment of participants who met the study criteria.

The sample size for this study was calculated using a 5.8% prevalence of HIV among key populations in Kano State, according to Adeoye et al.^[16] and a single proportion formula: $$n=\frac{Z^2\times p\times (1-p)}{E^2}$$

Where Z is the confidence level with Z-value for a 95% confidence level = 1.96.

Prevalence of HIV among KPs in Kano State, p = 5.8%, = 0.058 (Adeoye et al.^[16]).

E is the margin of error, often set at 1.38% or 0.0138, to ensure a precise estimation of the HIV prevalence among key populations in Kano State while accounting for possible variations in the sample.

Adding 20% attrition, n = 1,100 + 220, = 1,320 (approximately).

To achieve maximum sample size, 20% attrition and 1.38% marginal error were used because of the anticipated decline to participate in the study by KPs due to stigmatization and unwillingness to disclose their status.

A proportionate allocation method was used to determine the minimum sample size from each LGA based on the population size of each LGA: Fagge (1,282,500), Gwale (588,500), and Tarauni (364,900). The estimated maximum sample sizes were Fagge (757), while the minimum estimated sample sizes for the remaining two LGAs were Gwale (347) and Tarauni (216). However, 1,320 valid data were collected across the three LGAs, representing 100% of the estimated minimum sample size. The sample size is justified due to the use of snowball sampling, which relies on participant referrals and can result in a broader reach, especially when recruiting hard-to-reach populations. This approach helps ensure the sample is sufficiently representative of the target population across three local government areas in Kano State, Nigeria.

Study Variables and Instruments

The survey employed a well-structured questionnaire comprising both open-ended and closed-ended questions to collect primary qualitative data from consenting KPs. The questionnaire was originally and specifically developed for this survey to address the unique focus areas of the research. This customization ensured relevance to the targeted KPs, facilitating the collection of specific primary qualitative data directly related to the study objectives. The questionnaire was divided into sections covering socio-demographics, willingness to access HIV services, HIV status, and the reasons for and against utilizing HIV services. Participants were provided with self-test kits to determine their HIV status. To address potential hesitancy in reporting HIV-positive results, participants were assured of confidentiality and provided with a supportive environment for disclosing their test results. Each participant self-reported their HIV status, with trained counselors available to offer guidance and support throughout the process, ensuring a non-judgmental atmosphere for full participation.

Data Analysis

The collected data were recorded, cleaned, and analyzed using Microsoft Excel and the Statistical Package for the Social Sciences (SPSS) for Windows, Version 28.0.^[17] The data analysis included descriptive statistics, frequency distribution, and binary logistic regression, with the results presented in tables and figures for clear interpretation. Binary logistic regression was employed to assess the influence of socio-demographic variables on HIV prevalence and the willingness to access HIV services. Additionally, the reasons for and against HIV service uptake were illustrated using charts. The study adhered to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) reporting of observational studies guidelines, as recommended by the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network, to ensure transparent reporting of methods and findings.^[18] Following these guidelines, data were systematically recorded, cleaned, and analyzed. This adherence enhances the reproducibility and reliability of the findings.

Informed consent was obtained from all participants, who were also informed of their right to withdraw from the study at any point without the need to provide any justification for their decision. Also, given the socially sensitive nature of the study, participants’ privacy and confidentiality were prioritized throughout the research process. All personal information and data collected were kept strictly confidential and securely stored, with access limited to authorized personnel only.

Socio-Demographic and Behavioral Characteristics of the Respondents

Table 1 highlights the socio-demographic and behavioral characteristics of KPs in Kano State. The sample includes 49.2% FSWs, 32.6% MSM, and 18.2% PWIDs. Most respondents are young, with 78.1% aged 18–34. Educational attainment varies, with 47.1% having secondary education, 25.7% tertiary education, and 16.8% having no formal education. The participants are evenly distributed across three local government areas: Gwale (37.9%), Fagge, and Tarauni (31.1% each). Drug abuse is common, with 58.4% reporting a history of abuse and 39.9% having injected drugs. Sexual behaviors reveal that 63.4% had multiple partners in the last three months, with vaginal sex being the most prevalent (66.7%), followed by anal (18.9%) and oral sex (12.9%). The age of first sexual debut is mostly between 14 and 17 years (37.0%). Motivations for sexual activity include fun/love/marriage (57.5%) and financial reasons (20.2%). Transactional sex is prevalent, with 29.4% paying for sex and 27.8% receiving gifts for sex. Condom use is inconsistent, with only 36.6% always using condoms in the last three months and 33.3% not using them during their last sexual encounter.

Prevalence of HIV and the Associated Factors Among FSWs in Kano State

Table 2 presents HIV prevalence and associated factors among KPs in Kano State, revealing a 10.8% HIV positivity rate. FSWs had a significantly lower HIV prevalence compared to MSM (AOR: 0.346, p = 0.001). In contrast, PWIDs were at a higher risk of being HIV-positive than MSM (AOR: 2.827, p = 0.019). Interestingly, those who had ever injected drugs were less likely to be HIV-positive compared to those who had never injected (AOR: 0.253, p = 0.001). Engaging in vaginal or anal sex in the past three months significantly increased the likelihood of being HIV positive, with adjusted odds ratios of 5.270 (p < 0.001) and 2.213 (p = 0.030), respectively. Other factors such as age, education, location, drug abuse, sexual debut, sexual partner, oral sex, transactional sex, and condom use during the last sexual encounter or over the past three months did not show significant associations with HIV prevalence.

Factors Associated With Willingness to Access HIV Service Among KPs

Table 3 highlights key factors influencing the willingness of KPs in Kano State to access HIV preventive services, with an overall willingness rate of 57.7%. FSWs were initially more willing to access these services than MSM (COR: 2.136, p < 0.001), but this significance disappeared after adjusting for other variables (AOR: 1.075, p = 0.756). Education level had mixed effects; both secondary and tertiary education were linked to lower willingness compared to those with no formal education in the crude analysis, but these associations were not significant after adjustment. Geographical location played an important role in willingness, with respondents from Tarauni being much more willing to access services than those from Fagge (AOR: 26.404, p < 0.001). Those from Gwale showed less willingness in the crude analysis (COR: 0.752, p = 0.034), but this reversed in the adjusted model (AOR: 1.729, p = 0.013). Drug use history showed a positive association with willingness in the crude analysis but lost significance after adjustment. Sexual practices were strong predictors; individuals who engaged in vaginal sex in the last three months were significantly more likely to seek HIV services (AOR: 4.344, p < 0.001), while those who engaged in anal sex were less likely to be willing (AOR: 0.413, p = 0.002). Engagement in transactional sex initially appeared to increase willingness, but this was not significant after adjustment. Condom use during the last sexual encounter was associated with a higher desire to access services (AOR: 1.660, p = 0.012).

HIV Services Uptake Among KPs

Figure 1 presents the uptake of two key HIV services among KPs. A substantial majority of KPs, 95.9%, reported using HIV self-testing (HIVST), while the uptake of PrEP was 68.0%.

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Figure 1 HIV services uptake among KPs.

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Reasons for Accessing HIV Services Among KPs

Figure 2 outlines the primary reasons KPs access HIV services. The overwhelming majority, 91.0%, cited the desire to “know and confirm my status” as their main motivation. A smaller portion, 5.6%, accessed services for precaution, protection, and treatment. Only 2.6% sought HIV services to gain more information and knowledge about HIV. A very small fraction, 0.8%, accessed services for other reasons.

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Figure 2 Reasons for accessing HIV services among KPs. KPs: Key populations.

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Obstacles to Accessing HIV Services Among KPs

Figure 3 shows the key obstacles faced by KPs in accessing HIV services. The most significant barrier, cited by 24.2%, is the lack of free, accessible, and comprehensive HIV services. The issue of stigmatization and harassment was reported by 22.6% as the obstacle to accessing the services. Lack of knowledge about HIV service providers is another significant obstacle, with 19.5% reporting this as a barrier. Lack of friendly facilities was identified by 11.3%, and 10.8% cited a lack of information about my group as a barrier to accessing HIV services among the KPs. Smaller percentages of respondents reported the non-availability of HIV service providers (6.1%) and inability to provide adequate HIV counseling services (5.6%) as barriers.

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Figure 3 Obstacles to accessing HIV services among KPs. KPs: Key populations.

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Limitations of the Study

The study’s reliance on self-reported data for sensitive topics such as drug use, sexual behavior, and condom use introduces potential bias. Participants may have underreported or overreported their behaviors due to social desirability or recall bias, which could affect the accuracy of the findings. Additionally, while the study primarily focused on HIV prevalence, it did not explore other sexually transmitted infections (STIs) or broader health issues among (KPs). Including these factors would have provided a more comprehensive understanding of the health challenges faced by KPs. Furthermore, the pervasive stigma and discrimination experienced by KPs may have influenced their willingness to participate and their honesty in reporting behaviors, potentially skewing the results and impacting the effectiveness of future interventions. The study’s generalizability is limited due to the purposeful selection of study sites and the use of snowball sampling, which may not represent the broader KPs. This sampling method introduces potential biases in participant selection, limiting the applicability of the findings to other settings or groups outside those specifically targeted in the study. Also, the findings may not fully reflect the diverse experiences and health challenges of KPs worldwide.

Strengths of the Study

• The study achieved its targeted sample size (1,320 participants), ensuring robust statistical power for analysis.

• A well-structured, specifically developed questionnaire allowed the collection of focused and relevant data on willingness to access HIV services.

• Providing free self-testing kits and immediate treatment referrals addressed both health and ethical concerns, benefiting participants directly.

• Advanced statistical methods enhanced the reliability of findings by accounting for socio-demographic influences on HIV prevalence and service willingness.

• Adherence to STROBE guidelines and obtaining ethical approval ensured transparent reporting and ethical integrity throughout the study.

Key Messages

1. The overall HIV prevalence among key populations in this study was 10.8%. Men who have sex with men (MSM) and people who inject drugs (PWIDs) showed higher HIV prevalence rates compared to female sex workers (FSWs). 2. Willingness to access HIV preventive services was recorded at 57.7%, influenced by geographical location and sexual practices. Participants from Tarauni were more willing to access services, and those engaging in vaginal sex were more likely to seek preventive services. 3. HIV self-testing had a high uptake of 95.9%, whereas pre-exposure prophylaxis (PrEP) uptake stood at 68.0%. 4. Major barriers included stigma, lack of comprehensive services, and limited knowledge among service providers. Targeted interventions that address these barriers are crucial for improving service uptake and reducing HIV transmission. Enhancing accessibility and tackling stigma are key strategies for achieving epidemic control in Nigeria by 2030.