Contextualizing the Process of Diffusing an HIV Self-Testing Innovation Among Refugee Youth Living in Informal Urban Settlements in Kampala, Uganda: Findings from a Community-Based Qualitative Study

Background: UNAIDS identifies forcibly displaced persons, including refugees, as a key population at a significantly higher risk of contracting HIV. Uganda is the third-largest refugee-hosting country globally, with a high HIV prevalence rate among youth, limited access to sexual health interventions for refugees, and an overburdened health system. Despite the potential of HIV self-testing (HIVST) in increasing HIV testing in key populations, scant evidence exists on the adoption process of such an innovation among refugees. Guided by the Diffusion of Innovations theory, this study fills this gap by providing an in-depth and contextual understanding of how young refugees in Kampala, Uganda, adopt HIVST.

Methods: We conducted a qualitative community-based study with urban refugee youth aged 16–24 living in Kampala’s informal settlements (Nsamyba, Katwe, Rubaga, Kansanga, Kabalagala) between March and May 2019. Data were collected using five in-depth, semi-structured key informant interviews (KI) with community-based HIV/STI service providers and five focused group discussions (FGDs) with young refugee men and women. FGDs and KI interviews were audio-recorded, transcribed verbatim, translated to English, and verified with community collaborators. Thematic analysis involved inductive analysis – Diffusion of Innovation theory-driven coding was used to explore the extent to which the data aligns with the two processes of the diffusion of innovation processes (i.e., dissemination and adoption). This analysis employed an iterative team coding process to increase the confirmability and credibility of findings, including independent co-coding and the auditing of analytical techniques and procedures. This team coding process aimed to gain additional perspective, deepen the understanding, and enhance methodological rigor.

Results: Our study yielded in-depth insights into the key actors and processes involved in adopting HIVST. 1) At the dissemination process, participants felt that the social system, including churches, schools, football events, religious and community leaders were key actors, events, and spaces that could generate attention, interest, and understanding of the aim and use of HIVST. Participants said that the relative advantage of HIVST to the current service model of HIV testing centers could persuade refugees to consider HIVST. It offers privacy and confidentiality, a buffer against exposure to sexual and HIV stigma, reduced transport costs, and eliminates the discomfort of drawing blood via needle piercing. However, participants were quick to point out that the need to go to HIV testing centers after testing HIV positive using HIVST may prevent uptake or engagement with care when deciding to adopt and use HIVST. 2) At the adoption process, most participants were comfortable with peers and peer educators as change agents; the preference for sexual partners and family members varied by age group and gender.

Conclusions and Implications: Overall, the theoretical framework appeared to be a valuable tool to contextualize, systematically analyze the data collected, and map out the different considerations and actors involved at various stages of the entire diffusion of the HIVST process. Our findings demonstrate that while HIVST could address concerns about the current HIV testing service model, widespread uptake and utilization of the innovation may require tailored adoption strategies.