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Background: Early sexual debut, low educational attainment, history of rape and transactional and intergenerational sex have been associated with HIV infection among Nigerian adolescents, especially females. We sought to understand the “why”, and how to mitigate against these determinants and barriers to addressing adolescent sexual and reproductive health (SRH) and HIV prevention needs. Methods: This qualitative study generated data from 49 focus group discussions with male and female adolescents living with and without HIV, healthcare workers, members of civil society organizations working with young people, and parents of adolescents living with HIV. Participants were recruited from all six geopolitical zones in Nigeria. Data was analysed with ATLAS.ti software. Hermeneutic units were created, and codes developed from focus group transcripts. Network View Manager was used to create maps of codes, memos and quotations, and relevant quotes were retrieved from transcripts. Results: Four major themes were identified, relating to individual, parental, community and government roles in reducing the risk of HIV and unplanned pregnancy among adolescents in Nigeria. Individual factors influencing sexual risk behaviours of adolescents include peer pressure, poor risk perception for HIV, and misconceptions about the efficacy of contraceptives and condoms. Respondents entrusted State responsibilities such as facilitation of HIV-affected adolescents’ access to education, rather, to individuals, parents and the community; and placed the blame for rape on rape survivors. Findings also highlighted the inadequacy of health systems to address adolescents’ needs for treatment of sexually transmitted infections and to provide appropriate education on secondary HIV prevention for those living with HIV. Conclusion: Rigorous studies are needed to understand dynamics between adolescents’ risk behavior, HIV risk perception, parental roles in mitigating HIV risk in adolescents, and the role of communities and government in HIV prevention and treatment for adolescents in Nigeria.
This was a qualitative study based on data generated from interviews in our large 2014 nationwide adolescent study. Transcripts of focus group discussions (FGDs) were analyzed to generate results for the specific objectives for the current study. FGD participants were recruited from six states in Nigeria (one state per each of the six geopolitical zones): Plateau (North-Central), Lagos (South-West), Borno (North-East), Edo (South-South), Imo (South-East) and Kano (North-West). Details of study settings have been previously published [38]. FGDs were conducted at healthcare facilities providing comprehensive HIV services. Study participants were male and female adolescents 10 to 19 years old living with and without HIV, parents/guardians of adolescents living with HIV (ALHIV), health care providers providing services to ALHIV, and members of Civil Society Organisations (CSOs) working with young people living with HIV. A facilitator and a note-taker were recruited to conduct FGDs in each of the six States. Recruited facilitators were adults (including people living with HIV) experienced in conducting FGDs who resided in the study states and were familiar with local cultures and fluent in local languages. The six facilitators received three days’ training on the study protocol, research ethics and specifics of conducting FGDs on SRH. All facilitators pilot-tested the FGD guides in the field during the training. Modifications were made to FGD guides for the purpose of enhancing cultural sensitivity, improving data collection process, and reducing time spent on data collection. Edits included modifying some words to more appropriate and culturally sensitive terminology, such as changing words like “contraceptives” to local terms representing “family planning”. FGD guides for adolescents and parents were first developed in English (Nigeria’s official language), translated to three major local languages (Yoruba, Igbo and Hausa) and back translated to English by certified translators. Where the need was identified, FGDs were conducted in local languages using the relevant guides. The guides for healthcare providers and CSOs were administered in English. With the exception of the guide for parents of ALHIV, all FGD guides were adapted from the tool used by the Network of Zambian People Living with HIV [39]. The guides for adolescents living with and without HIV had 13 questions on SRH needs, sources of SRH information and services (e.g. condoms, abortion, STI treatment), satisfaction with these services, and challenges and barriers faced in accessing them. Also, participants were asked to discuss their preferred options for obtaining information, counselling and other SRH services. The guide for healthcare providers had five questions that enquired about the sexual, reproductive and socio-developmental needs of ALHIV, ethical dilemmas encountered during SRH case management, SRH services provided at their health facilities and how accessible these services were to adolescents, challenges their facilities faced in addressing SRH needs of ALHIV; and measures taken to mitigate these challenges. Focus group participants were encouraged to discuss specific cases (while respecting privacy and confidentiality), and to make recommendations for improving ALHIV access to SRH services and other HIV-related health needs in their facilities. The guide for parents of ALHIV had seven questions, which explored 1) parents’ perceived roles in SRH development of their children; 2) their discussions, and challenges with discussing sex and contraception access and use with their children; 3) their discussions, and challenges with discussing HIV with their children; 4) their perceptions of HIV and SRH needs of their children; and 5) their perception of the quality of HIV and SRH services received at health facilities. Finally, they were asked to make recommendations on how to improve the quality of HIV and SRH services that adolescents need. The guide for CSOs had four questions that explored perceptions of the SRH needs of ALHIV based on their work experience, and on HIV and SRH services provided to ALHIV by their organisations. The facilitator probed on the availability of family planning services and services for STI and SRH education, prevention of unsafe abortion and post- abortion care, maternal and newborn care, and management of gender-based violence through direct provision or referrals. Participants were also encouraged to share the challenges they faced with providing SRH services to ALHIV, including policy constraints, demand for services, and skills to initiate SRH discussions and identify STI symptoms. The session ended with a discussion on recommendations for improving SRH service access for ALHIV. Under confidentiality and privacy guidelines, discussions were guided by specific cases that had been managed by the respondents. The target sample size for each focus group was 5 to 10 participants. Solicitation of study participants continued until the maximum size for each FGD was reached. ALHIV were recruited mainly through their physicians, who introduced the study to parents of minor ALHIV and directly to older ALHIV. Interested parents and adolescents contacted the study team through a study phone number provided by recruiting physicians. Support groups and networks of persons living with HIV in study states were also informed about the study; interested and eligible members would then contact the study team in person or through phone calls. Adolescents living without HIV and those who did not know their HIV status were recruited from youth centres located in the study states. Interested adolescents were recruited for participation after study information was provided. Parents and guardians of ALHIV were recruited similar to ALHIV; prospective study participants were recruited by their clinicians and from among networks and support groups of people living with HIV, at health facilities. Healthcare providers contacted for FGDs were identified through the hospital administrator of each health institution after discussions on study eligibility criteria. Nurses, pharmacists and doctors working in HIV treatment centers for six months or longer were contacted individually for study participation after they were provided information. CSOs working with young people living with HIV in study states were identified through contact with the secretariat of the National Association of Young People Living with HIV. The head of each CSO was contacted and briefed about the study. They were then asked to recommend staff members who had been actively working with young persons for more than six months. The study team then contacted these individuals and sought their interest in participating in the FGD. Eight FGDs were conducted in each State (nine in Borno) as follows: 1) Two FGDs among adolescents 10–14 years old: one for ALHIV and another for adolescents living without HIV or status unknown. Both groups had both male and female participants, with the exception of Borno state, where FGDs were separated by gender in compliance with Islamic guidance; 2) Two FGDs (one each for males and females) were conducted for adolescents age 15 to 19 years living with HIV; 3) One FGD was conducted for male and female adolescents age 15 to 19 years who were living without HIV or untested; 4) Three additional FGDs were conducted: one each among parents/guardians of ALHIV, healthcare providers, and members of CSOs working with ALHIV. FGDs were conducted in meeting rooms that were conducive for the participants, ensured privacy, and supported quality audio-recording. On arrival, each participant was taken through the informed consent/assent process and given the opportunity to ask clarifying questions. For adolescents 10 to 17 years old, parental consent forms had to be submitted or freshly administered to parents. All participants were provided transport reimbursement (approximately $14 at the time of the study) prior to signing consent forms. Those who wished not to participate were able to leave immediately. FGD sessions started with facilitators confirming participant approval for audio-recording the session, describing ground rules for conduct, and starting with an ice breaker. FGD guides allowed for probing and exploration of spontaneously generated themes. Notes were taken during each session as a back-up to the audio-recording and to document non-verbal cues. At the end of the FGD, a one-page debriefing form was completed, which summarized basic information about the session (duration, mood of interview, number of participants, facilitators and observers present). A summary report of the discussion was also completed. Audio recordings were transcribed within 72 h, and were deleted from the password-protected computers of all transcribers once transcripts were completed. ATLAS.ti software for qualitative data analysis was used to analyse FGD transcripts. Hermeneutic units were created and codes developed from all eight FGD types in order to aggregate the codes that remained after merging. Network View Manager was used to create maps composed of codes, memos and quotations. Relevant quotes were retrieved from transcripts. Themes developed from qualitative analysis were: reasons for low HIV testing rates among adolescents; lower educational attainment among ALHIV compared to adolescents without HIV or unknown HIV status; sexual risk behaviors; early sexual debut and associated increased HIV risk for adolescent females; poor SRH and HIV knowledge; access, uptake, and use of contraceptives among adolescents; the incidence of rape and related risk of HIV infection. This study was approved by the Nigeria Institute of Medical Research Institutional Review Board and the Health Research Ethics Committees of the State Ministries of Health in Plateau, Lagos, Borno, Edo, Imo, Kano States, and the Federal Capital Territory, Abuja. Written informed consent was obtained for all study participants. Parental consent was obtained for participants 10 to 11 years old; parental permission and participant assent were obtained for adolescents 12 to 17 years old. Participant consent was obtained for adolescents 18 and 19 years old. All staff, researchers, and field workers engaged in this study were trained on research ethics emphasizing the importance of informed consent and confidentiality. No names or personal identifiers were recorded on any study instruments or transcripts.
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