Description of participants. Participants' ages ranged from 18 to 31 years. Among the twenty participants, ten had completed secondary education, four had completed tertiary education, five had completed primary education, and one had no formal education. Regarding religiosity, most participants identified as religious; specifically, fifteen identified as Christians, four as atheists, and one as a practitioner of Islam. All participants were employed, reporting a monthly average income of GH₵830.15 ($70), which falls within the low-income bracket in Ghana, with incomes ranging from GH₵200 to GH₵2003 [20]. Regarding sexual behavior within the past year, nineteen participants exclusively reported having male sexual partners, while one participant indicated involvement with both male and female sexual partners.
Description of categories and subcategories.
Our analysis revealed three categories of preferences for HIV testing with varying reasons: 1) preference for HIVST at home, 2) preference for HIV testing at a health care facility, and 3) Mixed location preferences.
1) Preference for HIVST at home. Some trans-women expressed a preference for HIVST at home or a private location because (a) it ensures privacy and confidentiality, (b) saves time and transportation costs, and (c) it swerves stigmatizing attitudes of health workers.
Privacy and confidentiality. Some trans-women stated they would prefer to conduct HIVST at home because it ensures privacy compared to testing elsewhere. These trans-women found HIVST more comfortable because they considered it more confidential than visiting a clinic, and they could contact professionals if they needed to.
For me, I think private testing at home is good. I believe in privacy. And for one, it will offer me confidentiality and (make testing) being comfortable. -Trans-woman
So, I may prefer privacy from home over the health facility. Okay. When you test in the comfort of your home, there is a contact you will call and tell him the result. -Trans-woman
For some trans-women, HIVST at home reduces interference from people and prevents the fear of healthcare workers disclosing their HIV status with others or sharing their private information with community members.
With the oral test kit, I usually have privacy at home, so I have no one interacting or interfering with my results. - Transwoman
I would prefer to do it at home. At the health facility, they will share your private information with the community, so I was very scared when my friend took me there for the first time. I was hoping that I would not test positive so they would not get the chance to share my status with everyone, so I was told I was negative, and I said thank you. -Trans-woman
Saves time and transportation costs. For some trans-women, testing at home saves them from unfavorable bureaucratic and delayed processes at the health care facility. HIVST at the health care facility requires moving from one place to another, employing their time and money. Thus, a preference for HIVST at home will avoid delays and costs.
I will not feel comfortable coming to the health facilities for testing and moving from one department to another; that will be another cost. So, as for me, I think the health facility would not be the better place for me. -Trans-woman
I will not feel comfortable visiting the health facilities and moving from one department to another or nurse to nurse; that will be another headache. -Trans-woman.
Aside from transportation, I think time, too. With the oral test kit, I usually have privacy at home. So, I have no one interacting with my results or interfering. But with the facility, you are now going to pick transport, and you know, your time. Sometimes, you go and meet many people, and you may be in a hurry. -Trans woman
I would prefer to do it at home. It will save me time, and I can just do it and go back to my business. - Trans woman
Negative and stigmatizing attitudes of health workers. Some trans-women indicated that health professionals (e.g., nurses) are sometimes abusive to them and act in an unprofessional manner. Hence, they prefer to test at home using the HIVST. Recounting their experiences, some said they witnessed abuse and screaming at people because of some errors. Hence, it discourages them from going back.
The nurses shout and abuse people. If a person fails to show up on his or her clinic date, you will hear them shouting things like, "You are annoying! You know the work we do is difficult!" But this is not right. At least you have to talk to the person calmly. I can say that most people I know who get treated disrespectfully at the facilities would not like to go back there. So, I would prefer to test at home. - Trans woman
I do not want to go through that trauma I went through at the hospital because when he was coming to give me the result, his demeanor was so bad. He put me in a tense mood like I was so much tensed, and at a point, I felt discouraged that I almost gave up. - Trans-woman
Some trans-women reported feeling stigmatized when seeking healthcare services due to their gender expression. They shared that when they visit healthcare facilities unfriendly to KPs, they experience poor treatment because of how trans-women dress or express their gender. This stigmatization can take many forms, including a lack of attention to their needs, nonverbal gestures indicating disapproval, and invasive staring.
Mostly, when I visit a health facility that is not key population-oriented for testing, the workers there make me feel like I should not be attended to because of the way I appear looking feminine. Sometimes, too, their body language, you know, when you are at the facility, they can look at you from top to bottom. Without saying anything, their body language is speaking to you negatively. - Trans-woman
There was an instance when I went to the hospital that was not key population-friendly for testing, and all of a sudden, everyone was looking at me because of the way I dressed. Everyone was looking. The nurses started gossiping. I sat there for about one hour until I approached them to tell them why I was there. But on a normal basis, you go through the Out-Patient Department, and a nurse will attend to you. In my case, no one wanted to attend to me because of how I looked and identified myself. I had to approach them before I was attended to. – Trans woman
2) Preference for HIV testing at a health care facility. Compared to those who preferred to conduct HIVST at home, others preferred to visit the healthcare facility for HIV testing because (a) the availability of professional care, (b) they cannot conduct HIVST and interpret the results successfully, (c) they can access counseling therapy at healthcare facilities compared to home HIVST, and (d) the opportunity to conduct other STI tests.
Availability of professional care. Some trans-women preferred health care facilities to HIVST at home primarily due to the professional care given during one-on-one interaction with the health worker. Some found this option to lack privacy and confidentiality, while others indicated having experienced privacy and confidentiality with some providers. They highlighted the expertise qualified nurses offer to conduct tests effectively as a reason for their preference.
I will choose the health facility rather than doing it at home because it will provide some professional care. -Trans-woman
They received me well. They will talk with you well before you do the test. If you test positive, they will give you medication and tell you how to take care of yourself. The drug is free. If you test negative, they will advise you to protect yourself. – Trans-woman
I will choose the health facility rather than doing it at home because it will provide some professional care. – Trans-woman.
I prefer health facilities because of their privacy. At the health facility, it is between you and the nurse, but someone can see your results at home. You might not know. I would instead go to a professional doctor or a nurse. - Trans-woman
Low HIVST capacity. Some Trans-women opt to visit a healthcare facility for HIV testing rather than conducting the test at home due to their lack of confidence in administering the test independently. They believe that healthcare professionals are better equipped to accurately perform and interpret the test results. Furthermore, they trust that the healthcare facilities have the necessary laboratory equipment to confirm the results.
I prefer to test in the facility because I may not be able to confirm the results. I am not well educated about the test kit or virus issue; I would instead go to a professional doctor or a nurse. -Trans-woman
I feel that going to the health facility is good because of the counseling. Aside from that, when you are doing the oral test, sometimes people lack education on how to do it (test), so they do it anyhow, giving the wrong results. -Trans-woman
The health facilities are better for HIV testing because they have laboratories to confirm your HIV results. - trans-woman
Availability of counseling therapy. Some trans-women mentioned that they found the counseling sessions provided by healthcare workers at healthcare facilities beneficial. As a result, they preferred to get tested at the facility. Some of them shared their experiences where healthcare professionals encouraged them to get tested and provided them with education on prevention. They thought that self-testing at home may be satisfactory if an individual tests negative; however, the availability of counseling can help prevent adverse outcomes if they test positive.
When you are home and do the test, you, yourself, will not do the counseling. The only thing you will do, especially when you are negative, is, you will be happy, but what if you are home and it turns positive? No counseling or anything. So, when you visit the health facility and do the test, and it is negative, they counsel you and give you more ways to protect yourself. But when it is positive, they take you through other tests to confirm the results. Take you through counseling before you go to commit suicide or something. So, I think at the health facility, too, it is very good. -Trans-woman
I will go to the hospital because of the counseling they provide in case I test positive for HIV- Trans-woman.
So, with the nurse I had…like the nurse that tested me, she was really friendly. So, while she was testing me in the process, we were talking; we were having a conversation about how I protect myself, the things I do, the things I do not do. So, with such things, you will always be encouraged to go there because they are friendly. – Trans-woman
Opportunity to conduct other STI tests. Several transgender women have discussed the benefits of being screened for sexually transmitted infections (STIs) in addition to HIV testing when visiting a health facility. They have expressed confidence in the fact that healthcare professionals will collect their fluid samples and screen them for other STIs beyond HIV. This provides them with an opportunity to identify and treat any infections that may have been missed during an HIV self-test (HIVST) done at home, where other STIs may not be detected.
When it comes to the health facility, and I think the health facility samples blood. So, for example, when they go to the test, they take a sample of your blood, and if you have syphilis, they've got to know you have syphilis, but you test at home, and you're negative you won't know you have syphilis, but something is there. - Trans woman
I will pick the hospital because, you know, hospital, they will know, even if I have maybe a sickness now, how will I know (the results) if I do it (self-test at home) at home? Because they have been doing the doctoring course, and they know all the things, so, they will tell me that, with this, you are this, so, let's do this and that, but if you are home alone and you check it, how will you know whether you are positive? - Trans woman
Mixed location preferences. A few trans-women had preferences for HIVST at home and testing at the health care facility, expressing that they do not have concerns about using both testing options because they can (a) benefit from both and (b) use either option based on availability.
Benefit from both options. Some trans-women found conducting HIVST at home and testing in healthcare facilities beneficial because they can take advantage of the privacy and comfort that HIVST at home provides but may also benefit from counseling at healthcare facilities. Also, visiting healthcare facilities would prevent challenges in administering HIV self-testing at home due to capacity limitations.
For me, I think privacy (home-based HIVST) is good. I believe in privacy because of one, confidentiality, and two, being comfortable. But at some point, too, I feel going to the health facility is good due to the counseling and all that. - Trans woman
when doing the oral test sometimes people lack education on how to use it, so they do it anyhow, and it gives the wrong results. So, all ways are good - Trans-woman.
Use either option based on availability. Some trans-women also believe that preference for both options gives them the flexibility to conduct HIVST at home or at the facility based on the option available at the time of need.
Okay. So maybe I might be far from a clinic. The reason why I am saying both is that I don't know where I might find myself. So, let's say if I have traveled, I can't move all the way from where I am to the facility. That means I have to do it myself wherever I am. -Trans woman.
I will choose both because there might be instances where there is no health facility, and you need to do the test. - Trans woman