Uptake and determinants of community-based HIV testing services amongst key populations in Ekiti State, south-west Nigeria: A cross-sectional mixed-methods study

Key populations (KPs), including female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID), and transgender (TG) individuals, bear a disproportionate HIV burden in Nigeria, yet sub-national evidence on community-based HIV testing services (HTS) uptake remains limited, particularly in culturally conservative settings such as Ekiti State. This study assessed knowledge, attitudes, and uptake of community-based HTS among KPs in Ekiti State and examined associated sociodemographic and psychosocial factors. A cross-sectional mixed-methods study was conducted from April to June 2025 among 424 KPs recruited through purposive selection of nine high-burden Local Government Areas and exponential non-discriminatory snowball sampling. Quantitative data were collected using an interviewer-administered questionnaire, while qualitative data comprised one focus group discussion (n = 8) and one key informant interview. Descriptive statistics summarised knowledge, attitudes, and community-based HTS uptake; Pearson’s chi-square and Fisher–Freeman–Halton exact tests assessed associations between explanatory variables and HTS uptake status (never tested, previously tested, or tested within the preceding 12 months). Awareness of community-based HTS was high (90.6%), and attitudes were predominantly positive (88.7%), yet recent community-based HTS uptake, defined as HIV testing through a community-based modality within the preceding 12 months, was 64.2%. Recent uptake was lowest among MSM (58.9%) and FSWs (63.6%) and highest among PWID (78.6%) and transgender individuals (100.0%). Ever community-based HTS uptake was higher, at 72.6%. Bivariate analysis showed statistically significant associations between HTS uptake status and knowledge (Fisher–Freeman–Halton exact p < 0.001), attitude (Fisher–Freeman–Halton exact p < 0.001), sex (Fisher–Freeman–Halton exact p = 0.024), age (Fisher–Freeman–Halton exact test, p = 0.002), educational level (Fisher–Freeman–Halton exact test, p = 0.001), religion (Fisher–Freeman–Halton exact test, p < 0.001), and KP typology (Fisher–Freeman–Halton exact p < 0.001). Marital status was not significantly associated with uptake (Fisher–Freeman–Halton exact p = 0.484). Qualitative findings complemented and contextualised the quantitative patterns, identifying trust in peer-led testers, affordability, and flexible outreach as facilitators, while stigma, self-stigmatisation, and funding constraints emerged as barriers. Despite high awareness of community-based HTS (90.6%) and predominantly favourable attitudes, recent uptake remained lower, suggesting that recent uptake reflected not only individual-level factors but also social and health-system conditions, including stigma, social barriers, and constraints affecting the availability, accessibility, and continuity of services. Peer-led delivery models, strengthened confidentiality protections, and sustained programme financing are needed to close this gap and advance Nigeria’s progress toward the UNAIDS 95-95-95 targets.