Theme 1: HIV testing services.

Accessibility of testing: Youth’s access to HIV testing was a critical factor in their engagement with SRH services. Accessibility encompassed the availability of testing facilities, the cost of tests, and the proximity of these centers to their homes or schools. One youth described their experience, saying “I was tested for HIV five months ago at the BABA Moustapha cultural center. It was part of a workshop. Accessing the service was very simple” (Participant #11, age range 22–24 years). Despite these examples of easy access, the financial aspect remained a barrier for many, as highlighted by another youth who noted the high costs associated with hospital visits and the need to seek more affordable options like pharmacies. Furthermore, the lack of free additional testing as healthcare often required multiple screenings were not always covered, making it financially burdensome for youth. For instance, a youth shared, “Going to the hospital for tests costs a lot of money. We young people are looking for shortcuts like going to the pharmacy, which is less expensive” (Participant 4, age range 20–22 years). Another mentioned, “Hospitals are expensive for examinations and due to the lack of resources, we can’t do them. If rates can be reduced for us young people, it would be good because we don’t have the financial means” (Participant #1, age range 20–22 years). These challenges were compounded by issues like reagent shortages, which limited the availability of necessary tests, as noted by a community actor: “On the financial side: access is voluntary; however, we are dealing with reagent shortages, and this has been the case since August 2023 except for pregnant women (prioritized)” (Community actor, FGD #1).

Youth approached HIV testing influenced by various factors, including family, social environment, and personal health experiences, navigating fragmented care pathways across multiple healthcare sectors (Fig 2). Regular testing for HIV was mentioned as a common practice among HIV-negative youth, often driven by personal or parental initiative, which highlighted the importance of early detection and periodic testing after risky behaviors such as “unprotected sex” (Participant #34, age range 18–19 years). Many youths relied on health centers, hospitals, school programs, family referrals, and health campaigns for testing. For instance, one youth shared, “I am taken by my dad for testing. After testing, we went home, and he came back to get the results” (Participant #26, age range 18–19 years). Similarly, others described straightforward access to testing through school campaigns and cultural center workshops. Healthcare workers and community actors have played pivotal roles in facilitating access to these services. For example, community actors mediated between young people and healthcare facilities, providing information and support to navigate the testing process: “My role is to help, accompany, and guide them. In my opinion, it is important to raise awareness in churches, schools, and in the neighborhood” (Community actor, FGD #2). Besides biomedical strategies, behavioral HIV preventive interventions were also employed since service providers offered advice and counseling to HIV-negative youth. Youth reported receiving advice from “psycho-social counselors, attending physicians” (Participant #27, age range 18–19 years), and noted that these providers are key sources of information and support.

Awareness and knowledge: The level of awareness and knowledge about HIV testing among youth significantly influenced their likelihood of getting tested. Youth gathered information from various sources, including “associations working to combat sexually transmitted diseases” (Participant #9, age range 15–17 years), “social networks and educational institutions” (Participant #23, age range 20–22 years). These sources provided crucial information about where and how to get tested, the importance of regular testing, and understanding the implications of the test results. Some youth received referrals from family members, while others took the initiative to seek testing due to health concerns: “I did not feel well and went straight to the hospital for testing because I did not want to suffer. The fear of dying was great. I took the test and when I found out it was negative, it prompted me to take preventive measures in the future” (Participant #4, age range 20–22 years). However, misconceptions and a lack of comprehensive knowledge deterred youth from seeking testing. For instance, one youth mentioned, “Some people think that once you take the test, you will get infected” (Participant #2, age range 18–19 years). Another added, “I thought you could only get tested if you were already sick” (Participant #1, age range 20–22 years). Healthcare workers were instrumental in educating and advising youth about the importance of regular testing and HIV prevention.

Psychological barriers: Psychological barriers played a significant role in youth’s decision-making regarding HIV testing. Young women often faced higher barriers to accessing HIV testing due to societal norms and stigma associated with sexual health. Females were more likely to encounter negative reactions from healthcare providers and fear of judgement, which discouraged them from seeking testing. A challenge identified was the mandatory parental presence required for minors due to Chad’s legal framework, significantly impacting confidentiality. As one community actor explicitly noted, “The obstacle is the lack of confidentiality” and “family presence is required” (Community actor, FGD #2). This requirement often heightened anxiety and fear among young people, directly compromising their willingness to seek testing. Additionally, some young women reported being coerced into testing by their parents, sometimes without fully understanding the process or its implications. Healthcare providers attempted to mitigate some of these confidentiality barriers; a healthcare worker explained their practice: “When a teenager presents (always accompanied), if the doctor refers them to us for screening, the child is isolated from the parents to find out if sexual intercourse was protected or not” (Healthcare worker, FGD #1). These practices underscored the tension between legal requirements and the youths’ need for privacy and autonomy.

In contrast, young men experienced less societal pressure but still faced significant obstacles. Many young men reported challenges related to the convenience of testing facilities and the fear of receiving their status, which deterred them from seeking testing. A youth shared, “It’s not easy. For us students, we have to be on vacation and every time we take the test, we are afraid of being positive” (Participant #3, age range 22–24 years). This fear could be overwhelming and prevent youth from getting tested, even when they recognized the importance of knowing their status. Despite the fear and stigma associated with HIV testing, some youth still found the courage to get tested, driven by risky behaviors or symptoms, as expressed by: “The fear is there, but you have to have the strength to go and take the test” (Participant #3, age range 22–24 years) or “I do not think it’s easy. You have to be brave. The first day I refused, but once I made love with someone I did not know without protection, I had to find the courage to take the test” (Participant #2, age range 18-19 years). Addressing these psychological barriers requires creating a supportive and non-judgmental testing environment, providing counseling services to help youth cope with their fears, and normalizing HIV testing as a routine part of healthcare. Healthcare workers and community actors contributed significantly by providing reassurance where youth felt safe and supported during the testing process, as expressed by: We the psychosocial counselors mediate between young people and the hospital. There are young people who lack information, and some are trying to access these services. So, we are the hyphen, we give them the information” (Community actor, FGD #1).

Support systems: Support systems, including family members, peers, and healthcare providers, were crucial in encouraging youth to undergo HIV testing. The presence of a supportive environment can significantly reduce the fear and stigma associated with testing. For example, one youth mentioned, “My aunt is a nurse so I ask her to take me to the hospital” (Participant #1, age range 20–22 years), illustrating the importance of having trusted individuals who can facilitate access to testing (Fig 2). Additionally, schools and community organizations played a vital role in providing information and support, helping to create a culture where HIV testing was seen as a responsible and routine health behavior. For HIV-positive youth, diagnoses often occurred during routine medical visits or emergencies prompted by recurrent illnesses or family-initiated tests (Fig 2). A youth recounted, “I had pimples on my body and my mom took me to the hospital and after the test, I was diagnosed with HIV” (Participant #50, age range 15–17 years). Many discovered their status through parental intervention, such as Participant #33 who was screened at age 5 by their mother, or Participant #32, who was screened at age 12 due to frequent illnesses. Youth also encountered diagnoses in unexpected medical contexts, like Participant #30, who tested positive during additional tests following surgery. Table 3 shows selected quotes from HIV-positive youth.

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Table 3. Quotes from HIV-positive youth on diagnoses following HIV testing with family support.

https://doi.org/10.1371/journal.pone.0309497.t003

Service providers have been crucial in offering continuous support and follow-up, ensuring that youth remained engaged with the healthcare system. Strengthening these support systems by involving families, peers, and community leaders can enhance youth’s willingness to get tested and ensure they receive the necessary support throughout the process. Thus, while these barriers were significant, the support systems and personal determination of youth played crucial roles in their decision to undergo HIV testing.

Theme 2: Linkage to HIV care and ART.

Referral processes: This process was shaped by various factors, from initial referral processes to the barriers and facilitators youth encountered. Effective referrals and supportive healthcare professionals were crucial in helping youth transition from testing to treatment. For instance, one youth recounted, “The psychosocial counselor gave me advice, which helped me to accept treatment” (Participant #44, age range 20–22 years). Healthcare workers played a vital role in this stage by providing clear guidance and support, ensuring that youth understood the importance of immediate engagement with care, as expressed by, “It’s not the end of the world. You are going to take ARTs and be like other kids. You should come in for the viral load tests in 3-4 months, so if it’s undetectable, you can’t transmit the virus to another person anymore, and you are going to do whatever other people do too” (Healthcare worker, FGD #2).

Initial engagement: Youth’s first experiences with HIV care were important in determining their long-term engagement with treatment. Positive initial interactions with healthcare providers could significantly influence their decisions to seek care post-diagnosis. One youth highlighted this importance, saying, “It’s difficult at first, but once trust is established between the patient and doctor, everything becomes easy” (Participant #37, age range 22–24 years). Healthcare workers often provided emotional support and reassurance during this critical period. For example, one healthcare worker mentioned, “My role is to see the youth living with HIV with a smile. It’s very important for me to listen, advise, guide, and lead the person to access his diagnosis” (Healthcare worker, FGD #3). Additionally, a community health worker said, “When they learn that they are infected they believe that life is over. But when we tell them that with treatment, they will have HIV-negative children and then, they find hope again” (Community actor, FGD #1). This supportive approach helped youth overcome initial fears and uncertainties about treatment.

However, despite these efforts, youth faced significant barriers to linkage to HIV care and ART. Financial constraints were a major obstacle, as noted by a youth who said, “I have no money to pay for medication” (Participant #44, age range 20–22 years). Due to this situation, some youths were forced to seek non-traditional care options such as charlatans and traditional healers, further endangering their health conditions (Fig 2). Logistical challenges, such as transportation issues and the fear of stigma, also hindered effective linkage. Community actors highlighted the importance of confidentiality and trust, with one noting, “Dealing with teenagers is difficult and there needs to be an emphasis on confidentiality” (Community actor, FGD #1). Some youth found it easier to discuss their health with community actors such as peers rather than healthcare workers due to the perceived lack of confidentiality. This was further discussed by a healthcare worker who noted, “Youth often fear the judgment and lack of confidentiality from healthcare workers” (Healthcare worker, FDG #1). A community actor explained, “These youth are not wrong because some youths are not kind and expose children” (Community actor, FGD #1), which emphasized the need to create a supportive and stigma-free healthcare environment.

Facilitators of linkage: Youth’s preferences for certain facilities over others, despite geographic proximity, were influenced by several factors. They often favored specialized HIV health facilities and social clubs over public hospitals due to the quality of care, the reception, and the supportive environment provided. As one youth noted, in specialized establishments, “care is assured and their products are effective because they are subsidized” whereas in public hospitals, “care is not total and the welcome is not as good” (Participant #26, age range 18–19 years). Specialized facilities and social clubs were perceived to offer more comprehensive and empathetic care, free from stigma and discrimination, which was crucial for youth managing sensitive health issues like HIV. This sentiment was echoed by another youth who mentioned that in clubs, “we feel good” (Participant #45, age range 20–22 years) whereas in public hospitals, the staff sometimes “neglect and stigmatize us” (Participant #44, age range 20–22 years).

Additionally, the availability of trained staff, confidentiality, and effective communication in specialized centers contributed to youth’s preferences. Social clubs, in particular, offer a space for open dialogue and guidance, making them attractive to young people seeking both medical and psychosocial support. As one youth described, “we share everything in words; they encourage us to go to the hospital to get tested and to use the services” (Participant #4, age range 20–22 years). These facilities also provided a sense of community and emotional support, which public hospitals often lack. Although healthcare workers emphasized the need for continuous education and support, with one stating, “We must advise them and support them as much as possible” (Healthcare worker, FGD #2), the specialized facilities and social clubs stood out because they offered tailored environments that prioritized confidentiality, empathy, and comprehensive care. This combination of factors made them particularly appealing to youth who required both medical and psychosocial support in managing their health.

Theme 3: Retention in ART care.

Adherence to treatment: Youth’s commitment to staying on ART was often influenced by their understanding on the importance of consistent medication intake and managing side effects. One youth expressed their determination, stating, “I agreed to continue ART to avoid transmitting HIV to others and to stay healthy” (Participant #50, age range 15–17 years). Healthcare workers played a crucial role in this process by providing clear and consistent information about the benefits of adherence and helping manage any side effects that may arise. For example, a healthcare worker noted the importance of therapeutic education, stating, “It is important to remain clear about the examples of therapeutic education” (Healthcare worker, FGD #3). This clarity helped youth understand the critical nature of their treatment regimen and reinforced their commitment to maintaining it.

Continuous engagement: Retention in ART care also involved regular follow-ups with healthcare providers and continuous engagement with healthcare services. Frequent interactions with healthcare providers helped reinforce the importance of adherence and provide ongoing support. One youth reflected on their routine, mentioning, “When you feel like you’re taking a risk during sexual intercourse, you must be aware and take precautions, including regular follow-ups and adherence to ART” (Participant #34, age range 18–19 years), illustrating the continuous engagement needed. Healthcare workers emphasized the need to spend adequate time with patients to build trust and ensure they understand their treatment. One healthcare worker stated, “The patient must always have a little bit of time with the doctor after the first consultation because he is the one who accompanies him through the process” (Healthcare worker, FGD #4). This ongoing relationship between healthcare providers and youth is essential for maintaining adherence and addressing any issues that may arise during treatment.

Retention challenges and support strategies: In previous steps of the HIV care continuum, barriers such as stigma, financial constraints and logistical challenges were identified for HIV testing as well as during the process of linkage to HIV care and ART, respectively. Despite the support from healthcare providers, financial difficulties, transportation issues, and experiences of stigma or discrimination further hindered retention in ART care (Fig 2). For example, logistical issues such as transportation made regular clinic visits challenging. One youth shared, “It’s difficult to access care because of travel” (Participant #34, age range 18–19 years). Another example involved a teenager who preferred to travel a longer distance to a different health center to avoid stigma, “There is this teenager who lives in Koundoul (25 km) and prefers to go to the Atrone health center for the pills despite the referral proposal I made to him and this for the simple reason that his sister-in-law works at the Koundoul health center” (Community actor, FGD #1). Youth have advocated for tailored services to address these challenges, expressing a desire for services that cater specifically to their needs, including tailored hours that accommodate their schedules. For instance, one youth suggested, “We need special centers for teenagers to make them feel comfortable, with hours that fit our school and work schedules” (Participant #8, age range 15–17 years). This sentiment was echoed by community actors who recognized the need for flexible service hours: “It would be important to create special structures with everything in it, including tailored hours that allow youth to access care without disrupting their daily routines” (Community actor, FGD #1).

Youth often stopped treatment when they started feeling better, which disrupted their long-term care. Healthcare workers have responded to these needs by providing longer drug stocks to youth who have earned their trust, which helps to maintain continuity in their treatment. One community actor explained, “We call them (by phone) if they don’t keep the appointments. We’re going to pick them up (move). At first, they are put on ARVs and when they get better, they leave and only come back when there is a complication” (Community actor, FGD #1). Another one shared, “When we gain their trust and they become more attached to us than their own parents, we can trust them with 3 to 6 months of drug stocks” (Community actor, FGD #1). This approach not only addressed the logistical challenges but also helped ensure that youth remain engaged in their ART regimen.