Facilitators of Self-Initiated HIV Testing Among Youths: A Qualitative Study

ABSTRACT Background Youth experience disparities in HIV infection but have significantly low rates of HIV testing that lead to late diagnoses, increased transmission rates, and adverse health outcomes. There is limited knowledge regarding self-initiated HIV testing, which is a promising strategy for improving testing rates among youth. Purpose This study aimed to identify the facilitators of self-initiated HIV testing among youth. Method Thirty youths aged 18–24 years were recruited to participate in a qualitative descriptive study. Potential participants were recruited from a combination of HIV testing sites, including community testing events, a community-based organization, an adolescent health clinic, and a college campus. A demographic and sexual history questionnaire and audio-recorded interviews were used to collect data. Transcribed interviews were analyzed using qualitative content analysis. Results Salient themes and subthemes that explain the study findings are as follows: testing within the context of a sexual relationship (e.g., infidelity), support and influence from social relationships (e.g., family support), taking the initiative for health (e.g., signs and symptoms of infection), HIV testing preferences (e.g., free testing), and HIV testing experiences (e.g., provision of other health services). Conclusions The findings of this study advance scholarly understanding regarding the predictors of self-initiated testing and provide critical information necessary to further improve evidence-based nursing clinical practice and develop public health nursing interventions that target self-initiated HIV testing. Encouraging self-initiated HIV testing is an effective approach to increasing testing rates and, consequently, preventing new HIV transmissions in this vulnerable population.


Introduction
In the United States, more than 1.1 million people currently live with HIV infection (Centers for Disease Control and Prevention [CDC], 2019a). Youth, defined by CDC (2019b) as individuals aged 13-24 years, account for more than one fifth of all new HIV diagnoses in the United States, and individuals aged 20-24 years account for 79% of new HIV infections among youth (CDC, 2019b). In comparison with other age groups, HIVinfected youth experience worse health outcomes in the United States and are the least likely to be linked to care (CDC, 2019b).
HIV testing is an essential point of care that facilitates the identification and counseling of people at risk for HIV infection and linkage of HIV-infected individuals to care, leading to the prevention of new HIV infections (CDC, 2020; U.S. Preventative Services and Task Force [USPSTF], 2013). However, youth have the lowest rates of HIV testing of all age groups in the general population (CDC, 2019b;Van Handel et al., 2016). In a nationally representative sample, only 33% of youth aged 18-24 years who had sexual intercourse reported having received HIV testing (Van Handel et al., 2016). An estimated 44% of HIV-infected youth are unaware of infection (CDC, 2019b). This is the highest percentage of undiagnosed HIV infection among any age group in the general population in the United States, which exacerbates HIV transmission in this population (CDC, 2019b).
An integrative literature review by Adebayo and Gonzalez-Guarda (2017) on the factors associated with HIV testing among youth in the United States synthesized 44 studies and identified several notable findings. Youth who were female, relatively older, and Black or African American and/or who identified as lesbian, gay, or bisexual were more likely to undergo testing for HIV infection (Adebayo & Gonzalez-Guarda, 2017). Some modifiable facilitators associated with HIV testing included sexual risk behaviors; higher perception of vulnerability to HIV infection; and having convenient, accessible, and private HIV testing locations (Adebayo & Gonzalez-Guarda, 2017). Barriers to HIV testing included misconceptions regarding HIV infection transmission, fear of HIV testing procedure and results, and not knowing the location of HIV testing sites (Adebayo & Gonzalez-Guarda, 2017). Even more significantly, this study showed that the absence of an offer of HIV testing by a clinician is a salient barrier to HIV testing among youth (Adebayo & Gonzalez-Guarda, 2017).
Persistently low rates of HIV testing suggest that clinicianinitiated HIV testing (i.e., clinician assessment of sexual risk and recommendation of HIV testing) is insufficient to meet the testing needs of youth (Adebayo & Gonzalez-Guarda, 2017;Talib et al., 2013;Van Handel et al., 2016). Clinicians' assessment biases related to sexual orientation, sexual risk behaviors, and recommending or providing preventive HIV services to youth currently limit clinician-initiated HIV testing (Eisenberg et al., 2017;Leonard et al., 2010). In addition, youth experience barriers such as inability to afford clinician visits and fear of or shame at disclosing sexually risky behaviors that further limit clinician's recommendations of HIV testing (Murchison et al., 2017;Phillips et al., 2015;Wallace et al., 2011).
Self-initiated HIV testing, defined as testing completed after a self-appraisal of the need, process, and benefits of HIV testing without the immediate recommendation of a clinician, is an effective strategy for increasing HIV testing, especially among youth (Adebayo & Salerno, 2019;Ma et al., 2016;Talib et al., 2013). In the process of self-initiated testing, the individual is responsible for appraising their own risk behaviors, deciding that HIV testing is needed, seeking out HIV test sites, and initiating and completing HIV testing (Adebayo & Salerno, 2019;Joore et al., 2017;Ma et al., 2016). Previous studies involving adults have found self-initiated HIV testing to be associated with an increased likelihood of subsequent HIV testing, the adoption of risk reduction behaviors such as more frequent condom use, having fewer sexual partners, and achieving better sexual health outcomes (e.g., absence of other sexually transmitted infections [STIs]; Fonner et al., 2012;Ren et al., 2017;Udeagu et al., 2017). Resources that facilitate self-initiated HIV testing may mitigate the experienced barriers to HIV testing, including clinicians' biases that prevent offering HIV tests, stigma, fear of testing procedures or results, limited access to clinical institutions for testing, and the cost of clinician visits (Jürgensen et al., 2012;Pai, 2014;Salako et al., 2012).
Despite these remarkable benefits, limited knowledge is available about self-initiated HIV testing among youth or about the resources necessary to encourage testing. Self-initiated HIV testing shows promising advantages for improving testing rates among youth. The implications of self-initiated HIV testing among youth in addition to the benefits described above include individual sexual risk assessments and increased linkage to care and resources that will further prevent HIV transmission. Therefore, the purpose of this qualitative study was to explore the facilitators of self-initiated HIV testing among a sample of youth aged 18-24 years in South Florida.

Design
Owing to the knowledge gap in understanding regarding self-initiated HIV testing among youth, a qualitative descriptive design (Sandelowski, 2000) was adopted in this study. Most of the previous studies on HIV testing among youth were conducted using quantitative designs, which limits the findings by identifying factors associated with HIV testing without an understanding of how they influence testing behavior (Adebayo & Gonzalez-Guarda, 2017). A qualitative design approach was deemed particularly suited for this study, as we sought a thorough exploration and understanding of the experiences of youth who self-initiated testing for HIV infection (Sandelowski, 2000).

Ethical Considerations
The protocol, procedures, and study materials used in this study were approved by the institutional review board (Protocol #20170027) at the University of Miami. Before study participation, the principal investigator (PI; first author) reviewed the study purpose, data collection materials, and rights to refuse or stop the study at any time with youth who signified interest in the research study. Potential participants verbalized their understanding and did not state any questions or concerns before the study commenced. Study participants were assigned a random study identification number, which was unrelated to any identifiable participant information, to protect confidentiality. Study files were stored in a locked cabinet in a locked room that was secured at the school of nursing.

Procedure and Sample
The participants were recruited directly from HIV testing sites in South Florida through purposive sampling, targeting youth who had sought and completed HIV testing (Polit & Beck, 2012). Data collection was conducted from March to June 2017. The PI met with the staff at the HIV testing sites, explained the purpose of the study, and obtained letters of support. The staff performing HIV testing introduced the research study to the youth after the completion of testing. If a youth verbalized interest, the PI further explained the study, screened for eligibility, and ascertained that the participants self-initiated HIV testing (i.e., without an immediate recommendation from a clinician). Eligibility to participate in this study were as follows: (a) aged 18-24 years, (b) able to speak and understand English fluently, (c) able to provide informed consent, and (d) had self-initiated HIV testing.
The PI interviewed youth who met screening criteria and provided verbal informed consent in a private area at the HIV testing site. A demographic and sexual history questionnaire and audio-recorded interviews using a semistructured interview guide (see Table 1) were used to collect data from participants. The interview questions elicited information from participants about their knowledge of HIV testing, about facilitators of self-initiated HIV testing, and about experiences initiating and completing testing. The semistructured interview guide allowed participants' responses to determine the probes for subsequent questions, which prevented external influences on participants' perspectives. The interviews were approximately 30-60 minutes in length. Data collection ended when no new themes emerged, indicating that saturation had been achieved (Polit & Beck, 2012). Participants received US$20 after the completion of data collection.

Analytic Strategy
Data collection and analysis occurred concurrently, enabling the phenomenon under study to be understood holistically (Polit & Beck, 2012;Sandelowski, 2000). Qualitative content analysis is the method of choice for qualitative descriptive studies and was used to analyze the data from this study (Sandelowski, 2000). The first author and trained transcriptionists performed verbatim transcriptions. Upon verbatim transcription, the first author read the transcripts thoroughly to obtain an overall idea of what the participants were reporting. In the first level of coding, each participant's sentence was coded with as many keywords as possible, mainly using the participant's own words. In the second level of coding, keywords identified from Level 1 were categorized into clusters, which are larger groups that are mutually exclusive. The first and second authors reviewed and discussed the first and second levels of coding. In the third level of coding, broad themes were identified that formed an umbrella for more than one cluster identified in the second level of coding.

Rigor
Several steps were implemented to ensure rigor throughout the data collection and analysis process and to correctly represent the study participants, their experiences, and conclusions (Polit & Beck, 2012). We ensured credibility (i.e., confidence in the results of the study as a representation and interpretation of the data) by collecting data using open-ended questions (Cypress, 2017;Polit & Beck, 2012). These questions allowed the participants to interpret and lead responses. In addition, data were analyzed using codes derived from the data itself rather than external codes (Polit & Beck, 2012;Sandelowski, 2000). To ensure dependability (i.e., consistency in the methods of data collection and analysis) and transferability (i.e., the applicability of study methods and findings to similar contexts, environments, or populations), the first author kept audit trails and field notes, detailing the events that surrounded the study, participants, and reflections on the study process (Cypress, 2017). The second author reviewed audit trails carefully to verify that the conditions and process of data collection were similar and that resulting findings were consistent. The study team established confirmability (i.e., the corroboration of findings) by reviewing the themes, participant quotes, and interpretations to verify congruence and to validate findings (Cypress, 2017).

Results
Sixty youths were identified as potential participants across HIV testing sites. After discussing the study requirements, 13 individuals met the inclusion criteria but declined to participate either without reason (n = 9) or citing lack of time to participate (n = 4), and 17 individuals agreed to proceed with the study but did not meet inclusion criteria for age. The remaining 30 individuals met the inclusion criteria and were enrolled in the study. Most of the participants were female (n = 21, 70%) and Black or African American, non-Hispanic (n = 17, 56.7%). With regard to sexual risk behaviors, almost half of the participants reported having six or more lifetime sexual partners (n = 14, 46.7%). More than half did not use a condom during the most recent episode of sexual intercourse (n = 17, 56.7%). All of the participants reported a seronegative test result. A complete description of the participants' demographic and sexual history characteristics is summarized in Tables 2 and 3.
The findings from this study represent participants' acknowledgment of risks for HIV infection and the experiences that facilitate self-initiated HIV testing. The five themes and corresponding subthemes that further explain the experiences of the individual's self-initiation testing for HIV infection are described below (see Figure 1).

Theme 1: Testing Within the Context of a Sexual Relationship
This theme describes events in sexual relationships that heightened the risk of HIV infection and encouraged self-initiated HIV testing. The two subthemes below further illustrate this main theme.

Infidelity
Multiple participants (n = 12) in or just ending committed relationships reported that personal infidelity, partner infidelity, or suspicion of partner's infidelity facilitated HIV testing. Infidelity heightened the perception of HIV vulnerability and encouraged self-initiated HIV testing.
Me and my boyfriend got in a big situation there. I just wanted to get tested because he had unprotected sex with another girl, and I was just afraid. I didn't want to get nothing if me and him will still have intercourse. (Female, 22 years old) A sense of security Similar to the subtheme of infidelity, several participants (n = 7) indicated that self-initiated HIV testing provided a sense of security in committed relationships. Participants described a sense of security as an assurance of a partner's fidelity, HIV infection-free status, and trust.
Yeah, in a way. I did it (HIV testing) a part for me, but part because I wanted him (boyfriend) to have a sense of, like security and, like clear ease of mind, too. (Male, 20 years old)

Theme 2: Support and Influence From Social Relationships
This theme encompassed the relationships and interactions that provided "support" in the process of self-initiating HIV testing. These social relationships were sources of information and provided safe and comfortable environments to seek HIV testing while helping alleviate concerns related to testing. The subthemes emerging from this theme are discussed in the following paragraphs.
Family support Most participants indicated that they would prefer or did not want family members to become aware of their HIV testing. However, the participants (n = 7) who received family support described it as an essential facilitator of self-initiated  HIV testing. Family support stemmed from being able to discuss sexual health with family members, family members being aware of the decision to seek testing, and advice from family members to seek testing. The quote below describes how the participant's siblings' testing experience and advice to get tested facilitated her own self-initiated HIV test.
I was scared because I didn't want to know…but after everyone (siblings) did it, I gained the confidence. Telling me all the possibilities of not knowing, and the damages it could do to you not knowing, made me more confident to just get it over with, and find out if anything's wrong. (Female, 20 years old) Family support also helped participants pay for HIV tests and deal with the fear of a possible seropositive result. Furthermore, in the presence of family support, participants described being able to seek testing freely without worry of family members finding out about tests or judging their sexual behaviors and actions.
Yeah, because like, say I did have it, I know I have the support system to like to be like, okay yeah you have it, now we have to take initiative to get like treatment for it, they'll be there, they're not gonna judge me or anything because they're gonna be there for me. (Female, 18 years old) Friends' support The support of friends was an essential facilitator of self-initiated HIV testing described by multiple participants (n = 11). Friends' support was respectively identified as advice from friends to seek testing, experiences of friends' HIV testing or STI diagnoses, reminders from friends for ongoing testing events or free testing sites, and being accompanied by friends to seek testing. Having support from friends helped in the management of stigma associated with getting tested for HIV infection.
I feel like there's a stigma around STD testing like if you go, you just know you're dirty. So, the fact that she (friend) was willing to go with me, just like, it meant a lot. Cause a lot of people don't want to go by themselves or want that support system. So, she (friend) gave me that push to definitely go and want to do it. (Female, 19 years old) HIV testing staff Another salient facilitator of self-initiated HIV testing described by most participants (n = 19) was the influence of the HIV testing staff. HIV testing staff facilitated self-initiated HIV testing by clearly explaining the process of HIV testing and obtaining results, engaging in friendly conversations beyond HIV infection  LGBT = lesbian, gay, bisexual, or transgender.
Self-Initiated HIV Testing VOL. 28, NO. 5, OCTOBER 2020 risks and testing, and not making judgmental remarks or gestures. This interaction with HIV testing staff also helped with the management of stigma as well as the process and behavior of self-initiated HIV testing.
Initially, there's kinda like a stigma…. I think in general when someone is explaining to you the process more and explaining to you the term, you feel kind more engageful in that experience, and so I think it's kinda like positive, I think more comfortable, is the word to describe it, if anything. Yeah. I think.
(Male, 23 years old) Lesbian, gay, bisexual, and transgender community The multiple participants (n = 7) who identified as sexual or gender minorities (i.e., lesbian, gay, bisexual, or transgender [LGBT]) described the influence of the LGBT community. Being a part of the LGBTcommunity increased awareness of the high prevalence of HIV infection and instilled a desire to self-initiate testing.
In addition, LGBTevents and organizations that encouraged HIV testing also helped participants deal with HIV-testingrelated stigma and shame, develop the courage to seek HIV testing, and normalize the process of self-initiating HIV testing.
I started doing more LGBT-related events lately. And I would look and think more like the flyers that they had. Like before. I would be like let me not look at it. Because I can't. It's like embarrassing to even look at the flyers. But I would look at the flyer. I would take the flyers, and I would look at them. I would look at the places and the times, stuff like that. Um. That was. That was one of the biggest steps. Actually, looking at the information that they were giving me because I was ashamed to even look at the information. Then when I started looking at the information, I started thinking about going and doing testing or whatever. Um. And then, yeah. Finally, I went to testing. (Transgender female, 19 years old)

Theme 3: Taking the Initiative for Health
This theme describes the facilitation of self-initiated HIV testing by changes in physical health that indicated the presence of an STI and the desire and actions to assuage health concerns. Further detail about subthemes is provided in the following paragraphs.

Signs and symptoms of infection
A few of the participants (n = 7) discussed the desire to diagnose HIV infection early and how experiencing telltale signs and symptoms that might signify the presence of an STI facilitated self-initiated HIV testing. These participants explained that identifying HIV infection sooner rather than later would provide the option to engage in treatment early, take steps to stay healthy, and reduce the likelihood of premature death.
Basically, I look at myself like it's either you could find out now, or you could probably find it out at early time. You don't know the stuff you could do to make it better. But if you keep waiting and waiting, you probably even not going to even know, make it-try to help you with treatments and stuff. You never know. Even if it doesn't go away, there is stuff that you could avoid if you find out early.

(Female, 22 years old)
Peace of mind The participants generally described feelings of fear and anxiety associated with concerns regarding HIV infection risk. Multiple participants (n = 9) described peace of mind as the sense of assurance stemming from the knowledge regarding their HIV status after testing. Being tested created a relaxed feeling, alleviated the stress of not knowing one's HIV status, and confirmed a state of good health.
Yeah, um. Peace of mind for sure. Just being much more relaxed. Even now that I don't even know my results yet, I just think that doing it alone kinda alleviates stress and kinda makes you feel like you're doing your thing in whatever direction. (Male, 23 years old)

Theme 4: HIV Testing Preferences
Under this theme, participants reported their preferences for HIV testing methods, the attributes of HIV testing sites, the costs associated with HIV testing, and the aspects of personal schedules that facilitated self-initiated HIV testing. These findings are discussed further as part of the following subthemes.

Rapid testing and results
Participants described rapid HIV testing as sites that allowed participants to complete HIV tests and receive results in "15 minutes" as opposed to spending "long hours." In managing class or work schedules, most participants (n = 18) spoke of sites that provided rapid HIV testing and said that the availability of rapid testing facilitated self-initiated HIV testing.
…It makes it easier and then we have our breaks so that we just get tested and then the situation of it, the way of it is fast. It's not like we're going to be sitting there for long hours, trying to wait on somebody to call us. You go in, get tested, and walk right out. It's a fast process; basically, the process is fast. (Female, 22 years old)

Convenience
Most participants (n = 21) discussed the convenience of testing sites as a significant facilitator of self-initiated HIV testing. Convenient HIV testing sites were locations visited regularly by participants such as nightclubs and community-based organizations; that either did not require transportation or a long commute or were within walking distance (e.g., testing vans) and that allowed walk-in visits or short-notice appointments.
…So you don't have to go out of your way to go to the clinic. The clinic I had to actually go there, wait Free testing Not having to pay for an HIV test was identified as a facilitator of self-initiated HIV testing by multiple participants (n = 11). Participants who reported being without health insurance sought free HIV testing. Similarly, not knowing places to get free HIV testing delayed self-initiated HIV testing.
Honestly. I don't…. I'm not aware where other test locations are. I really don't. I've been wanting. Like I Googled it to see where I can get it for free, and I couldn't find places online. And I think that also pushed me back also as whether to get tested for it or not because I remember 2 years ago I got it for free. So, I was like, there had to be places where they come and do locations for free. So, I was like…Oh my God, that's perfect. They did it right here. (Female, 21 years old)

Free time
Participants reported being busy with work or school, which led to difficulties in finding the time to be tested. Several participants (n = 8) reported that free time was necessary to selfinitiate HIV testing.
Today is usually my really free day. I'm a really busy person, in general, so like. I've never been tested before, so like I didn't know how long it would take. So, I didn't want to go, have them tell me it's going to take an hour, and not have that hour. (Female, 19 years old)

Theme 5: HIV Testing Experiences
This theme summarized participant experiences at testing sites that facilitated self-initiated HIV testing. The relevant findings were the privacy of testing sites and test results and being able to access healthcare services in addition to HIV testing. The following paragraphs provide further detail on this theme.

Privacy or confidentiality
Several participants (n = 8) described privacy as a testing site without waiting rooms where people could identify them, sites without bold HIV testing signs, and sites that were located an appropriate distance away from residential areas to further decrease the risk of identification. Participants did not want their being tested for HIV infection or information about test results to be discovered by others without their consent.
I want to…I want to keep private. I'm not that comfortable for people knowing that I am (getting tested). (Female, 21 years old)

Provision of other services
Sites that provided services beyond testing facilitated self-initiated HIV testing among several participants (n = 5). Services discussed were testing sites that fostered a sense of community for LGBT youth, provided incentives like free condoms, provided testing for other STIs, and allowed consultation with healthcare professionals for other health needs.
…They tend to test everything all together. So, I was okay with that because I wanted to check everything at once. And the practitioner that I went with was very…she made me feel very comfortable about it. (Female, 21 years old)

Discussion
As one of the few initial studies exploring self-initiated HIV testing among youth, findings from this study provide unique, new insight into factors that facilitate self-initiated HIV testing.
Most of the participants were Black or African American (n = 17, 56.7%). Previous quantitative studies have noted that Black and African American youth are more likely to engage in HIV testing (Decker et al., 2015;Rakhmanina et al., 2014). This may be because of targeted messaging on HIV prevention and testing that provided education and intervention information for youth (Adebayo & Gonzalez-Guarda, 2017). Most participants in this study were female (n = 21, 70%). Several previous quantitative studies have shown that female youth are more likely to test for HIV infection (Decker et al., 2015;Rakhmanina et al., 2014;Talib et al., 2013). Moreover, two thirds of the participants in this study were aged 21 years or older (n = 20, 66.7%). Previous quantitative studies have also found relatively older youth to be significantly more likely to test for HIV infection (Decker et al., 2015;Rakhmanina et al., 2014;Talib et al., 2013). One reason for this finding may be that older youth tend to seek healthcare services independently of their parents or guardians. The presence of a parent or guardian and fear of their reactions are significant deterrents to HIV testing (Rakhmanina et al., 2014). Nurses and other healthcare professionals should assess youths' sexual health and sexual risk behaviors privately to provide the opportunity for responses free of parental/guardian influences.
For some participants, self-initiated HIV testing was embedded contextually in sexual relationships complicated by personal or partner infidelity and a desire to provide relational security. This suggests that youth may be more cognizant of the risks of HIV infection when in a committed sexual relationship. This finding is similar to those of previous quantitative studies, which show that youth in committed relationships are more likely to test for HIV infection than those who are not (Talib et al., 2013;Teitelman et al., 2015). An associated concern is that youth may depend mainly on changes in relationship commitment level rather than engagement in risky behaviors to increase their engagement in HIV testing. These findings indicate a need for further nursing assessment of knowledge related to HIV risks and education among youth. Self-Initiated HIV Testing VOL. 28, NO. 5, OCTOBER 2020 Similar to previous studies, relationships with family members and friends facilitated self-initiated HIV testing (Leonard et al., 2014;Phillips et al., 2012). The influence of HIV testing staff was a unique element reported by most of the participants. Interactions with HIV testing staff who are nonjudgmental, friendly, open, and humorous are instrumental in helping youth with anxiety related to the process of completing self-initiated HIV testing. Educating nurses, HIV testing staff and counselors, and other healthcare professionals on the qualities of interactions that facilitate self-initiated HIV testing will help alleviate the stigma and fear that may delay or impede self-initiated HIV testing.
In addition, the participants reported taking the initiative for personal health when they discovered signs and symptoms of infection to achieve peace of mind regarding HIV serostatus. Although relatively fewer participants discussed this finding, it indicated that youth with these experiences possessed knowledge about HIV infection and the benefits of early diagnosis and treatment. This finding is important as it highlights that the inclusion of information on the availability of resources and treatment in the event of HIV diagnoses may help alleviate the fear of seropositive test results that often delays HIV testing in this population (Phillips et al., 2015;Schnall et al., 2015;Wallace et al., 2011).
Most of the participants had completed high school or a general educational development as their highest educational level (n = 23, 76.7%) and earned $20,000 or less per year (n = 23, 76.7%). Previous quantitative studies have noted that youth with lower levels of education and socioeconomic status are more likely to test for HIV infection (Decker et al., 2015;Inungu et al., 2011). Youth with lower educational levels and income may have jobs that pay less and require longer hours of work, which may make it more challenging to seek or afford HIV testing. Hence, there is a pressing need for rapid tests and results and free time to self-initiate HIV testing. The appeal of rapid testing and results is in the decreased wait time and the ability to test between other daily activities such as school and work. Sites that provide rapid HIV testing should advertise the estimated duration of HIV tests as an incentive to attract youth to self-initiate HIV testing. Similarly, HIV testing sites that offered free tests, were easily accessible with little to no transportation, or allowed appointments to be scheduled at short notice facilitated selfinitiated HIV testing. This also indicates the need for publicizing information on free HIV-testing sites on directions to sites that are cost-effective for youth.
As reported in previous studies, privacy is a significant facilitator of HIV testing among youth (Phillips et al., 2015;Schnall et al., 2015). The participants in this study further described privacy as testing sites without bold HIV testing signs, with few people entering the room during testing, and with no waiting for testing or test results, which could lead to identification by others. These findings indicate the importance of ensuring and maintaining privacy during the testing process. Furthermore, youth should be reassured that their results will be kept confidential from those who perform the tests.
Testing sites that provided other services such as free condoms, testing for other STIs, and access to healthcare professionals encouraged self-initiated HIV testing among the participants. Youth who reported having limited time for HIV testing supported the decision to go to sites offering a "one-stop shop" (Hagell & Lamb, 2016) healthcare experience. Previous studies on access to care among youth confirm these findings and highlight the effectiveness of "one-stop shop" facilities, where youth are able to receive multiple healthcare services at the same time (Hagell & Lamb, 2016).

Limitations
This study was affected by several limitations. The study sample was largely female (n = 21, 70%) and African American (n = 17, 56.7%) and was recruited from community testing events with mobile testing vans (n = 17, 56.7%). Consequently, the current study should be interpreted within these contexts. However, this sample consisted of high-risk youth who were very vulnerable to HIV infection. Thus, findings may reflect the influences of self-initiated HIV testing in a similar population. In addition, the youth in this study all received seronegative HIV test results. Youth with seropositive HIV test results may have different experiences with sexual risk behaviors and experience unique facilitators or barriers to self-initiated HIV testing. Furthermore, this study aimed to examine only the facilitators to self-initiated HIV testing. Thus, the findings did not address barriers. To accurately capture barriers, future studies should include youth who have never self-initiated HIV testing.
Despite these limitations, this is one of the few initial qualitative studies to elicit the facilitators that are specifically related to the behavior of self-initiated HIV testing among youth. The findings of this research study may be used to support evidence-based practice and research to facilitate HIV testing among youth. Future nursing research will benefit from mixed methods approaches to understand the predictors of selfinitiated HIV testing among youth and develop an intervention to improve self-initiated HIV testing.

Conclusions
In summary, HIV testing based on healthcare professional recommendations falls short in meeting the HIV testing needs of youth. Current clinical guidelines recommend one-time HIV testing for youth and adults aged 15-65 years and routine screening for individuals engaging in risky sexual behaviors or living in areas with high HIV prevalence (CDC, 2018;USPSTF, 2013). Most efforts to increase the rates of HIV testing have focused on encouraging healthcare professionals to offer HIV testing (CDC, 2018;USPSTF, 2013).
The findings from this study show that self-initiation of HIV testing by youth is facilitated by events in sexual relationships like infidelity; support from familial relationships, peers, the community, and HIV testing staff; the appearance of signs and symptoms of STIs; the desire to attain peace of mind; and HIV testing preferences and experiences. Nurses are at the front line of community and public healthcare and will benefit from knowledge on the facilitators of self-initiated HIV testing among youth. The practical implications of the findings of this study include educating nurses on the needs of youth for the self-initiation of HIV testing. Moreover, nurses should educate youth on sexual risks and the benefits of HIV testing, help youth identify social support systems (e.g., family, friends, community-based organizations), and link youth to appropriate and available resources (e.g., HIV testing sites, free testing). Furthermore, when structuring HIV testing services for youth, nurses and other healthcare professionals should advocate for HIV testing preferences and experiences such as rapid testing, privacy, convenience, and the provision of other health services that appeal to youth (e.g., additional STI testing).
Self-initiated HIV testing among youth provides an alternative way for youth to seek testing services independently. The findings from this study may inform current guidelines regarding different approaches to increasing HIV testing rates among youth. Furthermore, public health nursing is instrumental in addressing the HIV infection burden among youth. Initiatives that facilitate selfinitiated HIV testing will increase rates of HIV testing among youth and consequently prevent HIV transmission in this population.