Objectives HIV self-testing (HIVST) offers a promising approach to increase HIV diagnosis and advance progress towards the UNAIDS 95-95-95 targets. We aimed to understand patterns of HIVST awareness and utilization in nine sub-Saharan African (SSA) countries, with the goal of identifying populations to target in disseminating this technology. Design Cross-sectional study. Methods We pooled individual-level population-based data from nine Demographic and Health Surveys (DHS) in SSA conducted 2015-2019 (Burundi, Cameroon, Guinea, Malawi, Senegal, Sierra Leone, South Africa, Zambia, Zimbabwe). Primary outcomes were HIVST awareness and utilization. We used logistic regression with survey fixed effects to explore the relationship between sociodemographic characteristics and these outcomes. Models were adjusted for sex, age, rural/urban residence, education, wealth, and marital status. We accounted for complex survey design. Results The study sample included 177,572 people (66.0% women, mean age 29±10 years), of whom 86.6% (95%CI 86.4-86.7) were unaware of HIVST, 11.7% (95%CI 11.6-11.9) were aware of but never used HIVST, and 1.7% (95%CI 1.6-1.8) had used HIVST. In adjusted models, women were less likely to be aware of HIVST (OR 0.75, 95%CI 0.71-0.79), but more likely to have used HIVST (OR 1.17, 95%CI 1.03-1.32) compared to men. Rural residents, those who were least educated, and poorest were less likely to have heard of or used HIVST. Conclusions HIVST awareness and uptake were low. Rural, less educated and lower income populations were least likely to have heard of or used HIVST. Efforts to scale-up HIVST in these settings should aim to reach these less advantaged groups.

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Perceptions of HIV acquisition risk and prevalence shape sexual behavior in sub-Saharan Africa (SSA). We used data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa baseline survey. Data were collected through home-based interviews of 5059 people ≥ 40 years old. We elicited information on perceived risk of HIV acquisition and HIV prevalence among adults  ≥ 15 and ≥ 50 years old. We first describe these perceptions in key subgroups and then compared them to actual estimates for this cohort. We then evaluated the relationship between sociodemographic characteristics and accurate perceptions of prevalence in regression models. Finally, we explored differences in behavioral characteristics among those who overestimated risk compared to those who underestimated or accurately estimated risk. Compared to the actual HIV acquisition risk of < 1%, respondents vastly overestimated this risk: 35% (95% CI: 32–37) and 34% (95% CI: 32–36) for men and women, respectively. Respondents overestimated HIV prevalence at 53% (95% CI: 52–53) for those ≥ 15 years old and 48% (95% CI: 48–49) for those ≥ 50 years old. True values were less than half of these estimates. There were few significant associations between demographic characteristics and accuracy. Finally, high overestimators of HIV prevalence tested themselves less for HIV compared to mild overestimators and accurate reporters. More than 30 years into the HIV epidemic, older people in a community with hyperendemic HIV in SSA vastly overestimate both HIV acquisition risk and prevalence. These misperceptions may lead to fatalism and reduced motivation for prevention efforts, possibly explaining the continued high HIV incidence in this community.