Use, awareness and willingness to self-test for HIV: An analysis of cross-sectional population-based surveys in Malawi and Zimbabwe

Abstract

Background Many southern African countries are nearing the global goal to diagnose 90% of people with HIV by 2020. In 2016, 84% and 86% of people with HIV knew their status in Malawi and Zimbabwe respectively. Despite this progress, gaps remain, particularly among men (≥25 years). We investigated awareness, use and willingness to HIV self-test (HIVST) prior to large scale implementation and explored sociodemographic associations. Methods We pooled responses from two of the first cross-sectional Demographic Health Surveys to include HIVST questions: Malawi and Zimbabwe in 2015-16. Sociodemographic factors and sexual risk behaviours associated with previously testing for HIV, and awareness, past use and future willingness to self-test were investigated using univariable and multivariable logistic regression, adjusting for the sample design and limiting analysis to participants with completed questionnaire and a valid HIV result. Analysis of willingness to self-test was restricted to Zimbabwean men, as Malawians and women were not asked this question. Results Of 31 385 individuals, the proportion never-tested was higher for men (31.2%) than women (16.5%), p<0.001. For men, having ever tested increased with age. Past use and awareness of HIVST was very low, 1.2% and 12.6% respectively. Awareness was lower among women than men (9.1% vs 15.3%, adjusted odds ratio (aOR)=1.55; 95% confidence interval [CI]: 1.37-1.75), and at younger ages, and lower education and literacy levels. Willingness to self-test among Zimbabwean men was high (84.5%), with having previously tested for HIV, high sexual risk, and being ≥25 years associated with greater willingness. Wealthier men had greater awareness of HIVST than poorer men (p<0.001). Men at higher HIV-related sexual risk, compared to men at lower HIV-related sexual risk, had the greatest willingness to self-test (aOR=3.74; 95%CI: 1.39-10.03, p<0.009).Conclusions In 2015-16 many Malawian and Zimbabwean men had never tested for HIV. Despite low awareness and minimal HIVST experience at that time, willingness to self-test was high among Zimbabwean men, especially in older men with moderate to high HIV-related sexual risk. These data provide a valuable baseline against which to investigate population-level uptake of HIVST as programmes scale-up. Programmes introducing, or planning to introduce HIVST, should consider including questions in population-based surveys.

Reaching for the ‘first 95’: a cross-country analysis of HIV self-testing in nine countries in sub-Saharan Africa

“…Our findings are consistent with Johnson et al [10] but show that they are generalizable across nine countries in SSA; countries in this study represent about 40.7% of the HIV epidemic in the SSA region (see Table, SDC 9, http://links.lww.com/QAD/C353) [17,18]. Our findings that these less advantaged groups are also less likely to use HIVST are also similar to a recent single-country study undertaken in rural Malawi [19].…”

“…This initiative started in 2015 with implementation in three SSA countries (Malawi, Zambia, and Zimbabwe), followed by many others, and has resulted in 77 countries introducing policies that promote HIVST as of 2019 [8,9]. However, one study of HIVST awareness and uptake in Zimbabwe and Malawi found low levels of awareness (12.6%) and use (1.2%) [10], despit7e a high willingness to test (84.5%) among Zimbabwean men, the only sub-group in whom willingness was assessed [10]. Aside from this study, relatively little is known about the current levels of HIVST awareness and uptake in much of the region.…”

Effect of an opt‐out point‐of‐care HIV‐1 nucleic acid testing intervention to detect acute and prevalent HIV infection in symptomatic adult outpatients and reduce HIV transmission in Kenya: a randomized controlled trial

“…While our intervention required additional resources, our study provides proof‐of‐concept that most Kenyan patients are willing to be tested and can be linked to HIV care and partner notification within facilities, provided a system is set up to ensure HIV testing. Offering oral HIV self‐testing to patients presenting with symptoms of acute infectious illness would be one approach to increase feasibility; this strategy has proven effective in settings similar to ours [6,32]. While oral HIV self‐testing would not identify AHI, if applied in our study, it would have identified one chronic HIV infection for every 40 participants tested in the intervention period.…”

“…Challenges impacting uptake of PITC include logistics, data systems and human resources and management -reflecting the weaknesses of health systems in the region [5]. Most patients are willing to be tested [6,7], but the yield of PITC even in highly endemic areas has recently been estimated at around 1% [3]. Therefore, HIV testing of patients seeking healthcare should be strategic and targeted to increase both the yield and number of newly diagnosed patients.…”

Field evaluation of capillary blood and oral-fluid HIV self-tests in the Democratic Republic of the Congo

“…≥2) partners, homosexual intercourse (asked of men), receipt of gifts, cash, or other compensation in exchange for sex (asked of women), or infection with another sexually transmitted disease. Individuals exposed to any of these factors were classified as “high risk”; the remaining participants were classified as “low risk” if they did not report any sexual activity in the past six weeks, and as “moderate risk” otherwise [ 21 , 22 ].…”