Reaching for the "first 95": a cross-country analysis of HIV self-testing in 177,572 people in nine countries in sub-Saharan Africa


BACKGROUND: HIV self-testing (HIVST) offers a promising approach to increase diagnosis of HIV and advance progress towards the UNAIDS 95-95-95 targets. We aimed to understand patterns of awareness and utilization of HIVST in nine sub-Saharan African (SSA) countries, with a goal to identify populations to target in disseminating this technology.
METHODS: We pooled individual-level population-based data from nine Demographic and Health Surveys (DHS) in SSA from 2015-2019 (Burundi, Cameroon, Guinea, Malawi, Senegal, Sierra Leone, South Africa, Zambia, Zimbabwe). The primary outcomes of interest were awareness and utilization of HIVST. We then used logistic regression analyses with survey fixed effects to explore the relationship between sociodemographic characteristics and both (1) awareness and (2) utilization of HIVST. All models were adjusted for sex, age, rural/urban residence, education, wealth, marital status. We accounted for complex survey design.
RESULTS: The total study sample included 177,572 people (66.0% women, mean age 29 "± 10 years), among whom 86.6% (95%-CI 86.4-86.7) had never heard of HIVST, 11.7% (95%-CI 11.6-11.9) had heard of HIVST but never tested and 1.7% (95%-CI 1.6-1.8) had tested with 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 ever used HIVST (OR 1.17 95%-CI 1.03-1.32) compared to men. Moreover, rural residents were less likely to be aware of or use HIVST; in addition, there were significant gradients in both wealth and education, with those who were least educated and poorest also least likely to have heard of or used HIVST (Table 1).

Table 1. Multivariable logistic regression analysis
Awareness of HIVSTUse of HIVST
OR (95% CI)p-valueOR (95% CI)p-value
Rurala0.81 (0.75-0.88)<0.001**0.74 (0.62-0.89)0.001*
Primary educationb
Secondary education
Higher education
1.03 (0.96-1.11)
1.81 (1.68-1.95)
4.89 (4.45-5.37)
<0.001**0.79 (0.65-0.97)
1.64 (1.36-1.98)
4.20 (3.43-5.16)
1.26 (1.16-1.37)
1.45 (1.32-1.58)
1.70 (1.54-1.88)
2.36 (2.12-2.62)
<0.001**1.28 (1.04-1.59)
1.22 (0.96-1.55)
1.48 (1.17-1.86)
1.66 (1.31-2.11)
*p < .05. ** p < .001. Abbreviation: HIVST= HIV self-testing. Reference categories: a) urban, b) no education, c) poorest. Additionally adjusted for sex, age and marital status.
CONCLUSIONS: Overall awareness of HIVST was modest and uptake to date is low. Marginalized groups were least likely to have heard of or used HIVST. Efforts to scale-up HIVST in these settings should aim to reach rural, less educated and lower income populations.