Uptake and factors associated with HIV self-testing among women in South Africa

29 years, 30–34 years, and 40–44 years had about two times higher odds of HIVST, when compared with women aged 15–19 years. Women who read newspaper or magazine less than once a week or at least once a week were 1.90 and 2.25 times as likely to have HIVST uptake, respectively, when compared with those who do not read at all. Conclusion: The prevalence of HIVST uptake was low. HIVST was associated with women’s sociodemographic characteristics. The findings highlight the importance of addressing women’s needs to know their HIV status. Contribution: This study adds to the body of literature in understanding the utilisation patterns of HIVST across women in South Africa.


Introduction
In sub-Saharan Africa (SSA), adolescent girls and young women are at an increased risk of human immunodeficiency virus (HIV) infection than their male counterparts.In 2020, women and adolescent girls accounted for nearly two-thirds (63%) of all new HIV infections in sub-Saharan Africa. 1 Human immunodeficiency virus was a top cause of death for women of reproductive age (15-49 years) in 2017. 2 In SSA, more than 4000 adolescent girls and young women (age 15-24 years) were infected with HIV every 7 days in 2020. 3This age group of women also accounts for 26% of new HIV infections in the Eastern and Southern African region. 4South Africa remains excessively burdened by the HIV pandemic, as there is a rapid increase in the number of people living with HIV in the country, from an estimated 3.8 million people in 2002 to as high as 8.2 million people in 2021. 5The HIV epidemic in South Africa, just as in many other Southern African countries, remains concentrated among the higher-risk subgroups, particularly among women in their reproductive years.There is an estimate of 26.3% HIV prevalence among reproductive-aged women (15-49 years) in South Africa compared to HIV prevalence of 14.8% in men. 6Numerous factors influence the susceptibility of women to HIV; these include socioeconomic, biological, cultural, structural and behavioural risks. 7spite the high burden and high prevalence and incidence of HIV contamination among women in their reproductive age, uptake of HIV testing in this population is suboptimal. 6,8A recent survey conducted in South Africa revealed that 36% of women between 15 and 24 years were ignorant of their HIV status. 6By 2030, the Joint United Nations Programme on HIV and AIDS (UNAIDS) has established a global 95-95-95 objective of reaching 95% of adults who are aware of their HIV status, 95% of HIV-positive individuals who are engaged in antiretroviral (ART), and 95% of those on ART who have viral suppression. 9Although South Africa made an effort towards achieving the UNAIDS 90-90-90 targets, many HIV-positive people still did not know their HIV status. 6everal techniques have been used to deliver HIV testing services (HTS) to women of reproductive age, including embedding HTS within family planning or prenatal care programmes.However, many young women only get to know their HIV status during their first antenatal services, resulting in delay in testing, diagnosis and uptake of treatment. 10e World Health Organization has advocated HIV selftesting (HIVST) as a significant alternative to existing HIV counselling and testing (HCT) procedures, and many countries, including South Africa, have already included HIVST as a component of testing strategy. 11HIV self-testing knowledge and use remain low in South Africa as less than a quarter of the populace have heard of it and only 3% have used it. 12HIV self-testing acceptability rate ranges between 22% and 94%, with men having a higher HIVST acceptability rate than women in sub-Saharan Africa. 13Individuals living in urban areas, those highly educated and wealthy, have greater awareness of HIVST. 12It has been shown to have the potential to increase HIV testing uptake and frequency 14,15 because it has the benefit of privacy and could help to reduce structural barriers that influence HIV testing.Another study reported that HIVST acceptability was higher among women. 16While men preferred HIVST because of convenience and efficiency, women favoured HIVST as a result of its potential to provide autonomy and empowerment.
Several factors influence HIVST uptake among women; these include age, marital and parental status, educational status, wealth status, prior contact with HIV testing, and HIV uptake at the household levels. 17Determining the factors influencing the uptake of HIVST among women in their reproductive age is crucial, considering the added worth of HIVST programmes in closing the gaps of HIV testing coverage.Very few population-based researchers have inspected factors influencing HIVST uptake.This study, therefore, assessed the factors associated with HIVST uptake among reproductiveaged South African women and provided recommendations that would assist in facilitating HIVST use among key populations.

Data source
The authors utilised cross-sectional data from the South African Demographic and Health Survey (DHS) of 2016 to create a nationally representative sample.Data from 8182 women of reproductive age were used for this study.A previous article has reported the data extraction approach. 18he data are available on the public space and can be accessed at: http://dhsprogram.com/data/availabledatasets.cfm.Details of the DHS sampling procedure have been previously reported. 19

Outcome
The dependent variable was based on the question on use of HIV test kits; women who responded 'has tested with HIV test kits' were coded '1', while those who responded 'never used HIV test kits' were coded '0'.

Independent variables
A previous article has reported the independent variables used in this study. 18

Statistical analysis
A previous article has reported statistical analysis approach. 18tata version 14 (StataCorp., College Station, Texas, United States) was utilised for data analysis.

Ethical considerations
Ethics approval for this study was not required because the data are secondary and is available in the public domain.More details regarding DHS data and ethical standards are available at: http://dhsprogram.com/data/availabledatasets.cfm.
Table 1 shows the prevalence of HIVST across the levels of women's characteristics.Approximately 8.5% of women with higher education had HIVST uptake.About 5.5% of those from richest household had HIVST uptake.Few urban women (3.5%), employed (4.6%), read newspapers or magazines (4.5%), listened to radio (3.7%) or watched television at least once a week (3.5%) had HIVST uptake, respectively.The results are summarised in Table 1.
HIV, human immunodeficiency virus.Table 2 shows the factors associated with HIVST among South African women.Women with primary education had 75% reduction in HIVST, when compared with women with no formal education (OR = 0.25; 95% CI: 0.08-0.72).Women who are employed were 1.44 times as likely to utilise HIVST, when compared with those not employed (OR = 1.44; 95% CI: 1.09-1.92).Older women had higher odds of HIVST.Women who read newspaper or magazine less than once a week or at least once a week were 1.90 (OR = 1.90; 95% CI: 1.28-2.84)and 2.25 (OR = 2.25; 95% CI: 1.53-3.31)times as likely to utilise HIVST, respectively, when compared with those who do not read at all.See details in Table 2.
Table 3 shows the predictive marginal effect of HIVST by women's characteristics.To determine the influence of women's factors on HIVST, a marginal predictive analysis was performed.Based on the predictive marginal effects results, we would expect 5.8% of HIVST if the distribution of all characteristics stayed same but every woman had a higher degree.However, if every woman came from the richest household wealth quintile, or dwell in urban residence, we would expect 4.0% or 3.2% of HIVST, respectively.Moreover, if every woman was employed, read newspaper or magazine, listen to radio, watch television at least once a week, we would expect 3.7%, 3.9%, 3.0% and 3.1% of HIVST, respectively.The details of the predictive marginal interaction effects of HIVST are shown in Table 3.

Discussion
We examined HIV self-testing among South African women using nationally representative large dataset.Our results show approximately 3.1% of HIVST among South African women.This is lower than the overall prevalence of HIV testing reported by a study in east Africa, which was 66.9%, 20 albeit this varied substantially by location.The documented geographical disparities in HIV testing in eastern Africa 21,22 could be because of regional differences in quality and availability of HIV testing facilities, as well as HIV and/or AIDS awareness.This study's prevalence was consistent with a report from Kenya. 23This could be because of the fact that both studies utilised community-based study designs, involving youthful and adolescent age groups.This study's finding on the prevalence of HIVST uptake among South African women shows that more efforts are required to promote the practice.In a previous study, healthcare users had a reasonable knowledge of HIVST and there were indications that they would utilise it if it could be properly managed and made widely available to the public. 24On the other hand, the low prevalence of HIVST coverage among the study population may be because of a lack of health policy promoting HIVST that can be implemented among the key population. 25ere are several barriers to HIVST; these include the lack of policies and health programmes that can enhance access and use of HIVST especially among the key population. 25As a result of the low prevalence of HIVST observed in this study, it is recommended that existing healthcare and communalbased systems of HIVST be complemented with policies and programmes that will promote service use. 26Institution of such HIVST programmes could have positive effects on the populations' approach to HIVST uptake.It can also enhance decision making and the ability to choose better approach for HIV testing, timely diagnosis, taking of management actions and precaution particularly with regard to those in hard-toreach communities and groups.
Previous studies have reported that higher education and literacy have a positive impact for higher HIVST uptake. 17,27,28iteracy, enlightenment and higher-level education have been variously reported to influence positively, healthcare decision making and uptake of healthcare services especially among women of reproductive age.This study also found out that women with employment and those from the richest background or household had an increased rate or higher prevalence of HIVST than those without employment and from a poor household.Employed women were found to be about 1.5 times more likely to go for HIVST when compared with those who were not employed.This is in agreement with other studies indicating that the cost of testing 28,29 and  household wealth 30 significantly influence women's choice and uptake of HIVST, along with other demographic group such as men counterparts.Educated women are known to have higher odds of financial independence and can make informed health decisions without reliance on their husbands or partners.This study reinforced the significance of education as a means of empowerment, which facilitates women's autonomy in making decisions regarding HIV self-testing.
The role of higher education and literacy, outcomes of enlightenment or exposure to educational materials, is crucial in the context of healthcare service uptake and utilisation. 31ducation and enlightenment foster boldness, self-expression and independence. 31,32Our study found out that women who read newspaper at least once in a week or less than once in a week are 2.3 and 1.9 times, respectively, more likely to obtain HIVST than those who do not read newspaper or magazine at all.Higher levels of education have been part of the factors that give an individual the ability to seek for better health. 33It also gives an individual opportunity for financial freedom as those with higher levels of education are more likely to have employment than those without education. 34,35Thus, educated individuals are in a better position to access healthcare services without the immediate concern for financial implications, unlike the less educated counterparts who might lack the financial means.Therefore, it is imperative that efforts are made to provide these healthcare services free of charge or without cost especially among those with poor financial background, unemployed individuals and people in the rural areas who are more likely to be less educated, poor and financially constrained.
Our result was able to show that age of respondents was an HIVST associated factor.It was observed that women who were between the ages of 20 and 44 years had a higher prevalence of HIVST when compared with those aged below 20 years and those who are 45 years and above.Older age has been reported to be a barrier to HIVST compared with those who were young. 36,37,38Individuals within this demographic are often described as go-getters and may be more exposed to new information and experiences compared with adolescents and those over 50 years of age.This exposure advantageously positions them to access and acquire knowledge about health-related issues, including HIVST, more readily than other age groups.Given this, it is crucial to focus more attention on adolescents and older adults in terms of awareness creation and mobilisation of HIVST, along with other health-related concerns.It is well acknowledged that older individuals, particularly those above 60 years and adolescents face greater vulnerabilities and disadvantages in accessing healthcare services.Therefore, targeted efforts to engage these groups are essential to ensure equitable access to HIVST and to address the health needs of the entire population effectively.
Our marginal predictive analysis conducted to decode the effects that women's factors have on HIVST, shows that if all the distribution of the women's factors are assumed to be the same, but every woman is educated to the level of tertiary levels, we would anticipate that about 6% of the women would have HIVST.Similarly, if we assume that all the study participants were to come from the richest households, reside in urban areas, are employed and engaged in regular enlightenment activities such as reading newspapers or magazines at least once a week, listening to the radio and watching television at least once weekly, it suggests a potential increase in HIVST uptake by 3% -4%.This shows that higher education, richest household, urban residence and enlightenment positively influence the uptake of HIVST among South African women but less so than if all women had tertiary education.

Strength and limitations
This study used nationally representative data, which is suitable for making plausible comparisons.However, data from a cross-sectional study were analysed, and therefore only association and not causality can be determined.Another limitation is the assumption that respondents who are living with HIV will have a greater knowledge of HIVST.
A previous study has reported on the strengths and limitations of the study. 18The recommendations for increasing the utilisation of HIVST focus on improving education and economic conditions, as these are critical factors that contribute to higher testing rates.Furthermore, integrated strategies that combine socio-economic advancement with tailored media campaigns can effectively increase HIVST uptake among reproductive-aged women in a concise and impactful manner.

Conclusion
The prevalence of HIVST uptake was low.HIV self-testing was influenced by sociodemographic factors.The findings highlight the importance of addressing women's needs to know their HIV status as a cornerstone for implementing programmes and research to increase HIVST uptake.The HIVST is recommended for women who would not otherwise test, and it may be critical to achieve the first of the UNAIDS 95-95-95 targets, knowing one's HIV status.
A.B. took part in drafting, revising or critically reviewing the article.M.E., O.C.O., C.I.N. and A.B. gave final approval of the version to be published, agreed on the journal to which the article has been submitted, and agreed to be accountable for all aspects of the work.

FIGURE 1 :
FIGURE 1: Uptake of HIV self-testing among South African women.

TABLE 1 :
Distribution of HIV self-testing among South African women (N = 8182).

TABLE 2 :
Factors associated with HIV self-testing among South African women.

TABLE 3 :
Marginal effect of HIV self-testing among South African women.