Prevalence and associated factors of HIV testing among young (15–24) women in eastern Africa: a multilevel analysis of demographic health survey data (2008-2018)

Globally, 36.7 million people were living with human immune deficiency virus (HIV) / Acquired immune deficiency syndrome (AIDS) in 2015 with 70 % of infected people were living in sub-Saharan Africa [1, 2]. Developing countries account for 97% of worldwide HIV cases and Sub-Saharan Africa is the world's first disease-affected region [3]. In 2017, the United Nations Joint AIDS Program reported that approximately 3.9 million young people worldwide were infected with HIV [4]. Around 2.9 million of the 4.9 million young people living with HIV / AIDS live in eastern and southern Africa [5]. Only 15 % of young women aged 15-24 years in sub-Saharan Africa were aware of their HIV status in 2013 [6]. The prevalence of HIV testing among young woman in Africa ranges from 23.5% to 60.10% [4‐7]. Despite a high prevalence of HIV infection among adolescents and young women in sub-Saharan Africa, policymakers give less attention to HIV testing and counseling services. Young women are exposed to HIV in two stages of their lives, from mother to child, at an early age and during their adolescence because of their sexual preference and gender differences [8]. Also, young women are vulnerable to HIV due to extreme peer pressure and the emergence of their sexual and social identities [9]. Factors associated with young people's HIV testing include demographic factors (age, education, wealth) [10, 11], HIV risk behavior [12] psychosocial variables associated with HIV awareness [8], and stigma attitudes [12]. Multiple sexual partners [12, 13] and age at sexual initiation [8] were also other factors associated with HIV testing and counseling. Although HIV counseling and testing (HCT) is very important for all strategies related to care, prevention, and treatment of HIV, health care planners and policymakers give less attention, particularly in developing countries [1, 4]. Understanding the factors affecting HIV testing and counseling utilization also helps policymakers to formulate effective strategies for HIV prevention and control. Besides, there is limited studies in HIV testing prevalence and associated factors in the study area using advanced model. Most previous studies in different regions of Africa on the prevalence of HIV testing have been focused on samples of adults and pregnant women [8]. This study extends previous studies focused on the populations of adult and/or pregnant women and attempts to fill the literature gap by addressing the determinants of HIV testing among young women. This study was therefore aimed at investigating the pooled prevalence and factors related to HIV testing among young women in east Africa.

Most studies have shown that knowing one's serostatus helps to prevent and monitor the spread of infection [16]. The pooled prevalence of HIV testing among young women in east Africa was 55.3% (95% CI = 54.97%, 55.69%). The prevalence in this study was greater than the report in Ethiopia and sub-Saharan Africa [4, 8]. The prevalence in this study was smaller than many studies conducted in Africa [5, 11, 17‐19]. Regional variations in access to HIV testing facilities as well as knowledge related to HIV / AIDS may also be the reasons for the reported regional inequalities in HIV testing implementation [18]. Young women who had primary and above education had a higher chance of being tested for HIV compared with women without formal education. This finding was supported by a study conducted elsewhere [4, 18, 20]. The explanation for this might be as education will enhance awareness about HIV and empowers women to make healthcare decisions by visiting the health facility [4]. Older women are more likely to get HIV tests than younger women. This is in line with the studies conducted in South Africa and sub-Saharan Africa [5, 8]. The variation in the odds of being tested for HIV among different age groups may be attributable to the possibility that younger women have a shorter sexual experience and are less knowledgeable about sexual issues than older people [10].

Married women had a higher chance of HIV testing than their counterparts, which is similar to the findings in Zambia and Ethiopia [4, 11]. This might be explained by the fact that married women used HIV counseling and testing better than unmarried women as they had regularly visited health facilities during pregnancy [12]. Young women living in rural areas had 20% lower odds of being tested for HIV compared to their urban counterparts. A similar conclusion was drawn from studies conducted in Ethiopia [4] and Nigeria [21]. Women attending health facilities were more likely to be tested for HIV compared to their counterparts. This finding was similar to studies conducted in South Africa [22, 23]. This may be because health professionals advise people who have visited health facilities to have HIV counseling and testing and this service is offered by almost all governmental and public health facilities [24]. Young women who had an experience of risky sexual activity were more likely to use HIV testing and counseling. The study conducted in Ethiopia and Ghana supported this finding [12, 25]. Besides, age at first sex is a significant predictor of HIV testing, which is in agreement with a study conducted in Malawi [17]. This may be explained as early age is associated with a higher risk of contracting various sexually transmitted diseases and risky sexual behavior, which could contribute to a higher risk of HIV infection [26]. Compared with those with one sexual partner, young women with multiple sexual partners had lower odds of being tested for HIV which is consistent with the study conducted in Ethiopia [4]. This might be because women with multiple sexual partners had a higher perceived risk of acquiring HIV infection which in turn, increases their motive to be tested [23]. Concerning HIV / AIDS knowledge, young women having higher and comprehensive knowledge about HIV had higher chances of being tested compared to women with low knowledge. This finding was supported by different studies [5, 8]. This might be justified by people with a good understanding of HIV / AIDS, including its transmission and preventive measures keeps themselves away from these devastating problems [13]. Looking at media exposure, there was a significant association between media exposure and HIV testing, which is supported by another study conducted in sub-Saharan Africa [8]. This outcome underlines the potential importance of media exposure for behavioral change, playing a key role in promoting young women's sexual and reproductive health [25].

The pooled prevalence of HIV testing among young women is higher in east Africa compared to the report from other studies. In the multilevel multivariable analysis; respondent age, marital status, educational level, knowledge about HIV/AIDS, HIV stigma indicator, risky sexual activity, women who have visited health care facilities, early sex initiation and community educational level were positively associated with HIV testing among young women. While being a rural dweller, wealth status and being having multiple sexual partners were negatively associated with HIV testing and counseling. So there should be a systematic and integrated approach and policy for HIV counseling and testing among young women to prevent the transmission and spread of HIV/AIDS in these populations. Besides, all the stakeholders should have an integrated approach to increase awareness of the benefit of HIV testing and counseling to control the spread of HIV/AIDS.