Factors associated with HIV self-testing among female university students in Uganda: a cross-sectional study

In this cross-sectional study of 483 female students at Makerere University, we found that majority of students (93%) were willing to self-test for HIV, despite the low uptake of HIVST (19%). Respondent’s age was associated with a history of HIVST use whereas college type, number of sexual partners, alcohol or drug use, STIs, and HIV testing experience predicted willingness to self-test for HIV.

We found that one-in-five female students had ever used HIVST, which is higher than the 9% reported among Nigerian university students [20]. Students from Uganda were assessed at least 2 years after those in Nigeria, and because HIVST is being scaled-up in sub-Saharan Africa, Ugandan students in this study may have had better access to HIVST. Oral self-test kits were freely available at the University Hospital during the study period and could be purchased over the counter in pharmacies near the university. However, self-test kit utilization by university students was modest (19%) and its scale-up may have been impeded by COVID-19-related lockdowns [21] that happened in Uganda in 2020 and 2021. Nonetheless, uptake was higher than anticipated given that Uganda implemented its HIVST policy in 2019 and recommended HIVST in the 2020 HIV clinical guidelines [11, 22].

Nearly all students were willing to use self-test kits when freely available. HIVST was highly acceptable among AGYW who could interpret their results accurately [14]. Correspondingly, studies conducted at tertiary learning institutions elsewhere in Africa found that 59–86% of female students were willing to self-test for HIV [13, 23,24,25]. Students at Makerere University received free access to self-test kits from the institution’s hospital, which could have influenced their desire to use HIVST. Leveraging on the high acceptability of self-test kits, delivery through trained peers at female student’s places of residence could increase HIVST uptake and demand for HIV testing services [13].

Only 80% of female students had ever been tested for HIV, significantly below UNAIDS 95–95-95 targets of 95% people knowing their HIV status [12]. It is likely that some students who had never been tested, such as the 47% who were sexually inexperienced did not see the necessity for HIV testing or had a low self-risk perception of HIV [13]. Notably, HIV testing among female university students was below the national average for AGYW (92% for older AGYW) in Uganda [8]. HIVST can bridge the gaps in HIV testing because it is highly acceptable to AGYW [14, 20]. Additionally, HIVST is crucial in reaching key populations and their partners, especially when access to health facilities is constrained, as was the case of COVID-19 lockdown [21].

Young women at university are more likely to use HIV self-test kits as they get older (aPR: 1.23 per year). A study among AGYW in Kenya found that older age (adjusted Risk Ratio: 1.09 per year) was associated with HIVST uptake [26]. It is possible that as female students spend more time at university, their awareness of HIVST and where to get self-test kits grows. Older students may have been more sexually active and had a higher HIV-risk perception, both of which may have influenced their decision to self-test for HIV [20]. Senior students can be trained and supported as peers to distribute HIVST kits to younger students during their freshman orientation and places of residence.

Arts students were less likely to be willing to self-test for HIV, whereas students who had sexual partners, used alcohol or injectable drugs, had an STI in the past year, or had ever tested for HIV were more willing to self-test for HIV. Arts students may be less willing to self-test for HIV than their science colleagues, due to their lower HIV knowledge and sexual risk perception [20]. Due to their sexual risk for HIV, students with sexual partners maybe not be using condoms consistently and may be influenced by and willing to self-test with their male partners [23, 24]. Multiple sexual relationships, alcohol and injection drug use and STIs are among many factors influencing young women’s susceptibility to HIV [3]. Young women who engage in these high risk behaviours have a higher risk perception and desire to test for HIV [27]. Finally, students who have ever tested for HIV were probably sexually active, required frequent HIV testing, and opted for self-test kits which were convenient, easy to administer, and ensured privacy [28]. Student’s risk perception and HIV testing experiences may affect their desire to use HIVST. Students who offered science courses, had sexual partners, engaged in high-risk behaviours, and had previously tested for HIV should be given priority when distributing HIV self-test kits since they were more eager to self-test for HIV. These students could be identified through risk screening tools available online and at institutional hospitals.

The high response rate, student diversity, and the use of multivariable regression to control for potential confounders are all strengths of this study. Our findings, however, have limitations. First, responses were self-reported, which made them vulnerable to recall and social desirability bias. Notably, social desirability is less common with self-administered online surveys than face-to-face interviews [29]. Nevertheless, we included detailed explanations of HIVST and assured participants of anonymity of their responses, which may have further lowered the likelihood of these biases. Second, selection, misclassification, and confounding bias may have distorted the accuracy of the findings. The non-probability sampling technique (quota sampling) and response exclusion may have resulted in selection bias. Although graphics (in the online questionnaire) were used to demonstrate oral self-testing, it is possible that some students misconstrued blood tests for oral self-tests. Residual confounding might have arisen from unstudied variables that could have been key confounders. For example, we did not test for HIV and other STIs due to the study design. Third, due to research design constraints, we were unable to offer or follow up with students who were willing to use HIVST to assess whether they eventually used the HIV self-test kits. Finally, this study was conducted during the COVID-19 lockdown period, which may have masked HIV risk and awareness, as well as HIVST utilization and translation.

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