Background: HIV self-testing (HIVST) is an innovative strategy recommended by the World Health Organization (WHO) to increase HIV testing coverage. National estimates of its acceptability are lacking in Malawi.
Methods: MPHIA was a nationally representative survey with a stratified cluster sample design, in which 11,386 households and 19,652 adults aged 15-64 were interviewed. HIV testing was performed in consenting participants. This analysis excludes respondents who tested HIV positive and were aware of their status, and presents weighted estimates of the percentage of the population that would use an HIV self-test kit if it were available. Analysis weights account for sampling selection probabilities and adjust for nonresponse and noncoverage. Logistic regression was used to determine factors associated with the willingness to perform self-testing.
Results: Among 17,799 eligible respondents aged 15-64 years, 72% (95% CI 71%,73%) indicated that they would use HIVST. The willingness to use HIVST was significantly higher among males (76%, 95%CI 75%,77%) than among females (68%, 95%CI 67%,69%). Among females, age, education, socioeconomic status, and HIV testing history were independently associated with the willingness to use self-testing; while among males, only education, and testing history were independently associated (Table). The willingness to use self-testing was significantly lower among females aged 15-24 and 45-64 than among those aged 25-44 years, among males and females who had never tested for HIV in comparison with those who ever tested, and among those whose HIV status was unknown for the survey (did not consent to testing). Among females but not among males, those in the two highest wealth quintiles in comparison with those in the three lowest, and those HIV-positive who were unaware of their status in comparison with the HIV-negative were more willing to use HIVST.
Conclusions: In Malawi, the willingness to perform HIVST is high, especially among two priority populations: males and those HIV-positive unaware of their status. This represents an opportunity to increase testing coverage in a country where the major gap for the achievement of the UNAIDS 90-90-90 targets is in diagnosis, with 27% of those infected unaware of their status, and low testing frequency in the general population.

 Females Males
CharacteristicPercentage who would use an HIV self-test kit if available in the country % (95% CI)Number of observationsAdjusted Odds Ratio aOR (95% CI) Percentage who would use an HIV self-test kit if available in the country % (95% CI)Number of observationsAdjusted Odds Ratio aOR (95% CI)
ResidenceRural......... Urban65 (64,67) 79 (76,81)6415...... 3641Ref 1.17(0.99,1.37) 75 (74,77) 80 (78,81)4808........ 2935Ref 1.02(0.86,1.21)
EducationNo education or Primary Secondary or more than secondary63 (62,65) 83 (81,85)7024..... 3027Ref 2.39(2.07,2.76) 72 (70,74) 83 (82,85)4532........ 3209Ref 1.84(1.59,2.13)
Marital StatusEver married Never married68 (67,70) 66 (63,68)7883..... 2164Ref 0.93(0.77,1.13) 78 (77,80) 73 (71,75)4769........ 2963Ref 0.88(0.72,1.08)
Wealth QuintileLowest / Second/Middle Fourth / Highest61 (60,63) 76 (74,77)4362..... 5694Ref 1.53(1.38,1.70) 74 (72,75) 79 (77,80)3184......... 4559Ref 1.14(0.98,1.33)
Age (years)15-24......... 25-44......... 45-6465 (63,67) 73 (71,74) 61(58,64)3970..... 4595..... 14910.76(0.67,0.86) Ref--- 0.73(0.64,0.84) 73 (71,75) 79 (77,81) 77 (74,79)3037......... 3427......... 12790.85(0.68,1.06) Ref 0.99(0.83,1.20)
HIV Testing HistoryEver tested Never tested70 (69,72) 58 (55,61)8369..... 1682Ref 0.62(0.54,0.72) 80 (78,81) 70 (67,72)5049......... 2689Ref 0.66(0.57,0.76)
HIV Status (as tested by the survey) and HIV+ awareness (based on self-report and ARV detection)HIV-positive unaware of status.......... HIV-negative Unknown HIV status81 (75,86) 69 (68,71) 57 (53,60)289....... 8398..... 13691.69(1.15,2.49) Ref 0.55(0.47,0.65) 79 (71,86) 77 (76,79) 68 (64,71)200........... 6477......... 10661.07(0.66,1.71) Ref 0.56(0.47,0.67)
*Adults 15-64 who based on testing performed by the survey were HIV-negative, HIV-positive unaware of their status, and with unknown HIV status (i.e. did not consent to the testing).
[Table. Willingness to use HIVST among adults aged 15-64*. Weighted percentages and Adjusted Odds Ratios by selected demographic characteristics. Malaw]

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