Background: HIV testing must increase to achieve UN 90/90/90 targets in sub-Saharan Africa. A recent cluster randomized trial demonstrates that facility-based HIV self-testing (HIVST) among outpatient clients dramatically increases testing. However, a portion of clients offered facility-based HIVST still opted-out of testing. To improve HIVST strategies, programs will require a greater understanding of why individuals refuse to test. We examined characteristics and concerns of outpatient clients in the trial who were offered and opted-out of HIVST in Malawi.
Methods: Exit surveys were conducted with outpatients ≥15 years at 15 facilities in Central/Southern Malawi. Surveys included sociodemographic information and reasons for opting-out of HIVST. We analyze survey data from clients who were offered HIVST and eligible for HIV testing (not tested HIV-positive and tested ≤ 3 months ago). Multivariate logistic regression models were used to assess factors associated with opt-out. We then explore the primary concerns listed by clients who opted-out of facility-based HIVST.
Results: A total of 1,418 outpatients were offered HIVST. Among those offered, 218 (15%) tested < 3 months ago and 81 (6%) previously tested HIV-positive. Both groups were excluded from analyses. Among those eligible for testing, 454 (34%) opted-out of facility-based HIVST (median age 29 and 39% men). Men (OR:1.41, p-value=0.004) and adolescents (OR:1.32, p-value=0.05) were more likely to refuse HIVST compared to women and adults, respectively. Among men, having fewer sexual partners was associated with opting-out of HIVST (OR:0.82, p-value 0.01). Primary reasons for opting-out were perceived low-risk of HIV-infection (42%), feeling unprepared to test (30%), not seeing the HIVST demonstration (14 %), and being too busy (9 %). Less than 2% did not understand HIVST instructions and only 1% wanted more privacy to preform HIVST. Men were more likely than women to report being too busy to use HIVST (OR:2.1, p=0.03).
Conclusions: Facility-based HIVST is largely acceptable - primary concerns are not related to characteristics of the intervention. Concerns regarding facility-based HIVST are similar to concerns for other testing strategies. Future testing strategies should include extensive community sensitization to increase client preparedness for testing and their awareness of HIV-risk. Targeted HIVST strategies for men and adolescents may be warranted.

Table. Sociodemographic factors and concerns among clients who were offered and opted-out of facility-based HIV self-testing in Malawi
[Table. Sociodemographic factors and concerns among clients who were offered and opted-out of facility-based HIV self-testing in Malawi]

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