Determinants of HIV voluntary counseling and testing: a multilevel modelling of the Ethiopian Demographic and Health Survey | BMC Women’s Health

In the development of the current HIV National Strategic Plan, the government of Ethiopia has adopted the global goal to attain the 90–90-90 targets through intensify targeted HIV testing and counseling services, attain virtual elimination of MTCT, optimize and sustain quality care and treatment [16]. This study uses a nationally representative cross-sectional sample of women to investigate the individual and community-level determinants that affect the acceptance of VCT among women of reproductive-age in Ethiopia. Therefore, the results of this study indicate that several individual and community-level determinants are related to women of childbearing age receiving VCT.

In this study, the VCT uptake among ever-married women was high compared to never-married women. This finding is consistent with other studies conducted in Ethiopia [18, 25]. The high rate of testing among married women might be due to the majority of women believe that VCT is useful for preparing for marriage [20], and following marriage women are more likely to visit the health facility for perinatal service available in most health institutions and so for VCT.

The probability of having been tested was highest among women aged 35 years or older and 25–34 years. The results of this survey are consistent with those of other studies, indicating that the VCT uptake varies with age [18, 19, 22, 23, 25, 26, 28]. Previous documented study on awareness and knowledge about HIV/AIDS among women of reproductive age indicated that the odds of HIV/AIDS awareness and knowledge increase with women’s age, which might increase VCT uptake [31]. This fact is likely because the fear of stigma and discrimination from the society towards VCT uptake were less common among the older age compared to younger age group [28].

We found that VCT uptake increased with educational level and family wealth. This finding relates to other studies elsewhere in which women with a higher education level [1, 20,21,22,23,24] and higher family wealth [18, 19, 22,23,24] have a higher chance of HIV testing. This result highlighted the importance of education and higher wealth to the increment of HIV testing and counselling. The possible reasons may be the increased awareness and knowledge of HIV among educated women and women from the wealthiest households [31]. Also, this association was likely due to women with higher income and educational level were more likely to seek maternal health care services, have women’s autonomy, and they are near to information [32, 33]. Another possible justification might be that in this study, most women from the wealthiest families (91%) and higher education levels (94%) had ≥ 4 ANC follow-ups, which may increase VCT. However, the current study disagrees with a study conducted in China, which shows a negative association between income and VCT uptake [27]. This disagreement might be due to the differences of tools used for wealth index measurement, in which DHS program used Principal Component Analysis to calculate wealth index (a composite measure of a household’s cumulative living standards), while the previous study used monthly income.

As previously documented, we observed that women with comprehensive HIV-related knowledge are more likely to receive VCT [18, 21, 23,24,25,26, 28, 34]. A possible explanation may be that knowledgeable women may be aware of the benefits of getting an HIV test. This finding suggests that discussing HIV will increases the acceptance of HIV testing; therefore, dialogue on this issue and prevention of stigma are essential [35, 36].

The uptake of VCT was higher among individuals with risky sexual behavior. This was consistent with studies conducted in different countries [18, 19, 22, 24, 26]. This is because women with risky sexual behaviors are afraid and uncertain about their sero-status, which will cause them to be tested for HIV than those without risky sexual behaviors.

In agreement with previous studies conducted in Ethiopia [18, 19, 22], Nigeria [23], Malawi [21] and China [27], this study found that women who have a stigma against PLWHA had a decreased VCT uptake. This association could be possibly due to the cultural and moral values attached to sex orientation that greatly determine people’s attitude towards PLWHA. Individuals who are infected with HIV are perceived to be engaged in socially disapproved pre-marital or extra-marital sexual affairs, that might cause misconception of HIV testing due to the fear of negative consequences of the social disapproval [37].

This study also assesses the association between community-level determinants and VCT uptake. Our result indicated that VCT uptake was higher among women living in communities where the proportion of respondents were more educated than the median and where women were from wealthier communities, which was in agreement with the findings from a study conducted in Burkina Faso [24]. Also, this study suggested that women living in communities with high knowledge related to HIV were more like to be tested for HIV, i.e. living in communities where HIV is actively addressed seems to have a strong effect on the willingness to get the test. This is similar to previous literature, which indicates individuals’ engagement in community group discussions about HIV had increased odds of VCT uptake compared to those who had not participated [36]. A study showed that community characteristics/interventions are very effective in increase the use of preventive measures [35].

Strength and limitation of the study

The main strength of this study is the use of nationally representative data, which was collected using standard and validated data collection tools. In addition, a high-level model (multilevel analysis) was used, which takes into account the relevance of EDHS data when determining estimates. However, our study is without limitations. Due to the secondary nature of the data, Factors such as availability of treatment, health professional related factors, and support programs were not included in the analysis.

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