Prevalence of HIV testing and associated factors among young adolescents in Eswatini: a secondary data analysis

HIV testing is a crucial starting point for prevention, early diagnosis, and treatment of HIV to increase survival rate, improve quality of life, and preclude further transmission [1, 2]. In order to improve motivation toward maximizing HIV testing coverage, which is an optimal measure to achieve an HIV-free generation, the Joint United Nations Programme on HIV/AIDS (UNAIDS) outlined a global target named 90–90-90 in 2014. The 90–90-90 target aimed to ensure that 90% of the people living with HIV (PLHIV) should be diagnosed and know their HIV status, 90% of people living with HIV should be initiated on antiretroviral therapy (ART), and 90% of those started on ART should have their viral load suppressed by 2020 [3]. The 90–90-90 target was further accelerated to 95–95-95 by 2030, following the remarkable progress made by the UNAIDS and other global stakeholders in achieving the 90–90-90 targets in the general population of individuals aged 15–49 years in a couple of countries globally including the Sub-Saharan Africa by 2020 [4‐6]. In 2020, Eswatini was the first country in Africa to achieve the 95–95-95 target [6, 7]. However, considering the disparities in accessing HIV prevention and treatment interventions [8], it is not clear whether this success can be attributed to young adolescents.

Sub-Saharan Africa is a region with the highest prevalence rate of HIV among adolescents and young adults [9]. Considering the high prevalence of HIV and the anticipated increased risk of transmission in a high HIV-burdened country like Eswatini, the HIV management guidelines of Eswatini suggested that young adolescents should be tested for HIV at least once a year depending on risk assessment [10]. However, the latest report by United Nations Children’s Fund (UNICEF) showed that approximately 88% of all HIV-infected adolescents aged 10 to 19 years live in Sub-Saharan Africa, yet only 17 to 25% of this age group had tested for HIV in the past year in 2020 [11]. Similarly, another review study with data from 18 countries in Sub-Saharan Africa also reported the low rate of HIV testing among adolescents aged 15 to 19 years, showing 2–24% in male adolescents and 4–44% in female adolescents across countries [12]. According to a recent analysis of data from PHIA surveys conducted in seven countries, including Eswatini, about 39% of children and young adolescents (1–14 years) living with HIV were undiagnosed, meaning they were unaware of their HIV status [13]. Low rates of HIV testing can lead to a reduction of early treatment, resulting in insufficient support and increasing mortality in adolescents living with HIV [8, 14].

Considering that HIV-related mortality has ranked as a top killer in Sub-Sahara African adolescents between the ages of 10 and 19 years [15], these young adolescents should be prioritized early in the development life cycle before being exposed to environmental and societal factors with potentially damaging consequences for sexual and reproductive health [16]. However, sufficient attention has not been paid to young adolescents. This gap is probably related to limited age-specific data to identify potential factors for facilitating the availability, accessibility, and utilization of HIV testing services [17]. A systematic review on HIV testing among children and adolescents in the Sub-Saharan region highlighted that data from existing literature had not been adequately stratified by age [17]. For this reason, strategies used in HIV testing and treatment that were developed for older adolescents and young adults were mostly repeated with little consideration for the needs of young adolescents [17‐20]. As a result, HIV-related mortality varied with age [14]. Only a 10% reduction was reported among adolescents aged 10–19 years while 74 and 64% reductions were found in children aged 0–9 years and other age groups, respectively [21].

According to existing literature, HIV testing uptake among adolescents and young people was associated with several factors, including age, gender, residence, HIV knowledge, and risk perception, stigma, HIV-related belief, accessibility to HIV testing services, and prior experience to participate in sexual reproductive health (SRH) communication [18, 22‐27]. Despite the valuable information from previous studies regarding the low rate of HIV testing and associated factors, further investigations are needed to determine the relevance of what is given from different age groups as factors that can play the same role in explaining the HIV testing uptake in young adolescents. Young adolescence was highlighted as a critical target population for the prevention and treatment of HIV to achieve the global target of combating HIV by 2030 [28]. Therefore, this study aimed to identify the prevalence of HIV testing uptake and examine the factors associated with HIV testing among young adolescents aged 10 to 14 years in Eswatini.

Eswatini made remarkable progress in HIV testing coverage among the general population of individuals aged 15 to 49 years and was applauded for being among the first countries to reach the global target of the first 90% along with other countries like Botswana and Namibia in Africa in 2018 [5]. In 2020, Eswatini was the first country in Africa to reach the 95–95-95 global target [7]. However, it was difficult to say that the same progress was obtained in the age group of young adolescents. This study found that the lifetime HIV testing rate among young adolescents aged 10 to 14 years in Eswatini was 52% compared to 98% in the general population [7], indicating a huge gap between the rate in this study and the goal proposed by the global targets. This age-related hidden gap may be of serious concern and highlights the need for greater participation of marginalized young adolescents who may be missed out on HIV response programs as some may be unknowingly infected hence delaying enrolment into care [16].

HIV testing uptake was significantly associated with greater access to HIV testing services in this study. As anticipated perceived accessibility to HIV testing services was significantly associated with HIV testing uptake among young adolescents. Respondents who reported difficult accessibility to HIV testing services were less likely to have received an HIV test in a lifetime. This finding is consistent with previous studies showing that service accessibility issues were associated with lower participation in HIV testing among adolescents [24, 28]. To bridge the gap in receiving HIV tests by dealing with barriers to accessibility among young adolescents, introducing adolescent-friendly health services (AFHS) within the communities in which young adolescents reside was recommended [36, 37]. The AFHS was defined as an evidence-based and specialized approach to addressing health system barriers and catering to developmental needs by providing a more accessible, acceptable, equitable, appropriate, and effective social environment for young people [38]. A recently published systematic review study supported that AFHS in health facilities and clinical settings positively influenced health service utilization for HIV testing and other sexually transmitted diseases or performing preventive behaviors in Sub-Saharan Arica [39]. However, there is a lack of understanding and limited knowledge in the literature regarding implementing appropriate strategies for delivering AFHS to help young adolescents receive HIV testing in resource-constrained out-of-facility settings [39]. Considering the effectiveness of AFHS in meeting adolescents’ sexual and reproductive health needs, future research is needed to investigate how AFHS can be applied over an extended period in marginalized communities to achieve the desired goals, especially in ending HIV.

HIV risk perception is vital in determining health behavior practices such as routine HIV testing as prevention. However, HIV testing uptake was not significantly associated with higher risk perception for HIV infection in this study. More than 80% of young adolescents reported lower HIV risk perception regardless of HIV test status. Although young adolescents who reported lower HIV risk perception were more likely to get an HIV test than those with higher HIV risk perception, the difference did not reach the significance level. Interestingly, this age group tends to believe that they are at low risk of contracting HIV, and their misperception about HIV transmission may increase the likelihood of engaging in risky sexual behaviors and their vulnerability to HIV infection [36]. Similarly, a couple of other studies conducted among African adolescents showed that adolescents and young people were likely to have incorrect HIV risk perception such that even those at high risk of HIV acquisition had lower HIV risk perception [27, 36, 37]. Therefore, future research is required to understand better the drivers of HIV risk perception among young adolescents.

There is a growing literature showing that young adolescents who freely communicated about sex-related topics and HIV with their parents or caregivers were likely to practice safer sex behaviors, including HIV prevention [40]. Contrary to these findings, the association between parent-child SRH communication and HIV testing uptake was not significant in this study. This unexpected inconsistency in the effect of parent-child SRH communication on health behavior practices and HIV prevention may be associated with the characteristics of communications and the individuals involved in SRH communication. First, a meta-analysis study suggested that the frequency, content, or how pleasant the conversations were likely to influence the effectiveness of the parent-child SRH communication among adolescents [40, 41]. Our data did not provide detailed information about the nature of the communication according to the above-mentioned factors, except for the knowledge that some adolescents engaged in SRH communication with parents or caregivers. Second, significant differences in the effect of communication on healthy behaviors such as HIV prevention were found between the gender of the adolescents and parents or caregivers, with more substantial effects observed in girls than in boys. Parent-child SRH communication between mothers and daughters was more significantly associated with positive outcomes compared to father-son communication [40, 42, 43]. It is necessary to consider that the interaction between the nature of SRH communication and the gender of the individuals involved may have different effects on communication outcomes [33]. Therefore, robust and well-designed future research on the determinants of parent-child SRH communication’s positive effects on healthy behavior practices and HIV prevention among young adolescents is recommended.

This study shows that HIV testing among young adolescents in Eswatini is significantly lower than the global targets. Our findings highlighted some important factors associated with HIV testing among young adolescents, including increasing age, urban residence, and higher awareness of the ease of access to testing services. International organizations, national policymakers, and healthcare professionals need to carefully consider these factors and other differentiated approaches that cater to differences in personal characteristics and external resources when developing appropriate strategies to reduce possible gaps in receiving HIV tests. Additionally, primary research on the barriers to HIV testing is recommended to expand understanding and planning of programs to alleviate barriers and further research to provide more data about the prevalence of HIV testing and gender-specific associated factors among young adolescents. Age-and-gender specific, practical, and culturally appropriate strategies should be considered when developing interventions to enhance the uptake of HIV testing among young adolescents.