Awareness, use and willingness to self-test for HIV: An analysis of cross-sectional population-based surveys in Malawi and Zimbabwe

<jats:title>Abstract</jats:title> <jats:p>Background Many southern African countries are nearing the global goal to diagnose 90% of people with HIV by 2020. In 2016, 84% and 86% of people with HIV knew their status in Malawi and Zimbabwe respectively. Despite this progress, gaps remain, particularly among men (≥25 years). We investigated awareness, use and willingness to HIV self-test (HIVST) prior to large scale implementation and explored sociodemographic associations.Methods We pooled responses from two of the first cross-sectional Demographic Health Surveys to include HIVST questions: Malawi and Zimbabwe in 2015-16. Sociodemographic factors and sexual risk behaviours associated with never testing for HIV, and awareness, past use and future willingness to self-test were investigated using univariable and multivariable logistic regression, adjusting for the sample design and limiting analysis to participants with completed questionnaire and a valid HIV result. Analysis of willingness to self-test was restricted to Zimbabwean men as Malawians and women were not asked this question.Results Of 31 385 individuals, the proportion never-tested was higher for men (31.2%) than women (16.5%), p&lt;0.001. For men, having ever tested increased with age. Past use and awareness of HIVST was very low, 1.2% and 12.6% respectively. Awareness was lower among women than men (9.1% vs 15.3%, adjusted odds ratio (aOR)=1.55; 95% confidence interval [CI]: 1.37-1.75), and at younger age, and lower education and literacy levels. Willingness to self-test among Zimbabwean men was high (84.5%), with having previously tested for HIV, high sexual risk, and being older (≥25 years) associated with greater willingness. Wealthy men had greater awareness of HIVST than poorer men (p&lt;0.001). Men at higher sexual risk, compared to men at lower risk, had the greatest willingness to self-test (aOR=3.74; 95%CI: 1.39-10.03, p&lt;0.009).Conclusions In 2015-16 many Malawian and Zimbabwean men had never tested for HIV. Despite low awareness and minimal HIVST experience at that time, willingness to self-test was high, especially in older men with moderate to high sexual risk. These data provide a valuable baseline against which to investigate population-level uptake of HIVST as programmes scale-up. Programmes introducing, or planning to introduce HIVST, should consider including questions in population-based surveys.</jats:p>