Eastern and Southern Africa is home to 53% of the 36.9 million people living with HIV globally,¹ with an estimated 75% of people living with HIV who actually knew their HIV status by the end of 2017.¹

Furthermore, there was a 42% reduction of AIDS-related illnesses, as a result of the increase in HIV testing and treatment coverage between 2010 and 2017.¹

South Africa has one of the largest HIV testing services (HTS), which is a crucial component of national HIV response.² HIV testing services are vital in directing HIV-positive people to the treatment continuum, starting with antiretroviral therapy and, therefore, is critical in the fight against HIV.² The Joint United Nations Programme on HIV (UNAIDS) launched the 90-90-90 targets stipulating that by 2020, 90% of people living with HIV should know their status, 90% of those who know their HIV-positive status should receive antiretroviral therapy and 90% of those on treatment have a suppressed viral load to end the epidemic by 2030. The UNAIDS has revised 2030 targets of 95-95-95, which are set out to be achieved by 2030.³

South Africa has made progress towards the UNAIDS 90-90-90 targets, especially regarding HIV testing and viral load suppression.⁴ Over the past decade, the country had made excellent progress in involving more people to test and become aware of their HIV status, after the launch of two national HIV testing initiatives: firstly, the national HIV testing and counselling (HTC) campaign that took place in 2010, and secondly, the HTC revitalisation strategy in 2013.⁵ As a result of these campaigns and other similar campaigns, more than 10 million people in South Africa test for HIV every year.⁵ In scaling up efforts around HTS interventions, civil society organisations continue to work with government departments in South Africa. The South African National AIDS Council continues to provide a platform for engagement between the civil society and government to work together on the HIV response.⁶

Although South Africa has made steady progress towards reaching the UNAIDS targets, many people affected with HIV are still unaware of their HIV status.⁷ Despite the availability of HTS, research studies have revealed that only a fraction of South Africans who are at risk get tested for HIV.⁸ Evidence shows that access to HTS may be limited geographically because of the inadequacy and heterogeneous distribution of available services.^9,10 Achieving high coverage of HIV testing is critical for linking HIV-positive people to care across the country. Therefore, equitable geographical distribution of HTS is vital for achieving optimal coverage for HIV testing.¹⁰ This highlights the importance of conducting and collecting population-based HIV testing covereage data at the sub-national level needed for decision making.

In South Africa, gathering spatial data on HIV and mapping its distribution have been carried out in selected micro-geographical areas, limiting the generalisability of the findings to the country.¹¹ The main source of estimating the number of people who tested for HIV in the country comes from the District Health Information System and from modelling.¹² Both sources have limitations and rely on healthcare facility and programme data from districts to produce estimates.^13,14 The current study used large-scale nationally representative population-based household survey data to describe the spatial coverage in the uptake of HIV testing amongst youth and adults 15 years and older. The aim of this research study was to identify the spatial gap in the uptake of testing in people who had ever tested for HIV at the district level in South Africa.

HIV testing is a crucial component of the national HIV response in South Africa.¹⁷ This study presents the first geographic analysis of youth and adults (≥ 15 years) who have ever been tested for HIV in South Africa using simple GIS mapping and data obtained from a cross-sectional nationally representative population-based survey.

The mapping results revealed that the uptake of HIV testing varied across the various districts in South Africa. The age and sex distribution across the districts were different. Studies have revealed that age and sex are crucial factors in HIV testing.^18,19 The estimates from a multilevel model with district-level random effects showed that excess probability of ever having tested for HIV was different among the districts after adjusting for age and sex. Variations in the quality of healthcare services, health promotion activities, easier access to healthcare facilities and socio-economic status could have an impact on the uptake of HIV testing in districts.

The overall proportion of people who had ever tested for HIV at the district level in South Africa ranged from 54.7% to 86.1%. uMkhanyakude and Ugu districts in KwaZulu-Natal and Vhembe district in Limpopo had the lowest overall testing coverage of < 62%. Ngaka Modiri Molema district in North West, and Lejwelepuswa and Thabo Mofutsanyane districts both in Free State reported the highest coverage for HIV testing. None of the districts in the Eastern Cape or Limpopo had an overall coverage of higher than 80%. These districts are characterised as being predominately rural. Other studies have also found that people living in rural informal or tribal areas were significantly less likely to test for HIV when compared with those from urban areas.^20,21 The finding that uptake of HIV testing was less likely amongst those in rural areas could be linked to limited resources and structural barriers to healthcare in terms of geographical and financial accessibility.^22,23 Additional barriers included fear, discrimination and stigmatising attitudes, as well as lack of education and awareness.²⁴

Another factor playing a major role in the higher coverage districts included the epidemic control plans implemented by the President’s Emergency Plan for AIDS Relief (PEPFAR), which aims to achieve maximum impact and reach in areas with the highest burden of disease (COP19). This is informed by population-based surveillance. The PEPFAR country operational plan (COP) for 2017, in 27 districts with an estimated number of people living with HIV of 5.6 million, which account for 79% of number of people living with HIV in South Africa (COP19), identified 1969 sites for intensified support as part of the country’s district-level implementation plan (DIP).²⁵ According to the National Strategic Plan for 2012–2016,²⁶ the objectives included maximising opportunities for testing and screening to ensure that everyone in South Africa got tested for HIV and was screened for TB. The overall investment for HTS programmes in 2016–2017 was $126 663 865.00, with the South African Government funding being 45% and PEPFAR funding 55% (COP-19).

Most districts had a higher coverage of ever having tested for HIV amongst female than male participants. uMkhanyakude and Ugu had the lowest coverage for female participants. Vhembe and uMkhanyakude had the lowest HIV testing coverage for male participants. Despite the countrywide scale-up, the observed geographic disparities in HIV testing are relevant from an epidemic control perspective, especially if the people who do not get tested are at higher risk of HIV infection.⁶ Therefore, achieving high coverage of HIV testing amongst men is critical in the fight against HIV in the country. However, data elsewhere suggest that boys and men are lagging.^27,28 Men were found to have lower levels of participation in HIV testing.²⁹ Some of these reasons include fear of damaging reputations, losing their masculine pride, fearing both community rejection and a loss of emotional control because of the psychological burden of knowing one was HIV positive.²⁹ HIV testing programmes, therefore, need to carefully review who is being reached by their services and implement interventions specifically tailored to engage people who might be missed.

There are various settings in which HTS can be provided to the public and expanded further, for instance in healthcare facilities, such as hospitals, clinics and mobile clinics, and at community sites, be these stand-alone or even home-based services, where testing services are provided within the community.² There is also an option for HIV self-testing (HIVST), which is carried out by an individual who wants to know his or her HIV status and is carried out privately by the individual alone.⁵ HIV self-testing provides an opportunity for testing to be carried out discreetly and at one’s convenience, which could increase the uptake of HIV testing amongst those unable or unwilling to access other healthcare services.² Concerns raised regarding HIVST include lack of HIV counselling,³⁰ instructions are difficult to follow³¹ and there should be more of a focus on linkage to care.³²

This research study has a few limitations. ‘Ever testing’ for HIV is self-reported, and therefore, prone to biases related to social desirability, recall and under-reporting. Nevertheless, the results of the nationally representative population-based survey can be generalised to adults aged 15 years and above who tested for HIV in South Africa. There may be a high degree of within-district heterogeneity. In future, work will include examining the sub-district level estimates applying the robust methodology of small area estimation, which involves using auxiliary predictors to improve the precision of imprecise district-level estimates.

This study demonstrated the utility of visually displaying spatial inequities in HIV testing using nationally representative data by presenting simple maps for targeted priority setting. The findings suggest that provinces and districts with low testing coverage, especially amongst male participants, should prioritise tailored interventions to improve uptake of HIV testing. The strategies for HTS should include scaling up of HIVST and community HIV testing, specifically home-based testing to improve the uptake of HIV testing in those districts that are lagging behind in order to ensure equity in the geographical coverage of HIV testing.