HIV self-testing uptake and associated factors among the general population of Botswana: Insights from the 2021 Botswana AIDS Impact Survey V (BAIS V)

In the landscape of public health, knowing one's status is the first step toward stopping the spread of HIV, a virus that remains a significant challenge in Botswana. While traditional testing involves visiting a clinic, waiting in line, and speaking with a counselor, a newer approach allows people to test themselves in private using a small kit. This method, known as HIV self-testing, offers a way to bypass the fear of stigma and the inconvenience of long waits, potentially reaching people who might otherwise avoid medical facilities. The goal is simple: if more people know their status, more can get treatment, and the virus can be contained. However, for this tool to work, people must actually use it. Understanding why some individuals reach for these kits while others do not is crucial for designing health systems that truly serve everyone.

Researchers turned to a massive, nationwide survey conducted in 2021 to investigate how many people in Botswana were actually using these self-test kits and what influenced their choices. They analyzed data from nearly 13,000 adults, looking closely at factors like where they lived, how much money they had, their education level, and their personal relationships. The picture that emerged was stark. Despite the availability of these kits, only a tiny fraction of the population—just 2.2 percent—had ever used one to test themselves for HIV. This low number suggests that while the idea of self-testing is known, the reality of using it remains out of reach for most people.

The study revealed that the ability to use these kits is deeply tied to a person's financial situation and education. Those with higher levels of education were far more likely to have used a self-test kit compared to those with no formal schooling. Similarly, wealth played a decisive role. People from richer households were significantly more likely to purchase and use a kit than those from poorer households. In fact, the distribution of kit usage was heavily skewed toward the wealthy, with the poorest households accounting for a very small slice of the people who had tested themselves. This pattern suggests that the cost of the kit, which must be paid for out of pocket, acts as a major barrier. For many, the price tag is simply too high, preventing them from accessing a service that could save their lives.

Beyond money and education, the researchers looked at how a person's life circumstances affected their decision to test. They found that individuals who had more than one sexual partner were more likely to use a self-test kit, perhaps because they perceived a higher risk of infection and sought a private way to check their status. Conversely, people who did not know their partner's HIV status were less likely to use the kit, a finding that hints at complex social dynamics or perhaps a lack of awareness about the risks involved. The location of a person's home also mattered; those living in cities were more likely to use the kits than those in rural areas. This likely reflects the reality that self-test kits are sold in specific facilities that are more common in urban centers, leaving rural residents with fewer options to obtain them.

The researchers also compared self-testing with the more traditional method of going to a clinic. While self-testing was rare, the vast majority of people—about 95 percent—reported that they had ever been tested for HIV at some point in their lives. Interestingly, the groups that were most likely to have ever tested were often different from those who bought a self-test kit. People from poorer backgrounds were more likely to have ever tested, likely because traditional testing services are widely available, whereas self-testing kits involve a direct cost. This contrast highlights a critical gap: the very people who might benefit most from the privacy and convenience of self-testing are often the ones who cannot afford it.

The study concludes that for self-testing to become a widespread tool for fighting HIV in Botswana, the financial barrier must be removed. The authors suggest that if the government includes these kits in a proposed national health insurance plan, it could protect families from the burden of out-of-pocket costs and ensure that everyone, regardless of their wealth, has access to this private testing option. Without such a change, the promise of self-testing will remain limited to those who can pay, leaving the most vulnerable populations behind. The data makes it clear that while the technology exists, the system needs to adapt to ensure it reaches the people who need it most.