HIV self-testing and clinician-administered testing in Southern Africa: a systematic review of programmatic outcomes.

OBJECTIVE

In 2024, an estimated 5.3 million of 40.8 million people with HIV (PWH) globally were unaware of their status, with Southern Africa bearing the highest regional burden. This review synthesizes programmatic evidence on HIV testing uptake, test positivity, and linkage to care across clinician-administered testing and HIVST in Southern Africa.

DESIGN

Systematic review with pooled programme-level outcomes analyses of HIV testing outcomes.

METHODS

Searches were conducted for studies published between 2020 and 2025 from Southern African countries using Medline, Embase and OVID Global Health. Eligible studies reported HIV positivity and optionally testing uptake or linkage to care. Pooled odds ratios were calculated to describe programme-level differences across testing modalities for testing uptake and linkage to care, while HIV positivity was analysed using a binomial generalized linear model, adjusting for country.

RESULTS

Forty-three studies encompassing 290 428 participants across eight Southern African countries were included. Programmes offering HIVST frequently reported higher testing uptake [pooled odds ratio (OR) = 1.34, 95% confidence interval (CI): 1.30-1.38, P  < 0.001], though estimates varied substantially by country and implementation context. Lower HIV positivity yields were reported in HIVST programmes compared with clinician-administered testing programmes (adjusted OR = 0.63, 95% CI: 0.54-0.75, P  < 0.001). Linkage to care following a positive result was also consistently lower in HIVST programmes (pooled OR = 0.036, 95% CI: 0.025-0.051, P  < 0.001).

CONCLUSION

Across real-world programmes in Southern Africa, HIVST is commonly characterized by high testing uptake but lower HIV positivity yield and linkage to care, relative to clinician-administered testing. Interpretation is limited by ecological comparisons and heterogeneity in outcome measurement. Future research should prioritize robust linkage to care management.