Introduction

Human Immunodeficiency Virus (HIV) remains a significant global public health concern with an estimated 40.8 million individuals reported living with HIV in 2024 [1]. The World Health Organization (WHO) African Region inhabited by 12% of the world’s population accounted for over two thirds of the global HIV burden [1]. In addition, approximately 630, 000 lives were lost due to HIV-related causes worldwide with 97% of these deaths occurring in developing nations, Sub-Saharan Africa being the primary region carrying a disproportionate burden [1]. As a result, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has considered an acceleration of response aimed at eliminating HIV by the year 2030. To achieve this, the 95-95-95 targets was formulated [2]. This target aims to ensure that, by 2030, 95% of people living with HIV know their serostatus, 95% of people diagnosed as HIV-positive receive antiretroviral treatment, and 95% of people on antiretroviral treatment have their viral load sustainably suppressed. Thus, access to screening remains the main element to be taken into account to achieve this objective [2]. HIV testing is therefore a fundamental approach that serves as a crucial initial step in the continuum of HIV care enabling individuals to become aware of their HIV status and to seek treatment and/or preventive care [2,3]. In 2024, the global HIV response was closer than ever to reaching these testing and treatment targets. Globally, an estimated 87% (69– > 98%) of all people living with HIV knew their HIV status, 89% (71– > 98%) of people who knew their HIV-positive status were receiving antiretroviral therapy, and 94% (75– > 98%) of people on treatment had a suppressed viral load [1].

While global trends show an increase in HIV prevalence and significant declines in AIDS-related deaths, largely due to the increase of antiretroviral treatment (ART), Botswana a country endemic to HIV with a prevalence of 20.8% exceeded all UNAIDS 95-95-95 targets at 95.1%, 98.0%, and 97.9% among adults (15–64 years) living with HIV. However, while the country’s overall goals are being met, the rates of HIV testing among those aged 15–24-year-old are concerning, as many young people particularly young women are unaware of their HIV stats with only 85% diagnosed (15% Unaware of their status), 83% on treatment, and 76% virally suppressed indicating a lag behind among this age group [4]. Additionally, a total of 4,120 people contracted new HIV infections in Botswana in 2024, with 27 percent of them reported to be adolescent girls aged between 15 and 24 [5]. This lack of epidemic control could be attributed to the low HIV testing participation among these age groups. This is substantiated by the fact that a relatively low proportion of young people received an HIV test within a 12-month period and that young people made up the largest proportion of those who tested positive that were unaware of their status [4]. This demographic is primarily composed of tertiary institutions, with Boitekanelo college being one of the private tertiary institutions in Botswana, hosting over 3000 students. However, no study has been conducted to identify predictors of HIV testing uptake, highlighting a gap in knowledge and population understanding in this area of research thus the aim/purpose of the study was to identify and predict barriers to HIV testing among adolescents and young adults in a private tertiary institution in Botswana.

Methods

Results

Socio-demographic profile of the participants

The study population had a mean age of 20.78 years (Standard deviation (SD):1.539) and a median age of 21 years (IQR: 20–22 years). On measures of symmetry, age mean, median, and mode showed a zero-skewness suggesting a perfectly symmetrical distribution. Over three quarter of the respondents, were in the age category of 20–24 accounting for 75.9% (n = 268) with females making up more than two third of the respondents (n = 243; 68.8%). On marital status, single participants made up the largest population (77.1%; n = 272) and more than two thirds (n = 223) of the participants travelled less than 5 km to access HIV testing centers. Public transport was the most popular form of transportation (44.5%; n = 157) followed by those walking with 51.8% (n = 183) least being those who travelled using private vehicles at 3.7%(n = 13). Christians dominated the religious spectrum with 95.1%(n = 336), those with moderate knowledge on HIV testing services constituted 87.8%(n = 310) while over one third of the participants reported to be having negative attitude (36.5%; 129), neutral attitude (39.1%;138) and positive attitude (24.2% (86%) towards HIV testing. On access to HIV testing information, 69.7% reported to have heard of it from school, health facilities (n = 54;15.3%), social media(n = 33;9.3%) and the least with 5.7%(n = 20) reported hearing about it from friends and families. Almost three fifths of the participants reported-risk behavior of unprotected sex (41.1%; n = 145), multiple concurrent partnership (5.9%; n = 21), touching blood (4.5%; n = 16) and a relatively small percentage sharing needles (1.1%; n = 4). (Table 1).

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Table 1. Socio demographic characteristics of survey respondents.

https://doi.org/10.1371/journal.pone.0352165.t001

Multivariable predictive modelling of barriers to HIV testing

Our study showed that participants who were engaged in casual relationships were 1.7 times significantly likely to not undergo HIV testing compared to those not in any relationship (AOR 1.776,95%CI 0.998–3.160, P < 0.049). The likelihood of not undergoing HIV testing was significantly higher among participants residing more than 5 km from HIV testing centers (AOR 1.825, 95% CI 1.074–3.103, P = 0.026) compared to those living within 5 km. Participants with negative attitudes toward HIV testing were 69% less likely to forgo HIV testing than those with positive attitudes (AOR 0.310, 95% CI 0.1704–3.103, P = 0.026). Age was also associated with testing behavior, with individuals aged 15–19 years exhibiting higher odds of not testing compared to those aged 20–24 years (AOR 1.607, 95% CI 0.894–2.888). Religious affiliation influenced testing uptake: participants identifying as Christian (AOR 2.347, 95% CI 0.188–29.295), Muslim (AOR 1.765, 95% CI 0.046–59.506), adherents of African traditional religions (AOR 1.718, 95% CI 0.084–35.004) were more likely not to take an HIV test compared to non-believers. Marital status and relationship type were also relevant, with cohabiting (AOR 3.45, 95% CI 0.271–43.979), single (AOR 2.018, 95% CI 0.166–24.499), and participants engaged in transactional relationships (AOR 1.098, 95% CI 0.189–6.382) demonstrating higher odds of not taking an HIV test in the preceding year. Additionally, sources of HIV testing information impacted uptake; participants who received HIV testing information via social media (AOR 3.334, 95% CI 0.755–14.721), school (AOR 1.878, 95% CI 0.508–6.945), or health facilities (AOR 1.714, 95% CI 0.273–4.767) were more likely not to undergo HIV testing. See Table 2.

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Table 2. Multivariable logistic regression analysis of factors associated with non-uptake of HIV testing among adolescents and young adults.

https://doi.org/10.1371/journal.pone.0352165.t002

Discussion

HIV testing is a fundamental strategy that acts as an essential first step in the continuum of HIV care, allowing individuals to be aware of their HIV status and seek treatment and/or preventive care [2,3]. However, Botswana’s HIV testing rates among those aged 15–24-year-old are alarming, with a substantial proportion of young people remaining untested, hampering the national and global prospects of ending HIV by 2030. We assessed predictors of barriers to HIV testing uptake among this age group which is critical for the effectiveness of HIV programs.

Approximately one-third (35%) of the youths in this study had not undergone HIV testing in the preceding year and were therefore unaware of their HIV status. This finding is consistent with the finding from other studies done in Ethiopia [10] and a demographic and Health Survey (DHS) data from four geographic regions of sub-Saharan Africa where 34.9% and 36.5% of youths were ever tested for HIV [11]. The study also revealed a notable difference in the HIV testing uptake among young people who live varying distances from HIV testing facilities. Young people who travelled more than 5 km were positively associated with the likelihood of not receiving an HIV test in the past 12 months. These findings expand on prior research that suggests an association between traveling a longer distance to HIV testing sites and lower likelihood of getting tested for HIV [12]. This is further corroborated by a nested, explanatory-sequential study in Uganda which revealed that, young people living >10km from the nearest HIV testing facility were less likely to have tested than those who lived closer to it (<5km) [13]. Previous studies have also found that distance restricts young people from accessing health care services including HIV testing services [14] suggesting that the distance required to travel to receive HIV screenings possibly due to living in areas with lower provider density, resulting in reduced frequency of HIV testing thus a major barrier to testing in this population [12].

Interestingly, this study also found that participants holding negative attitudes towards HIV testing were less likely to forgo HIV testing. This is contrary to the current literature, which states that more negative attitudes are associated with refusal of an HIV test or never having had an HIV test in sub-Saharan Africa [15], and that accepting an HIV test is associated with more positive attitudes towards testing [15]. This may be due to the fact that overall negative attitude score does not account for the weight of these individual attitudes in their decision making. However, this does not mean that these factors are not important considerations when planning to implement a testing program, they remain a fundamental part of the HIV testing process and likely play a role in the complex decision-making process around testing acceptance.

Adolescents had higher odds of not undergoing HIV testing than young adults. This concurs with previous studies showing increasing age associated with testing [16]. This is corroborated by an explanatory sequential study in Uganda that young people aged 20–24 years were more likely to test for HIV than those aged 15–19 year [13]. Possible explanations could be that young adults are more knowledgeable about the risks and importance of testing, especially since they are more likely to be sexually active or have more sexual experience than adolescents and age of consent to testing laws and that they have more autonomy and decision-making powers [16]. However, these findings are contrary to a cross-sectional study conducted in Uganda which found that adolescents aged 15–19 years had higher odds of HIV testing [17].

Our study also found an increased odds for not taking an HIV test among risky sexual behavior categories like casual and transactional relationships, this is similar to a study in western Kenya showing that HIV testing use was lower among partners who engaged in casual or transactional sex with an index client, compared to sexual encounters within relationships [18]. Additionally, a cross-sectional population-based survey conducted in KwaZulu-Natal, South Africa found people with higher risk sexual behavior to be significantly less likely to know their HIV-positive status and, among those aware, less likely to be virally suppressed [19]. This could be explained that risky behavior clients are likely to test for HIV primarily due to perceived low personal risk, fear of stigma and potential results, and a lack of consistent, accessible testing, all of which contribute to them not seeking testing services. They may also underestimate the prevalence of HIV among their peer groups.

Majority of participants in the current study discovered HIV testing at school, meaning that HIV testing information is given more at a school setting than other settings. This is supported by a systematic review and meta-analysis study conducted in sub-Saharan Africa pronouncing that, sexual health education delivered in a school setting aims to promote sexual health by ensuring that they educate students on the HIV testing uptake [20] therefore, those that are not attending school stand at a high chance of not being aware of HIV testing thus the low uptake of HIV testing among them [20]. Adolescents and young adults’ religions were also independently predicted their HIV test uptake; for Christianity, Muslim and African traditional religion followers, the odds of undergoing an HIV test were lower compared to non-believer youths. This is in concordance with an Ethiopian youth study revealing that, Muslim and other religion follower youths’ odds of getting HIV test were lower [10]. Additionally, this finding supports the finding from the study done among reproductive age Ethiopian women where Christian and Muslim women were less likely to accept HIV testing [21]. A possible explanation could be that shame-related HIV stigma is strongly associated with religious beliefs such as the belief that HIV is a punishment from God or that people living with HIV/AIDS (PLWHA) have not followed the Word of God [10]. Thus, the differences in beliefs and dogmas across different religions may be playing a role.

The likelihood of taking an HIV test was lower among single and cohabiting relationships compared to the married. This concurs with a cross-sectional retrospective analysis of HIV programs in Rwanda showing that, the likelihood of being tested was lower among cohabiting relationships compared to other contact-index relationships such as unknown/occasional sex partners, children, boyfriends or girlfriends, and others [22]. This could be due to the nature of the relationship between the index case and the contact, which is likely to be a single or cohabiting partner in cases with one or two contacts in the last 3 months. This relationship may lead the index partner to fear disclosing their HIV status to their partners or fear of stigma among single index clients and thus, reduce their chance of being tested for HIV [22]. Additionally, another study revealed that married youths and youths with another form of marital status, were nearly 5.37 and 4.60 times likely to get HIV test compared to their peer youths who are not in marital union [10]. Studies from Malawi [23], and Senegal [24] using secondary DHS data analyses also showed that ever-married women more likely accept HIV testing as compared to never-married women which are consistent with the findings from the current study.

Conclusion

This study highlights the need for health policy makers and other stakeholders to sustain current efforts by targeting adolescent’s and younger people aged 15–24 with customised interventions to address disparities in HIV testing uptake. These tailored interventions addressing key factors are crucial for enhancing testing accessibility, emphasizing awareness campaigns, proximal HIV testing service access, and targeted behavioural and education efforts. Targeting these groups in a timely manner is a crucial and necessary step not only for achieving the UNAIDS’ 95–95−95 targets but for individuals to benefit from early diagnosis, treatment and HIV prevention efforts to sustainably reduce population level HIV transmission.