# Socio-ecological model: Understanding facilitators and barriers to HIV testing and counseling uptake in sub-Saharan Africa – A systematic review

## TL;DR

This study explores what encourages or discourages HIV testing in sub-Saharan Africa, using a model that considers personal, social, and community factors.

## Contribution

The study applies the socio-ecological model to identify specific facilitators and barriers to HIV testing and counseling in sub-Saharan Africa.

## Key findings

- Interpersonal support is the most significant facilitator of HIV testing uptake.
- Fear of partner reactions and stigma are major barriers to testing.
- Community education and supportive healthcare settings improve testing participation.

## Abstract

This systematic review examined the facilitators and barriers to HTC uptake among adults in SSA using the socio-ecological model (SEM).

A systematic search of Google Scholar, PubMed, Scopus, Sociological Abstracts, PsycINFO and Europe PMC identified 114 HTC uptake studies in SSA from 2010 to 2023 of which 6 met the inclusion criteria. The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Individual level facilitators of HTC included high perceived HIV risk, privacy, higher education, and prior testing experience while low HIV knowledge, fear of positive results, stigma, and lack of confidence in self-testing were barriers. Interpersonal facilitators included partner and peer support, and peer normalization of testing, while barriers involved fear of partner reactions, trust concerns, and fear of unintentional disclosure. At the health system-level, facilitators included counseling, positive experiences with providers, and no discrimination while privacy concerns, stigma, and judgmental attitudes of healthcare workers hindered HTC uptake. The community-level barriers included misconceptions and stigma, whereas community-based education improved HTC uptake. At the policy level, cost was a barrier, but availability of self-testing facilitated uptake. The interpersonal factors presented the most significant facilitators (53.3 %), while the policy-level factors were the most significant barriers (57.1 %).

HTC uptake in SSA is shaped by intersecting SEM factors. Understanding these influences are essential for designing effective interventions to improve HTC uptake and linkage to care.

PROSPERO ID: CRD42024583105.

•Critical gaps in HIV prevention impede achievement of 95–95-95 goals.•Interpersonal support strongly boosts HIV testing uptake in Sub-Saharan Africa.•Community education reduces stigma and increases HIV testing participation.•Fear of partner reaction is a major barrier to voluntary HIV testing uptake.•Supportive healthcare settings encourage HIV testing and counseling.

Critical gaps in HIV prevention impede achievement of 95–95-95 goals.

Interpersonal support strongly boosts HIV testing uptake in Sub-Saharan Africa.

Community education reduces stigma and increases HIV testing participation.

Fear of partner reaction is a major barrier to voluntary HIV testing uptake.

Supportive healthcare settings encourage HIV testing and counseling.