title: A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa.
abstract: BACKGROUND
  Despite Sub-Saharan Africa (SSA) being the epicenter of the HIV epidemic, uptake of HIV testing is not optimal. While qualitative studies have been undertaken to investigate factors influencing uptake of HIV testing, systematic reviews to provide a more comprehensive understanding are lacking.
  
  
  METHODS
  Using Noblit and Hare's meta-ethnography method, we synthesised published qualitative research to understand factors enabling and deterring uptake of HIV testing in SSA. We identified 5,686 citations out of which 56 were selected for full text review and synthesised 42 papers from 13 countries using Malpass' notion of first-, second-, and third-order constructs.
  
  
  RESULTS
  The predominant factors enabling uptake of HIV testing are deterioration of physical health and/or death of sexual partner or child. The roll-out of various HIV testing initiatives such as 'opt-out' provider-initiated HIV testing and mobile HIV testing has improved uptake of HIV testing by being conveniently available and attenuating fear of HIV-related stigma and financial costs. Other enabling factors are availability of treatment and social network influence and support. Major barriers to uptake of HIV testing comprise perceived low risk of HIV infection, perceived health workers' inability to maintain confidentiality and fear of HIV-related stigma. While the increasingly wider availability of life-saving treatment in SSA is an incentive to test, the perceived psychological burden of living with HIV inhibits uptake of HIV testing. Other barriers are direct and indirect financial costs of accessing HIV testing, and gender inequality which undermines women's decision making autonomy about HIV testing. Despite differences across SSA, the findings suggest comparable factors influencing HIV testing.
  
  
  CONCLUSIONS
  Improving uptake of HIV testing requires addressing perception of low risk of HIV infection and perceived inability to live with HIV. There is also a need to continue addressing HIV-related stigma, which is intricately linked to individual economic support. Building confidence in the health system through improving delivery of health care and scaling up HIV testing strategies that attenuate social and economic costs of seeking HIV testing could also contribute towards increasing uptake of HIV testing in SSA.
authors.affiliation: Zambia AIDS-related TB Research Project, University of Zambia, Lusaka, Zambia. maurice.musheke@unibas.ch
authors.forename: Maurice
authors.initials: M
authors.lastname: Musheke
authors.forename: Harriet
authors.initials: H
authors.lastname: Ntalasha
authors.forename: Sara
authors.initials: S
authors.lastname: Gari
authors.forename: Oran
authors.initials: O
authors.lastname: McKenzie
authors.forename: Virginia
authors.initials: V
authors.lastname: Bond
authors.forename: Adriane
authors.initials: A
authors.lastname: Martin-Hilber
authors.forename: Sonja
authors.initials: S
authors.lastname: Merten
mesh_terms: D017954:Africa South of the Sahara; D015658:HIV Infections / Q000517:prevention & control*; D006297:Health Services Accessibility; D006801:Humans; D008403:Mass Screening / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012959:Socioeconomic Factors