Factors associated with HIV testing among young females; further analysis of the 2016 Ethiopian demographic and health survey data.

BACKGROUND: HIV counseling and testing are key to control and prevent the spread of the virus and improve the lives of people living with HIV. Although the risk of acquiring the virus is high, only 27% of young Ethiopian women age 15 to 24 years old were tested and counseled for HIV. This coverage is low to achieve the 90-90-90 goal. Identifying factors associated with low utilization of HIV testing and counseling services among young females (aged 15 to 24 years) is important to identify the barriers and improve uptake. Therefore, this analysis was done to identify factors associated with low utilization of HIV counseling and testing services among young Ethiopian women.
METHODS: The study used the 2016 Ethiopian demographic and health survey data. The data was downloaded from The DHS program with permission. A total of 2661 young women (aged 15 to 24 years) were included in the final model. Data was weighted to consider disproportionate sampling and non-response. A Complex data management technique was applied to consider the complex sampling technique used in the DHS. Multivariable logistic regression was used to identify factors associated with HIV testing among young women. RESULT: Among sexually active young women, 33.5% (95%CI; 30.1, 37.1) were tested for HIV. Young women who attended primary ((AOR 2.8; (95% CI; 2.0, 3.9)), secondary (AOR 4.7; (95% CI; 3.1, 7.3)) or higher education (AOR; 5.6; 95% CI; 2.6, 12.0), those who had multiple sexual partners (AOR 5.5; 95% (CI; 1.3, 23.3)), young women who ever used alcohol (AOR 1.46; 95% (CI; 1.1, 2.0)) and young women who visited health care facilities (AOR 1.8; (95% CI; 1.4, 2.3)) had higher odds of being tested for HIV. On the other hand, young women from the rural areas had lower odds (AOR 0.5; (95% CI; 0.3, 0.7)) of being tested for HIV.
CONCLUSION: HIV testing among sexually active young women in Ethiopia was low. Educational status, place of residence, alcohol intake, number of sexual partners and visiting health facility 12 months before the survey were found significant predictors of HIV testing. Therefore, the Ethiopian government should encourage girls to complete secondary education to improve HIV testing and counseling. Young women should be encouraged to visit health facilities to improve HIV testing service uptake.

Introduction

Globally, 36.5 million people were living with HIV. Every day 5,000 people are infected with the virus. Eastern and Southern Africa remained the most affected regions accounting for 53% of people living with HIV [1]. Among people living with HIV, 30% were young people aged 15 to 24 years [2]. Young women accounted for 64% of the total young people (aged 15 to 24 years) living with HIV. The problem is more severe in Sub-Saharan Africa (SSA) [3].

Young people are exposed to HIV at two points of their lives; at the early age of life (due to mother-to-child transmission) and during their adolescence (as a result of their sexual behaviors and gender disparities) [1]. Young women and girls aged 15 to 24 years are disproportionately affected by HIV because of economic, cultural and social disparities in the society [4-7].

HIV counseling and testing services are essential for HIV prevention, treatment, care, and support. In 2016, the United Nations declared to end AIDS at the end of 2020. The declaration endorsed the 90-90-90 target. Increasing access to and uptake of HIV testing is critical to achieve this target [8]. However, around 30% of people living with HIV were not aware of their HIV status globally in 2016 [9].

HIV testing and counseling services uptake among young women aged 15 to 24 years in SSA remained considerably low. Only 15% of them received HIV testing and counseling in 2013 [10]. Studies in Nigeria, Rwanda, Uganda, and Kenya indicated that only 12%, 40%, 26.5% 27.7% of young women were tested for HIV respectively [11-14].

Studies conducted in different parts of the world identified those young women (aged 20–24 years), those who attended primary or higher-level of education, those who were married, and young women with better socio-economic status (young women with middle, richer and richest wealth index) had higher odds of being tested for HIV. On the other hand, young women living in rural areas had lower odds of being tested for HIV [15-17]. Young women who had multiple sexual partners, those who ever had been pregnant, those who started sexual intercourse after 15 years old, those who had good knowledge about HIV, those who discussed about HIV with mother or female guardian, those who had history of sexually transmitted infections and those who attended antenatal care had higher odds of being tested for HIV [18-23].

Ethiopia is one of the Sub-Saharan countries affected by HIV. The government planned to end the epidemic at the end of 2030 [24, 25]. Besides, the ministry of health planned to end new infections among newborns at the end of 2020 [26]. But the HIV prevalence increased by 10% from 0.30/1000 population in 2008 to 0.33/1000 population in 2016 [27]. Although HIV counseling and testing was one of the strategies designed to achieve the 2020 goal (ending new HIV infections among newborns), only 36.4% of young women were tested for HIV [28].

Identifying factors associated with HIV testing will help to understand the bottlenecks for HIV prevention. Therefore, this analysis was done to identify factors associated with HIV testing among young women in Ethiopia. The information obtained from this analysis may be used by the ministry of health and other organization working on HIV prevention.

Methods and materials

Data

For this analysis, we used the 2016 Ethiopian demographic and health survey (EDHS) data. The 2016 EDHS was a community based, nationally representative data collected from January 18, 2016, to June 27, 2016. The data was collected by the Central Statistics Authority (CSA) and ICF international. The data were downloaded from The DHS program after permission. EDHS followed two stages stratified random sampling technique. A total of 15,683 reproductive age (15 to 49 years old) women were included in the survey. From these 6,401 were aged 15 to 24 years. Among these women, 2,661 had a history of sexual intercourse within 12 months before the survey. Only these women were included in the analysis because they were at risk of contracting HIV and to reduce recall bias.

Variables

The outcome variable for this study was HIV testing; a dichotomous variable coded as “1” when a young woman reported that she was tested for HIV in the last 12 months before the survey and “0” when she reported otherwise (never tested or tested before 12 months). All reproductive age women included in the survey were asked whether they were tested for HIV or not. The information about the dependent variable was generated from this question.

The independent variables were categorized into two groups; socio-demographic and behavioral. The socio-demographic variables were age, religion, residence, wealth index, educational status, marital status and work status at the time of the survey. Behavior related variables were discussion about HIV with mother or female guardian, history of pregnancy, age at first sexual debut, history of sexually transmitted infections, number of sexual partners, substance use and history of antenatal care.

Statistical analysis

Data analysis was done using STATA 15.1. After the data set was downloaded from The DHS program, the dependent and independent variables were identified. First, descriptive analysis was done for each variable. Bivariate regression analysis was done to examine associations between HIV testing and the selected predictor variables. Variables that were significant at P-value <0.2 in the bivariate model were included in the multivariable logistic regression model. Besides, multi-collinearity among predictor variables was assessed using the variance inflation factor before recruiting variables to the final mode. Multivariable logistic regression analysis was done to identify factors associated with the outcome variable after adjusting for potential confounders. We weighted the data when computing proportions to consider the non-response and disproportionate sampling used in the DHS sampling process. Since DHS used two stages stratified random sampling technique, complex data analysis techniques were employed when computing standard errors and confidence intervals.

Ethics approval and consent to participate

The 2016 EDHS protocol was reviewed and approved by the National Ethics Review Committee of the Federal Democratic Republic of Ethiopia, Ministry of Science and Technology and the Institutional Review Board of ICF International. Interviewers collected blood specimens from people who consented for HIV testing. The protocol for blood specimen collection and analysis was based on an anonymously linked protocol developed for the DHS Program. HIV test results were merged with the socio-demographic data collected in the individual questionnaires after the removal of all information that could potentially identify an individual. The data were anonymous when we accessed it. We received a permission letter from the DHS program to access and use the data.

Result

A total of 2661 young, sexually active women were included in the final model. One thousand eight hundred ninety-eight (73.3%) of the respondents were aged 20 to 24 years. One thousand two hundred thirteen (45.6%) of the respondents were Muslims in terms of religion, 985 (37.0%) of respondents were Orthodox region followers and 463(17.4%) of respondents were followers of Catholic, protestant and traditional religion. One thousand one hundred eighty-eight (44.6%) of the respondents attended primary education. Two thousand three hundred fifteen (87.0%) of the respondents were married. One thousand nine hundred twelve (75.8%) of the respondents were not working at the time of the survey. One thousand nine hundred thirty (72.5%) of the respondents were rural residents. Two thousand three hundred sixty-eight (89.0%) of the respondents reported that they started sexual intercourse before the age of 20. Three hundred thirteen (11.8%) respondents reported that their most recent sex was non-spousal. One thousand four hundred three (52.7%) respondents visited a health facility within 12 months before the survey. Eight hundred seven (30.3%) of the respondents reported that they had ever drunk alcohol. Twelve (3.5%) respondents reported that they had sex in return for gifts and cash (Table 1).

Table 1

Socio-demographic characteristic of young, sexually active women in Ethiopia, EDHS 2016 (N = 2661).

Characteristics	Number (%)
Age at the time of the survey
15 to 19	763 (28.7)
20 to 24	1898(73.3)
Educational status
No formal education	894(33.6)
Primary	1188(44.6)
Secondary	405(15.2)
Higher	174(6.5)
Marital status
Single	187(7.0)
Married or living in union	2315(87.0)
Other**	159(6.0)
Age at first birth
Before 20 years	1315(76.3)
At 20 and after years	410(23.8)
Wealth index
Poorest	813(30.6)
Poor	383(14.4)
Middle	345(13.0)
Richer	312(11.7)
Richest	808(30.3)
Residence
Urban	731(27.5)
Rural	1930(72.5)
Age at first sex
Before 20 years	2368(89.0)
At 20 and after years	293(11.0)
Numbers of lifetime sexual partners
One	2636(99.0)
More than one	25(1.0)
Visited health facility in the last 12 months before the survey
Yes	1403(52.72)
No	1258(47.28)
Chewed khat
No	2426(92.0)
Yes	235(8.83)
Ever drunk alcohol
No	1854(69.7)
Yes	807(30.3)

Other** = divorced and widowed

HIV testing

Among young women who had a history of sexual intercourse within the last 12 months, only 33.5% (95% CI; 30.1, 37.1) were tested for HIV. HIV testing among young women varied across regions. The proportion of young women tested for HIV from Amhara (9.76%), Oromia (9.38%) and SNNPR (5.74%) regions was high. On the other hand, the proportion of young women tested for HIV from Harari (0.13%), Gambela (0.2%) and Dire Dewa (0.3%) regions were low.

HIV testing by women characteristics

Among those tested for HIV, 26.2% were aged 15 to 19 years, 15.1% did not attend formal education, 81.7% were married or living in union, 46.2% were urban residents and 66.0% visited health facility within 12 months before the survey (Table 2).

Table 2

Characteristics of HIV tested, sexually active, young women in Ethiopia, EDHS 2016 (N = 1003).

Characteristics	Number (%)
Age at the time of the survey
15 to 19	263(26.2)
20 to 24	740(77.8)
Religion
Orthodox	505(50.4)
Muslim	327(32.6)
Other*	171(17.0)
Educational status
No formal education	151(15.1)
Primary	481(48.0)
Secondary	246(24.5)
Higher	125(12.5)
Marital status
Single	116(11.6)
Married or living in union	820(81.8)
Other**	67(6.6)
Age at first birth
Before 20 years	396(69.0)
At 20 and after years	178(31.0)
Working status at the time of the survey
No	648(64.6)
Yes	355(35.4)
Wealth index
Poorest	125(12.5)
Poor	121(12.1)
Middle	114(11.4)
Richer	136(13.6)
Richest	507(50.6)
Residence
Urban	463(46.2)
Rural	540(53.8)
Age at first sex
Before 20 years	841(83.9)
At 20 and after years	162(16.1)
Visited health facility within 12 months before the survey
Yes	662(66.0)
No	341(34.0)

Other* = Protestant, Catholic and traditional other** = divorced and widowed

Factors associated with HIV testing

Age at the time of the survey, educational status, age at first sex, marital status, residence, working status at the time of the survey, the number of sexual partners, history of alcohol uptake and health care facilities visit in the last 12 months before the survey were recruited to the multivariable logistic regression model. In the multivariable logistic regression model, the number of sexual partners, educational status, marital status, and residence, history of health facility visit 12 months before the survey and history of drinking alcohol were found significantly associated with HIV testing.

The odds of being tested for HIV among young women who attended primary and secondary education was 2.78 (AOR 2.78; (95% CI; 2.01, 3.87)) and 4.73 (AOR 4.73; (95% CI; 3.07, 7.29)) respectively higher compared to those who did not attend formal education. The odds of being tested for HIV among young women who were widowed, divorced and separated was 2.18 times higher compared to young single women (AOR 2.18; (95% CI; 1.01, 4.71)). Young women who were living in a rural areas had 63.0% (AOR 0.47; (95% CI; 0.31, 0.72)) lower odds of being tested for HIV compared to their urban counterparts.

The odds of being tested for HIV among sexually active, young women who had multiple sexual partners was 5.49 (AOR 5.49; 95% (CI; 1.29, 23.27)) times higher compared to young women who had one sexual partner. The odds of being tested for HIV among young women who ever had drunk alcohol was 1.46 (AOR 1.46; 95% (CI; 1.09, 1.98)) times higher compared to those who had not. The odds of being tested for HIV among young women who visited a health facility in 12 months before the survey was 1.78 (AOR 1.78; (95% CI; 1.36, 2.32)) times higher compared to those young women who never drunk (Table 3).

Table 3

Factors associated with HIV testing among sexually active, young women in Ethiopia, EDHS 2016 (N = 2661).

Variables	HIV test		COR (95% CI)	AOR (95% CI)
	Yes	No
Age at the time of the survey
15 to 19	263	500	1	1
20 to 24	740	1158	1.21(0.91, 1.61)	1.14(0.84, 1.56)
Educational status
No formal education	151	743	1	1
Primary education	481	707	2.95(2.13, 4.09)	2.78(1.01, 3.86)
Secondary education	246	159	6.88(4.39, 10.77)	4.73(3.07, 7.29)
Higher	125	49	10.05(5.09, 19.84)	5.55(2.56, 12.02)
Age at first sex
Before 20 years	841	131	1	1
At 20 and after	162	162	1.87(1.25, 2.80)	1.11(0.96, 1.78)
Marital status
Single	116	71	1	1
Married/ in union	820	1495	0.45(0.27, 0.77)	1.31(0.74, 2.35)
Other	67	92	0.73(0.34, 1.62)	2.18(1.01, 4.71)
Residence
Urban	463	268	1	1
Rural	540	1390	0.25(0.16, 0.38)	0.47(0.31, 0.72)
Working status at the time of survey
No	648	1264	1	1
Yes	355	394	1.72(1.26, 2.35)	1.12(0.80, 1.57)
Numbers of sexual partners
One	989	1647	1	1
More than one	14	11	7.44(2.23, 24.84)	5.49(1.29, 23.27)
Ever taken alcohol
No	617	1237	1	1
Yes	386	421	1.66(1.24, 2.23)	1.46(1.09, 1.98)
Visiting health facility in the last 12 months
No	341	917	1	1
Yes	662	741	2.03(1.57, 2.62)	1.77(1.36, 2.32)

Other = divorced and widowed

Discussion

The magnitude of HIV testing among sexually active young women (who had sexual intercourse 12 months before the survey) was 33.5% (95% CI; 30.1, 37.1). This finding was consistent with a study conducted in South Africa which showed that 32.7% of young females (aged 15–24 years) were tested for HIV [29]. However, the proportion of young women tested for HIV in this study was lower than studies conducted in Uganda (92%) [30], Karamoja region (81.8%) [31] and another study conducted in South Africa (60.1%) [16]. The reason for this difference might be the difference in the modalities the Uganda government used to reach the community for HIV counseling and testing (HCT). The Uganda government integrated HCT to routine health care service at all levels, expanded community outreach or mobile HCT services targeting the grass root level and hard to reach areas and gave strong emphasis on provider-initiated HCT to minimize missed opportunities [32]. Uganda is one of the few Sub-Saharan countries which effectively implemented a home-based HCT service which played a major role in expanding access to HCT [33]. The Ethiopian government may take this lesson to improve HIV testing service uptake in the country.

This study identified that young women who attended formal education had more odds of being tested for HIV. This finding was consistent with studies conducted in Tanzania [15, 34] and Nigeria [22, 23]. The reason for this is that education can improve HIV knowledge. Education also empowers women to make decisions to visit the health facility and use health services. Besides, education improves income among women which in turn increases health service use [35]. Strengthening the available initiatives to enable all Ethiopian girls to attend primary, secondary or higher level of education may help to improve HIV testing service uptake.

Young women who were living in rural areas had 53.0% lower odds of being tested for HIV compared to their urban counterparts. A similar conclusion was drawn from studies conducted in Ethiopia [36] and Nigeria [22, 23]. The reason for this may be better availability and accessibility of HIV testing facilities in urban settings [37]. Ethiopia should make HIV testing facilities and services more accessible to the rural community.

Young women with multiple sexual partners were more likely to be tested for HIV compared to those with one sexual partner. This finding was similar to studies conducted in Tanzania [15], Uganda [30] and Thailand [19]. This might be due to the fact that women with multiple sexual partners had a higher perceived risk of acquiring HIV. This, in turn, increases their motive to be tested [38]. Moreover, program planners and health professionals give emphasis to these women considering them high risk.

Young women who ever drunk alcohol had higher odds of being tested for HIV compared to women who never drank. This could be due to risky sexual behavior after alcohol. This may have increased perceived susceptibility to HIV which in turn leads them to be tested for HIV [39, 40].

This study showed that women who visited health facilities 12 months before the survey had more odds of being tested for HIV compared to young women who did not visit health facilities. This finding was similar to a study conducted in South Africa [29]. This might be due to the fact that health professionals initiate people who visited health facilities for HIV testing. The service is provided at all governmental and public health facilities in Ethiopia [41]. Ethiopia adopted provider-initiated counseling and testing (PICT) for all outpatient and inpatient clients [41, 42]. Encouraging young women to visit health facilities may increase HIV testing uptake.

The strength of this analysis is that it was based on nationally representative data with a large sample size. However, recall and social desirability biases may have affected the results. To reduce recall bias, we restricted the analysis to young women age 15 to 24 that had a history of sexual intercourse within the last 12 months before the survey.

Conclusion

HIV testing among sexually active young women in Ethiopia was low. Educational status, place of residence, history of alcohol intake, number of sexual partners and visiting health facility 12 months before the survey were found significant predictors of HIV testing among sexually active young women in Ethiopia. The Ethiopian government needs to intensify efforts to expand education for all girls. Improving access to HIV testing for rural women may also increase HIV testing services uptake. Besides, encouraging young women to visit Health facilities is important to increase the proportion of women tested for HIV and achieve the 90-90-90 target.

12 Dec 2019

PONE-D-19-32104

Factors associated with HIV testing among young females; further analysis of the 2016 Ethiopian Demographic and Health Survey.

PLOS ONE

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Section Comment, question, suggestion.

Abstract 1. Well summarised abstract.

2. Lacked quantifications of the problem, how low is low HIV testing in Ethiopia?

3. Regarding the knowledge gap:

o What are the advantages of us having this information? Who will benefit from the study being conducted and how?

o Limited information does not warrant a study to be conducted. The missing information has to be useful in some way to the study stakeholders.

4. Would be better to mention the age range. Who is considered to be a young woman for this study? 15-19 years? Or 15-24?

5. The conclusion summarized the results without any further recommendations.

o Recommendations are needed to show the implication of the study findings either to policy and/or to practice.

Introduction

Background 1. Throughout the entire background, entire paragraphs had only one citation on the last sentence. Please revisit citations.

2. It is still unclear who is a “young woman”. It is informative for the reader to have an age range earlier on in the paper.

3. For the paragraph concerning previously identified significant predictors;

o It would be more informative to mention the exact levels/categories which were found to be significant predictors e.g. Rural/urban? Which category was significant?

o It would also be informative to mention whether they are predictors of higher/lower odds of HIV testing.

4. And thereafter identifying the factors, how would the results be used? After these bottle-necks have been identified.

Methodology 1. Why only include women who were sexually active in the past 12 months into the study? Please provide an elaboration.

o The risk of HIV does not change regardless of the time since last sexual intercourse.

o Wouldn’t a more appropriate exclusion criteria be women who NEVER had sexual intercourse?

2. For the outcome definition;

o Why the focus on those who tested in past 12 months?

o Why not use if she EVER tested for HIV?

o Why are those who tested before 12 months considered as if they have never tested and coded as 0?

3. How was HIV knowledge measured?

4. Did you consider using alternatives to logistic regression if you identified the outcome of interest to be common? >10% prevalent.

5. “Bivariate regression analysis was done to examine associations between contraceptive use and the selected predictor variables”;

o Does this study measure contraceptive use OR HIV testing?

6. “In addition, correlation among predictor variables was assed using variance inflation factor before recruiting variables to the final mode.”

o What do you mean? Is it correlation or collinearity?

Results 1. For every table caption, please include N=???

2. For every variable in the tables with category “other”, please provide an explanation on who/what “other” means.

3. Did you consider life time sexual partners? Or those in the past 12 months? Please make clear.

4. What is chat? Concerning the variable “chewed chat”

5. The percentages presented in Table 3 are column percentages,

o Which means the interpretations should be “among those tested for HIV, 26.22% were aged 15-19”.

o Please revise the interpretation provided above.

Discussion Please apply these for the entire discussion section;

1. For each finding, it would be more informative to report numbers/findings that these previous studies reported. It would be informative to mention them in brief so the reader may compare.

2. What is the implication of each study finding? Are you recommending for the Ethiopian government to adopt a similar strategy to increase HIV testing as Uganda?

3. Discussing only similarities/differences of study findings is not enough. You need to go a step further and show the implications of this study findings to either policy or to practice.

Strengths and limitations 1. This section is missing from the paper

Conclusion + Recommendations 1. The conclusion provided a summary of the main results of the paper.

2. Please provide recommendations basing on the results of this study. How can these findings be applied to benefit the stakeholders of the study? The women, policy makers, government officials?

Reviewer #2: Manuscript Number: PONE-D-19-32104

Full Title: Factors associated with HIV testing among young females; further analysis of the 2016

Ethiopian Demographic and Health Survey.

Review Comments

The manuscript presents the very interesting and useful study that is very crucial to inform the improvement in HIV counselling and testing in Ethiopia and other sub-Saharan countries. The authors presented straight forward findings that are easy to follow. However, authors need to revise the manuscript per the below recommendations. The writing style, mainly on structuring the paragraphs, gramma and typos may need to be given more attention in the whole manuscript.

Abstract.

1. Well structured,

2. Few grammatical errors exist and one statements (e.g ….. those who ever had alcohol (AOR 1.46; 95% (CI; 1.09, 1.98)) and young women who visited health facility (AOR 1.78; (95% CI; 1.36, 2.32)) higher odds of being tested for HIV.) has a word missing

Background

3. Paragraph 3, last statement needs further elaboration to put context. It is unclear as to which population is represented by the 30 % of people living with HIV.

4. Citations need to be specific to the statements rather than lumping all the references to the last statement of the paragraph.

5. The last paragraph of introduction indicates that there are few studies, on factors associated with HIV testing among young women in Ethiopia. Unless the gap is identified in those studies, the current study is unjustifiable. The authors may need to present what those studies found and their gaps to justify why the current study is needed.

6. The authors may need to revise the whole introduction section and correct the grammatical, spelling, and space errors.

Methods and Materials

7. Statistical analysis needs to be described clearer. The authors indicate that “Bivariate regression analysis was done to examine associations between contraceptive use and the selected predictor variables. Contraceptive use was not listed as an outcome variable in the above section. Authors may need to check if this is correct.

8. The procedure for weighting the data to account for non-response and disproportionate sampling need to be transparently described.

Results

9. The results are well written; however, the authors may consider making the results more concise. It is possible to fuse tables 1 and 3; and 2 and 3 by considering that the numbers in table 3 are subsets of Tables 1 and 2.

10. The authors may also need to indicate which variables were adjusted in the multivariate model, what criteria were used for selecting such variables for adjusting and/or justification.

11. The data for crude odds ratio for rural residency in table 4 is missing

12. The authors may also want to reformat the Table 4 so that numbers separated by comma are spaced.

Discussion

13. The discussion has interpreted and compared the findings with the previous studies. However, the authors may need to restructure the discussion a bit, so they begin the section by summarizing what they found and later discussing the results.

14. Discussion of the methodological strengths and weaknesses/limitations of their study is missing

15. Although they found the factors associated with HIV testing among sexually active young women in Ethiopia, their discussion needs to translate and discuss the findings by relating to the real issues among young women in Ethiopia.

16. To improve the success of the HIV counselling and testing program, the authors need to indicate the implications for practice and further research.

**********

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Reviewer #1: Yes: Michael Johnson Mahande

Reviewer #2: Yes: MASIKA, Golden Mwakibo

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Submitted filename: Mahande_PONE-D-19-32104_MASHA_edit.docx

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10 Jan 2020

Point by point response

S/N Reviewers’ /editor’s comments Authors response

Editor’s comments

1. Typo in Reference 7, 10 correct spelling of "Organazation" Thank you for the comment. We correct the spellings of “organization” on the updated manuscript. (line number 35-and page numbers)

2. Ref 8, 9, 11, 14 - Please change from CAPS Thank you for the comment. We change CAPS on the updated manuscript. (line number 259 and page number 13)

3. Ref 16 - Not consistent with referencing guidelines. Has initial then surname. Please correct Thank you for the suggestion. We accept and amend the correction on the updated manuscript

(line number 310 and page number 13)

4. Ref 17, 18, 19, 20 is non-compliant with referencing guidelines. Please correct Thank you for the comment. We made correction and in line with the referencing guide line. (line numbers 314-322 and page number 14)

5. Ref 39: Who is the author? Thank you for the comment. We correct it “Hopkins J. Drinking and Risky Sexual Behavior 2015”

(line number 364 and page number 15)

Reviewer 1

Abstract section

1. Lacked quantifications of the problem, how low is low HIV testing in Ethiopia? Thank you for the comment. We quantified the problem specially in Ethiopia context

(line number 35 and page number 2 )

2. Regarding the knowledge gap:

a. What are the advantages of us having this information? Who will benefit from the study being conducted and how?

b. Limited information does not warrant a study to be conducted. The missing information has to be useful in some way to the study stakeholders. Thank you for the comment. We revised the introduction to show the importance of conducting the study. In the revision, we included beneficiaries of the study output. (line numbers 36-39 and page number 2)

3. Would be better to mention the age range. Who is considered to be a young woman for this study? 15-19 years? Or 15-24? Thank you for the suggestion. In this study young means those women’s whose age 15-24 years old. And this is included in the revised version. (line numbers 35, 37, 41-42 and page number 2)

4. The conclusion summarized the results without any further recommendations.

a. Recommendations are needed to show the implication of the study findings either to policy and/or to practice. Thank you for the suggestion. Based on your comment we incorporate recommendation on conclusion section.

(Line numbers 56-58 and page number 2)

Introduction section

1. Throughout the entire background, entire paragraphs had only one citation on the last sentence. Please revisit citations. Thank you for the comment. We revise and made correction on the updated manuscript

(line numbers 65- 107 and page numbers 3and 4)

2. It is still unclear who is a “young woman”. It is informative for the reader to have an age range earlier on in the paper. Thank you for the suggestion. A young woman means, a woman’s whose age between 15 -24 years old.

(line numbers 65-67,72,81 and page number 3)

3. For the paragraph concerning previously identified significant predictors;

o It would be more informative to mention the exact levels/categories which were found to be significant predictors e.g. Rural/urban? Which category was significant?

o It would also be informative to mention whether they are predictors of higher/lower odds of HIV testing. Thank you for the comment. Based on the comment we clearly mentioned the level and categories significantly associated with HIV testing.

(line numbers 86-94 and page numbers 3 and 4)

4. And thereafter identifying the factors, how would the results be used? After these bottle-necks have been identified. Thank you for the comment. The ministry of health and other organizations working on HIV may use to strengthen HIV prevention activities. This idea is included in the revised section of the manuscript.

(line numbers 103-107 and page number 4)

Methodology section

1. Why only include women who were sexually active in the past 12 months into the study? Please provide an elaboration.

o The risk of HIV does not change regardless of the time since last sexual intercourse.

o Wouldn’t a more appropriate exclusion criteria be women who NEVER had sexual intercourse?

Thank you for the comment. We included women who had history of sexual intercourse with in the last 12 months. This to reduce recall bias.

2. For the outcome definition;

o Why the focus on those who tested in past 12 months?

o Why not use if she EVER tested for HIV?

o Why are those who tested before 12 months considered as if they have never tested and coded as 0?

Thank you for the comment. We limited the analysis HIV testing for the last 12 months to see the most recent trend. We feel that the most recent information is more important than the earlier ones for HIV prevention. If sexually active, the testing information in the last year is more informative than history of testing before four years. In addition, most of the variables, for example, characteristics of women are at the time of survey. Since the data collection was cross-sectional, events that happened years before the time of survey may have different implications. For example, if we take age, and include young women who were tested 5 years before, the information about age will be quite different.

3. How was HIV knowledge measured?

Thank you for the suggestion. This variable was not included in the analysis. Now it is deleted. (line number 128 and page number 5)

4. Did you consider using alternatives to logistic regression if you identified the outcome of interest to be common? >10% prevalent.

Thank you for the comment. We did not consider because the outcome variable is binary. We feel that this is the best option.

5. “Bivariate regression analysis was done to examine associations between contraceptive use and the selected predictor variables”;

o Does this study measure contraceptive use OR HIV testing?

Thank you for the comment and we would like to say sorry for the silly mistake we made. It was to say “HIV testing”. Finally we made amendment on the updated manuscript (line number 135 and page number 5)

6. “In addition, correlation among predictor variables was assed using variance inflation factor before recruiting variables to the final mode.”

o What do you mean? Is it correlation or collinearity? Thank you the comment and We would like to say sorry again for made this silly mistake using “correlation” instead of “collinearity”. Finally we made amendment on the updated manuscript (line number 137 and page number 5)

Result section

1. For every table caption, please include N=??? Thank you for the suggestion. Based on the comment we included N in the entire table in the updated manuscript.

2. For every variable in the tables with category “other”, please provide an explanation on who/what “other” means. Thank you for the suggestion. Based on the recommendation we provided footnote explanation what “other” means.

3. Did you consider life time sexual partners? Or those in the past 12 months? Please make clear. Thank you for the comment. In this analysis we considered “life time sexual partners” not “those in the past 12 months”.

4. What is chat? Concerning the variable “chewed chat” Thank you for the constructive comment. Chat is a flowering plant native to the horn of Africa and Arabian Peninsula commonly called as “khat” but it’s commonly called as “chat” in our country Ethiopia. But to make it familiar we change “chat” in to “khat” in the updated manuscript.

5. The percentages presented in Table 3 are column percentages,

o Which means the interpretations should be “among those tested for HIV, 26.22% were aged 15-19”.

o Please revise the interpretation provided above. Thank you for the constructive comments. The interpretation is corrected now. The data for those aged 15 – 19 is presented in the table.

Discussion

Please apply these for the entire discussion section;

1. For each finding, it would be more informative to report numbers/findings that these previous studies reported. It would be informative to mention them in brief so the reader may compare. Thank you for the constructive comment. Based on your recommendation we incorporated the findings of each study on the updated manuscript.

(line numbers 204-208 and page number 10)

2. What is the implication of each study finding? Are you recommending for the Ethiopian government to adopt a similar strategy to increase HIV testing as Uganda? Thank you for the constructive comment. Based on the recommendation we incorporated the implications of each finding on the updated manuscript.

(line numbers 213 -2014 and page number 10)

3. Discussing only similarities/differences of study findings is not enough. You need to go a step further and show the implications of this study findings to either policy or to practice. Thank you for the constructive comment. Based on the recommendation we included the implications of each finding on the updated manuscript.

(line numbers 220 – 222, 226-227, 242-243 and page number 10)

Strength and limitation

1. This section is missing from the paper Thank you for the constructive comment. We included the limitation and strength in the updated manuscript.

(line numbers 244-247 and page number 11)

Conclusion and Recommendation section

1. Please provide recommendations basing on the results of this study. How can these findings be applied to benefit the stakeholders of the study? The women, policy makers, government officials? Thanks for the constructive comment. Based on your recommendation we included recommendation in the updated manuscript.

(line numbers 252-255 and page number 12)

Reviewer 2

Abstract

1. Few grammatical errors exist and one statements (e.g ….. those who ever had alcohol (AOR 1.46; 95% (CI; 1.09, 1.98)) and young women who visited health facility (AOR 1.78; (95% CI; 1.36, 2.32)) higher odds of being tested for HIV.) has a word missing Thank you for the comment. All grammatical errors and missing statements are corrected in the revised manuscript.

(line numbers 49-51 and page number)

Background

2. . Paragraph 3, last statement needs further elaboration to put context. It is unclear as to which population is represented by the 30 % of people living with HIV. Thank you for the comment. It is revised and made clear now.

(line numbers 78-79 and page number 3)

3. Citations need to be specific to the statements rather than lumping all the references to the last statement of the paragraph. Thank you for the constructive comments. The citations are revised the revised manuscript.

4. The last paragraph of introduction indicates that there are few studies, on factors associated with HIV testing among young women in Ethiopia. Unless the gap is identified in those studies, the current study is unjustifiable. The authors may need to present what those studies found and their gaps to justify why the current study is needed. Thank you for the suggestion, the paragraph is revised to show the existing gaps and the importance of the study

(line numbers 103- 107and page number 4)

5. The authors may need to revise the whole introduction section and correct the grammatical, spelling, and space errors.

Methods and Materials Thank you for the comment. We corrected the grammatical, spelling and spacing errors in the revised manuscript.

Methods

6. Statistical analysis needs to be described clearer. The authors indicate that “Bivariate regression analysis was done to examine associations between contraceptive use and the selected predictor variables. Contraceptive use was not listed as an outcome variable in the above section. Authors may need to check if this is correct. Thank you for the comment. We understood that we made editing errors. The dependent variable was HIV testing, not contraceptive use. Now, we revised it. (line numbers 134- 137 and page number 5)

7. The procedure for weighting the data to account for non-response and disproportionate sampling need to be transparently described. Thank you for the comment. EDHS takes stratified random sampling technique. Samples taken from some regions may be high and in other regions low. Therefore, DHS recommend data weighting to reduce the effect of over sampling or under sampling. The details can be find in the DHS website.

Results

8. The results are well written; however, the authors may consider making the results more concise. It is possible to fuse tables 1 and 3; and 2 and 3 by considering that the numbers in table 3 are subsets of Tables 1 and 2. Thank you for the comment. We merged table 1 and 2.

9. The authors may also need to indicate which variables were adjusted in the multivariate model, what criteria were used for selecting such variables for adjusting and/or justification. Thank you for the comment. All variables were which were not multicollinear were included to the multivariate logistic regression model

10. The data for crude odds ratio for rural residency in table 4 is missing Thank you for the comment. It is included in the revised version.

11. The authors may also want to reformat the Table 4 so that numbers separated by comma are spaced. Thank you for the comment. It is formatted now.

Discussion

12. The discussion has interpreted and compared the findings with the previous studies. However, the authors may need to restructure the discussion a bit, so they begin the section by summarizing what they found and later discussing the results. Thank you for the constructive comment. The discussion is revised now.

13. Discussion of the methodological strengths and weaknesses/limitations of their study is missing Thank you for the comment. It is included at the end of the discussion section in the revised manuscript. (line numbers 244-247 and page number 11 )

14. Although they found the factors associated with HIV testing among sexually active young women in Ethiopia, their discussion needs to translate and discuss the findings by relating to the real issues among young women in Ethiopia. Thank you for the comment.

We tried to translate the findings to the Ethiopian context

15. To improve the success of the HIV counseling and testing program, the authors need to indicate the implications for practice and further research. Thank you for the comment. We included recommendation in the revised section of the manuscript.

Submitted filename: Response to reviwers.docx

Click here for additional data file.

15 Jan 2020

PONE-D-19-32104R1

Factors associated with HIV testing among young females; further analysis of the 2016 Ethiopian Demographic and Health Survey.

PLOS ONE

Dear Mr Yibeltal Bekele,

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Additional Editor Comments (if provided):

The manuscript requires significant copyediting before acceptance. The language in its current form is not acceptable. I strongly suggest a fluent native speaker copyedits the document. There are several language errors through the whole document too numerous to recount. I am highlighting a few

Title page: Correspondent should read corresponding

Abstract Line 5. low HIV testing and counseling service use better written low utilization of HIV testing and counseling service

Introduction: Line 1 5,000 people were infected should be 5,000 people are infected

Line 3 disproportionally should be disproportionately

Intro 2nd para Line 1 and 2 "early life of transmitted from mother to child …… needs to rephrase. There are many more in the narrative

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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22 Jan 2020

Point by point response

1. The manuscript requires significant copyediting before acceptance.

Thank you for your suggestion. For addressing the issue we consulted senior public health staff and language professors in my university. We also used online softwares, specifically grammerly and scribens (check for correctness of spellings).

2. Title page: Correspondent should read corresponding

Thank you for your comment. Based on your comment we made amendment

3. Abstract Line 5. low HIV testing and counseling service use better written low utilization of HIV testing and counseling service

Thank you for your suggestion. Based on your suggestion we rewrite it.

4. Introduction: Line 1 5,000 people were infected should be 5,000 people are infected

Thank you for your suggestion. Based on your suggestion we rewrite it.

5. Line 3 disproportionally should be disproportionately

Thank you for your comment. We correct the spelling error on the updated manuscript.

6. Intro 2nd para Line 1 and 2 "early life of transmitted from mother to child …… needs to rephrase.

Thank you for your suggestion. Based on your suggestion we rewrite it.

7. There are many more in the narrative

Thank you for your comment. Based on your comment we revise the rest parts of the document.

Submitted filename: piont by piont response.docx

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24 Jan 2020

Factors associated with HIV testing among young females; further analysis of the 2016 Ethiopian demographic and health survey data

PONE-D-19-32104R2

Dear Mr Yibeltal Bekele,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

29 Jan 2020

PONE-D-19-32104R2

Factors associated with HIV testing among young females; further analysis of the 2016 Ethiopian demographic and health survey data

Dear Dr. Bekele:

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on behalf of

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PLOS ONE