Effect of HIV-related knowledge on utilisation of voluntary HIV testing service among university students in Sub-Saharan Africa: a systematic review and meta-analysis protocol.

INTRODUCTION: Voluntary HIV testing is a vital preventive measure to reduce HIV transmission. Existing evidence on the association between HIV-related knowledge and HIV testing service utilisation shows inconsistent findings. Therefore, the aim of this review is to assess whether knowledge of HIV is related to improvement in voluntary HIV testing service utilisation among university students in Sub-Saharan Africa. METHODS AND ANALYSIS: A systematic review of studies on the association of HIV-related knowledge and voluntary HIV testing service utilisation among university students will be conducted. We will search several electronic databases, including PubMed/MEDLINE, African Journals Online, Web of Science and Cochrane Library, for all study types looking at the association between HIV-related knowledge and voluntary HIV testing service utilisation. Two reviewers will independently screen all retrieved records and full-text articles and extract data. The Higgins I2 test will be used to assess heterogeneity between studies. Random-effects meta-analysis will be conducted, if feasible and appropriate. Additional analyses will be performed to explore potential sources of heterogeneity. Stata statistical software (V.14) will be used to analyse the data. ETHICS AND DISSEMINATION: Formal ethical approval is not required because the systematic review relies on primary studies. The results will be disseminated through a peer-reviewed publication, conference presentation and the popular press. © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

This is a systematic review and meta-analysis of any epidemiological study design.

The methods described apply to reviews of any association between knowledge of HIV and HIV testing service utilisation.

The results will suggest concrete evidence on the importance of HIV education programmes in enhancing HIV testing uptake.

Exclusion of papers not published in English may mean that important additional findings are missed.

Introduction

HIV remains a major public health challenge worldwide. Globally, in 2018, about 37.9 million people living with HIV and the vast majority (57%) of people with HIV were found in Africa.1 In Sub-Saharan Africa (SSA), an area disproportionally affected by the HIV epidemic, young and adolescents are among the groups most vulnerable to HIV infection. In SSA, almost half of new HIV infections are among the youth age group (15–24 years).2

For young and adolescents, university campuses are spaces of sexual initiation and risky sexual behaviours (having multiple sex partners, premarital sexual debut and unprotected sex).3 4 A very recent study in Rwanda showed that 21% of university students had multiple sexual partners, 16% of students pay for sex and 10% receive payment for sex. Unfortunately, only 15% of sexually active students used condoms consistently.5 Similarly, in Ethiopia, risky sexual behaviours among college and university students are common.6 7 This risky behaviour significantly increases the incidence of HIV infection and unsafe abortion among the young and adolescent segment of the population.8–11 One of the effective strategies for facilitating behavioural change in HIV prevention among these vulnerable populations is voluntary counselling and testing of HIV.

HIV testing is an important preventive measure in reducing HIV transmission as well as in getting early access to care and support. However, recent worldwide evidence confirmed only 79% of HIV-infected people knew their HIV serostatus,1 which is far from the WHO target (to identify 90% of HIV-infected people in 2020).8 12 Similarly, majority of students at higher education institutions did not know their HIV serostatus even though they are classified as risky populations and vulnerable to HIV infections.13–17 Recent studies done in SSA indicated that only 14%–19% of adolescents have been tested for HIV.2 18 This suggests HIV testing service utilisation is low among the young and sexually active segments of populations. Voluntary HIV testing service utilisation has a significant outcome on adolescent and youth healthy sexual behaviour, including decrease in unprotected sexual intercourse, reduction in multiple partners, increase in condom use and more clients with negative results choosing abstinence.19

Although risky sexual behaviours and HIV infections are increasing in SSA, there is still a great reluctance among the youth to be tested for HIV.11 20 There are several possible contributing factors that must be addressed if HIV testing is to have an important role in HIV prevention and care. Therefore, understanding the determinants of HIV testing service utilisation will have significant public health importance in Ethiopia. Although several studies in Africa have reported on a wide variety of different barriers to HIV testing service utilisation, HIV-related knowledge is the most fundamental factor to intervene.

Multiple studies have demonstrated the impact of HIV-related knowledge on HIV testing practice. However, there was inconsistent finding on the association between HIV-related knowledge and HIV testing service utilisation across studies. Several studies identified HIV-related knowledge as facilitators for HIV testing service utilisation,21–23 but few studies reported that HIV-related knowledge was a barrier to accepting HIV testing.24 25 Hence, this systematic review and meta-analysis will serve as a synthesis of evidence on the effect of improvements in HIV-related knowledge on HIV testing service utilisation. Therefore, the main objective of this systematic review and meta-analysis is to assess the effect of good knowledge of HIV on voluntary HIV testing service utilisation.

Research question

Does improving knowledge of HIV prove to be effective in promoting the uptake of voluntary HIV testing services among university students in SSA?

Methods and analysis

Protocol registration and reporting

This systematic review protocol is reported per the reporting guidance provided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols criteria.

Eligibility criteria

Studies will be selected according to the following study characteristics: study design, participants, exposure/interventions, comparators and outcomes (PICO framework).

Study design

All epidemiological studies (cross-sectional, cohort, case–control) and interventional studies reporting the associations between HIV-related knowledge and voluntary HIV testing service utilisation will be included.

Population

We will include all types of university students in Africa irrespective of their age and type of university (public and private university).

Intervention/exposure

Studies assessing knowledge of HIV using all HIV knowledge measurement tools will be eligible. Different studies used different instruments for measuring HIV knowledge. We will include studies measuring knowledge of HIV using any questions about the modes of prevention and transmission, including unsafe sexual intercourse, unsafe blood transfusion, mother-to-child transmission, using contaminated sharp objects, and misconceptions such as eating together, shaking hands, mosquito bites and sharing toilets.26 27

Comparators

The comparator group will be students who had poor knowledge of HIV.

Outcome measure

The main outcome of interest will be utilisation of voluntary HIV testing service. We will include all studies examining utilisation of HIV testing service voluntarily after university admission.

There are no language restrictions to using and including articles in this study. If the language used in an article is other than English, we will ask for a translator to translate the article. We will include studies carried out in SSA. Articles that met the criteria will be considered irrespective of their publication status, that is, published, unpublished or grey literature.

Exclusion criteria

Eligible articles with unclear reporting of the association between HIV-related knowledge and voluntary HIV counselling and testing will be excluded. We will also exclude former reviews and articles presenting different parts of the same study.

Information source and search strategy

Relevant literature will be searched using electronic databases such as PubMed/MEDLINE, African Journals Online,28 Web of Science and Cochrane Library. To identify any additional unpublished work, grey literature will also be searched. Internet search using Google search engine and Google Scholar will also be conducted to look for relevant studies. We will perform hand searching of the reference lists of the included studies and relevant reviews to identify additional eligible papers. Every effort will be made to gather unpublished data when reports are available for full abstraction.

We will develop a search strategy using the following keywords in the research question: voluntary HIV counselling and testing, sexual and reproductive health service utilisation, HIV-related knowledge, university students, and Africa. For each key concept, appropriate free-text words and medical subject headings (MeSH) will be developed. To develop a final search strategy, an initial limited search of MEDLINE will be undertaken and then we will analyse the text words contained in the titles and abstracts and of the index terms used to describe each article. We will conduct search of both thesaurus terms and terms in the title and abstract fields and other appropriate fields that may be available. The free-text words and MeSH terms will be used separately and in combination using Boolean logic operators: AND and OR. A full draft of the search strategy for PubMed/MEDLINE is provided in the online supplemental additional file.

We will search PubMed/MEDLINE using the following terms: ((““Voluntary HIV counseling and testing” OR “HIV testing” OR “HIV testing*” OR “Voluntary HIV testing uptake” OR “Sexual and Reproductive Health Services” OR “Youth Friendly Reproductive Health Services”) AND (utilization OR use OR practice OR uptake) AND (“Knowledge on HIV” OR “HIV knowledge” OR Factors OR Determinants) AND (“University students “OR “Students”) AND (Africa OR “Sub-Saharan Africa”)).

Two independent reviewers (GD and MLE) will implement the electronic search strategy in the following electronic databases between 25 February 2021 and 25 September 2021: PubMed, African Journals Online, Web of Science and Cochrane Library.

Screening and selection procedure

All retrieved titles and abstracts of identified articles will be imported into the software EndNote V.X8 (Thomson Reuters). Two independent reviewers (GD and AA) will conduct a systematic and stepwise selection of eligible studies, that is, screening of titles, abstracts and full texts. When the reviewers disagree, the article will be re-evaluated and, if the disagreement persists, a third reviewer (MLE) will make a final decision. Potential conflicts between the two reviewers will be resolved after consultation with a third reviewer (MLE) from the study team. A flow diagram presenting the study selection process will be prepared.

Data collection process

Using a pretested data extraction format, necessary data will be extracted by two investigators (GD and AA) and imported to Excel (Microsoft Office Professional Plus, 2013). This step will be pretested with four articles to test for feasibility and completeness. Any disagreements between the two reviewers on the extraction of data will be settled through discussion and consensus. In addition, variations will be resolved by involving a third reviewer (MLE). Numerous main categories and individual data, including first author, country where the study was conducted, study design, year of publication, sample size and effect size (OR, relative risk), will be extracted from all eligible articles (table 1). Corresponding authors will be contacted when relevant information is missing.

Table 1

Data extracted from included articles

Categories	Data extracted
Study characteristics	First author
	Year of publication
	Country where the study was conducted
	Study design
Samples	Sample size
Assessment of exposure	Knowledge of HIV using all HIV knowledge measurements
Statistical analyses and reported results	Type of statistical methods and analyses
	Measures of the strength of associations between HIV-related knowledge and HIV testing service utilisation (OR, relative risk, with SE and 95% CI)
	P values
Control of confounders	Potential confounder variables

Outcome of interest

The outcome of this systematic review and meta-analysis will be the association between HIV-related knowledge and HIV testing service utilisation.

Risk of bias in individual studies (quality assessment)

To evaluate the quality of the included studies, we will use the Newcastle-Ottawa Quality Assessment Tool.29 Using the tool as a protocol, two independent reviewers will evaluate the quality of the original articles. Those studies with medium (fulfilling 50% of quality assessment criteria) and high (≥6 out of 10 scales) quality will be included for meta-analysis.

Statistical analysis

Necessary data will be extracted from studies using Microsoft Excel (2013) format and then analysed using Stata (V.14) software, respectively. First, we will present qualitative data on the included studies. Second, if an adequate number of high-quality studies are retrieved, we will summarise the data using forest plot. Heterogeneity across the studies will be assessed using I2 statistics.30 If substantial heterogeneity (I2 >50%) is detected across the studies, we will use a random-effect model to estimate the effect size based on DerSimonian and Laird.31 OR with 95% CI will be reported as an overall synthesised measure of effect size.

Meta-biases

Potential publication bias will be assessed subjectively by funnel plot (recommended when around 10 studies are included in the meta-analysis) and objectively using Egger’s regression test.

Confidence in cumulative evidence

The final results of the systematic review will be condensed in a Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profile. This table will contain the PICO question, the type and number of studies included, the number of participants in the studies, the effect sizes and their CIs, and the grading of the quality of evidence.

To evaluate the quality of the studies, we will use the Newcastle-Ottawa Quality Assessment Tool adapted to each study design. The tool has three indicators. The first section is graded out of five stars and assesses the quality of the methodology of a study. The second part of the tool is graded out of three stars and assesses the comparability of the studies. The last part of the tool is graded out of two stars and measures the quality of the original articles with respect to their statistical analyses. Using the tool as a protocol, two independent reviewers (GD and MLE) will evaluate the quality of the original articles. Studies with medium (fulfilling 50% of quality assessment criteria) and high (≥6 out of 10 scales) quality will be included for analysis.

Patient and public involvement statement

Patients were not directly involved in the design of this study. As this is a protocol for a systematic review, no participant recruitment will take place and participants will not be involved in the recruitment and dissemination of findings.

Discussion

HIV testing and counselling is one of the public health interventions to reduce new HIV infections in SSA, most importantly among vulnerable populations. This planned systematic review and meta-analysis will explore the evidence available on the association between HIV-related knowledge and HIV testing service utilisation among university students in Africa. By summarising information about the effect of HIV-related knowledge on the utilisation of voluntary HIV testing services, the findings will provide directions for future HIV education programmes. The results of our study may also have implications for HIV testing service improvements being planned by university higher officials.

Ethics and dissemination

This article does not contain any studies with human participants or animals performed by any of the authors because it relies on primary studies. The results will be disseminated through a peer-reviewed publication, conference presentation and the popular press.