HIV self-testing and clinician-administered testing in Southern Africa: a systematic review of programmatic outcomes

Objective In 2024, an estimated 5.3 million of 40.8 million people living with HIV (PLHIV) globally were unaware of their status, with Southern Africa bearing the highest regional burden. This review synthesises programmatic evidence on HIV testing uptake, test positivity, and linkage to care across clinician-administered testing and HIVST in Southern Africa. Design Systematic review with pooled programme-level outcomes analyses of HIV testing outcomes. Methods Searches were conducted for studies published between 2020 and 2025 from Southern African countries using Medline, Embase, and OVID Global Health. Eligible studies reported HIV positivity and optionally testing uptake or linkage to care. Pooled odds ratios were calculated to describe programme-level differences across testing modalities for testing uptake and linkage to care, while HIV positivity was analysed using a binomial generalised linear model, adjusting for country. Results 43 studies encompassing 290,428 participants across 8 Southern African countries were included. Programmes offering HIVST frequently reported higher testing uptake (pooled OR = 1.34, 95% CI: 1.30–1.38, p < 0.001), though estimates varied substantially by country and implementation context. Lower HIV positivity yields were reported in HIVST programmes compared with clinician-administered testing programmes (adjusted OR = 0.63, 95% CI:0.54–0.75, p < 0.001). Linkage to care following a positive result was also consistently lower in HIVST programmes (pooled OR = 0.036, 95% CI: 0.025–0.051, p < 0.001). Conclusion Across real-world programmes in Southern Africa, HIVST is commonly characterised by high testing uptake but lower HIV positivity yield and linkage to care, relative to clinician-administered testing. Interpretation is limited by ecological comparisons and heterogeneity in outcome measurement. Future research should prioritise robust linkage to care management.