Introduction

Globally, Human Immune Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) epidemic stage has been expanding at different times due to different risk factors that curb down the general productivity of the community, and the national economy [1].

Evidence showed that 71% of people living with HIV/AIDS found in Sub-Saharan Africa; among these women are more affected than men [2]. Ethiopia is one of the highly affected countries with HIV/AIDS pandemic as early as 1985 and the disease has spread at alarming rate throughout the country [3]. In Ethiopia in 2018 report, the prevalence of HIV among adults (15–49 years) was 1%, from this figure women account 63.08% [4].

A study done in New Jersey, United states of America (USA) showed that seroprevalence in unmarried couples were 0.55–0.62%. For this reason, voluntary HIV counseling and testing for marriage applicants is recommended [5]. As well in Africa, voluntary HIV counseling and testing has been acknowledged as cost-effective measure for the prevention and control of HIV [6, 7].

The government of Ethiopia has acceptedpremarital voluntary HIV counseling and testing, which is recommended by World Health Organizations (WHO), since it is one of the key elements in the prevention and control of HIV/AIDS in the country [8, 9]. Premarital voluntary HIV counseling and testing offers an opportunity where prospective couples can know their HIV status before marriage [8]. Therefore, it is one of the renowned strategies on preventing both heterosexual and vertical transmission of HIV [10–12].

According to Ethiopia demographic and health Survey (EDHS) 2016 report, the proportion of women and men who were ever tested for HIV increased from 2% for women and men in 2005 to 20% for women and 21% for men in 2011. However, the HIV testing coverage remains unchanged between 2011 and 2016. Furthermore, 24.5% of married women aged 15–49 ever tested before getting married or living with a partner [13].

Undeniably, women are particularly vulnerable to HIV infection because of increased biologic susceptibility to HIV transmission through heterosexual contact [14, 15]. Women are also at increased risk of HIV because they face a host of structural barriers and contextual gender inequalities such as poverty, economic disempowerment, cultural inequities, increased risk of sexual violence, and gender power imbalance in sexual interactions [16, 17].

A clinical trial study showed that about 65–85% of new infections are acquired from the married/cohabiting partner was due to HIV sero-discordant couples [18]. HIV positive individuals in sero-discordant marriages results in increased risk for HIV negative partners [19]. In the same vein, a study conducted in Zambia and Rwanda showed that an estimated 50% of new heterosexual HIV infections crop up among sero-discordant couples [20].

Various studies showed that being urban resident [21], having least stigmatizing attitudes [22, 23], attending secondary and higher education [22], women with aged 25–34 years and 35+ [21], being rich in wealth index, divorced/widowed [24], undergone sexual intercourse [24], drinking alcohol [25] were positively associated with premarital HIV testing. On the other hand, unable to read and write [24], being unemployed [26], were inversely related to premarital HIV testing.

Despite the aforementioned factors, different studies reveal inconsistent results; for instance, being older aged [26], urban resident [23], having comprehensive knowledge about HIV/AIDS [21], knowing the places for HIV testing [21], were less likely to be tested for HIV. However, a study done in Northeast Ethiopia showed that having comprehensive knowledge about HIV is risk factor for premarital HIV testing [24].

Step up prevention activities require a thorough understanding of the HIV epidemic character, modes of transmission and populations affected as these inform the extent to which evidence based modalities can be adapted and pooled to substantially reduce HIV transmission, which is critical in continuing the path to avert epidemic trajectory [27, 28].

In a nutshell, premarital testing is the best solution for prevention, care, treatment, and support services [29]. Make out and intervening thus factors enable for undertakes premarital HIV testing, which leads to trim down HIV acquisition among couples. Therefore, the endeavor of this study was to identify factors associated with premarital HIV testing among married women in Ethiopia.

Methods and materials

Results

Participant’s characteristics

A total of 9602 sub-sample of married women within the EDHS 2016 were included and analyzed. Majority of respondents (84.2%) were rural residents and 23.5% were found in the age range between 25–29 years. Regarding educational status, 61.8% of the respondents didn’t attend formal education. Only, 96.8% of married women’s didn’t have comprehensive knowledge about HIV, and 62.2% didn’t have access to media (Table 1).

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Table 1. Characteristics of respondents by premarital HIV testing (n = 9602).

https://doi.org/10.1371/journal.pone.0235830.t001

Factors associated with premarital HIV testing among married women in Ethiopia

All the variables were entered intomultivariate logistic regression analysis. After adjusting for potential confounders by logistic regression, being rural resident, education attainment (primary, secondary, higher), media access, being rich and richest, knowing the places for HIV testing, chewing khat, drinking alcohol, and having a discriminatory attitude towards PLHIV were positively associated with premarital HIV testing.

In this study, the odds of premarital HIV testing were 1.81[AOR: 1.81 (1.31–2.50)] times higher among urban compared to rural residents. Likewise, the odds of premarital HIV testing among women who attended primary, secondary, and higher education was 1.54[AOR:1.54(1.27–1.87)], 2.34[AOR:2.34(1.70–3.23)], 2.92[AOR:2.92(1.90–4.50) timeshigher compared to those who did not attend formal education respectively. In addition, the odds of premarital HIV testing were 1.44 times [AOR: 1.44(1.20–1.76)] higher among women who had media access than its counter parts. The odds of premarital HIV testing were 1.52[AOR: 1.52 (1.12–2.07)], and 1.67[AOR: 1.67(1.15–2.44)]times higher among women who had richer and richest wealth index category, compared to the poorest respectively.

The odds of premarital HIV testing were 4.95[AOR: 4.95 (3.44–7.11)] times higher among participants who had known the places for HIV testing compared to its counter parts.

The study revealed that the odds of premarital HIV testing were 1.47[AOR: 1.47 (1.23–1.76)] times higher among participants who had a discriminatory attitude to PLHIV than its counterparts. Moreover, the odds of premarital HIV testing were 1.60[AOR: 1.60 (1.11–2.31)], and 1.55[AOR: 1.55 (1.27–1.90)] times higher among khat chewer and alcohol drinker compared to their counterparts respectively (Table 2).

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Table 2. Multivariate analysis table for identifying factors associated with premarital HIV testing among married women in Ethiopia (n = 9602).

https://doi.org/10.1371/journal.pone.0235830.t002

Discussion

Premarital voluntary HIV counseling and testing is one of the well-known strategies for preventing both heterosexual and vertical transmission of HIV. This study aimed at identifying factors associated with premarital HIV testing among married women in Ethiopia.

In this study, premarital HIV testing was positively associated with residence, educational status, media access, wealth index, knowing the place for HIV testing, chewing khat, drinking alcohol, and having discriminatory attitude towards PLHIV.

Considering residence, women who were residing in urban area have higher odds to undertake premarital HIV testing. This finding is consistent with a study done in Malawi [21], and Nigeria [30, 31]. The reason for this may be better availability and accessibility of HIV testing facilities in urban settings.

The study further showed that women who were educated have higher odds to carry out premarital HIV testing. This finding is in line with a study conducted in Kenya [32] and Uganda [33]. This could be elucidated by educated women take care of HIV infection, as they easily understood both the transmission and prevention methods [33].

Regarding media access and wealth index, women who had media access and were richer and richest have higher odds to undertake premarital HIV testing. This could be expounded by the possibility that higher income for women enhances their status in the household, enables to be educated and can help to have better access to media easily without constraints [33].

Concerning the use of alcohol and khat, the proportion of women who consumed alcohol and chewed chat in Ethiopia in the last 30 days was 50% and 65%, respectively [13]. As well, the present study revealed that premarital HIV testing was higher among khat chewers and alcohol drinkers compared to their counterparts. This could be due to risky sexual behavior after alcohol and khat chewing. This may have increased perceived susceptibility to HIV which in turn leads them to be tested for HIV [34, 35, 36].

The odds of premarital HIV testing were higher among women who knew the place for HIV testing. This finding is contrasts with a study conducted in Gambela region, which is found in Ethiopia [23]. This discrepancy may be due to sample size variation, in which the current study was done based on nationally representative data. Surprisingly, the study revealed that the odds of premarital HIV testing were higher among participants who had discriminatory attitude towards PLHIV than its counterparts. This finding is contrasts with the studies conducted in Uganda [22], South Africa [37], Nigeria [38] and Gambela region, which is found in Ethiopia [23].

The strength of this analysis is that it was based on nationally representative data with a large sample size. However, we cannot assign causations to any of the associations between the identified factors and the outcomes of interest due to cross sectional data.

Conclusions

From the findings of the study, it is possible to conclude that being urban resident, attending education (primary, secondary, higher), having better media access, improved wealth index, knowing the places for HIV testing, chewing khat, drinking alcohol and having a discriminatory attitude towards PLHIV were positively associated with premarital HIV testing. The Ethiopian government needs to step up efforts to expand education for all women. Advancing access to HIV testing for rural women may also increase premarital HIV testing services uptake. Further qualitative researches need to be done to assess the relationship between discriminatory attitude towards PLHIV and premarital HIV testing.

Supporting information

Acknowledgments

We are grateful to the USAID–DHS program for providing access to the 2016 Ethiopian Demographic Health Survey