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. 2020 Aug 3;15(8):e0235830. doi: 10.1371/journal.pone.0235830

Factors associated with premarital HIV testing among married women in Ethiopia

Mohammed Ahmed 1,*, Abdu Seid 2
Editor: Benn Sartorius3
PMCID: PMC7398550  PMID: 32745083

Abstract

Background

Premarital HIV testing is the key entry point in prevention, care, treatment, and support services, in which people learn their HIV status and its implications to make informed decisions about their health. This study was, therefore, conducted to identify factors associated with premarital HIV testing among married women in Ethiopia.

Methods

A cross-sectional study design was used, and secondary data analysis was done using 2016 Ethiopian demographic health survey (EDHS). Two-stage stratified cluster sampling technique was used. The data were analyzed by using SPSS version 20. Frequencies and weighted percentage of the variables, and second-order Rao-Scott statistic were computed. Multivariate logistic regression analysis was performed to control confounders and to identify predictors of premarital HIV testing. Adjusted odds ratio with 95% confidence interval was considered to declare statistically significant associations.

Result

The total sample comprised 9602 married women. In this study, the odds of premarital HIV testing were associated with being urban residents (AOR: 1.81; 95% CI: 2.74–5.20), attended primary education (AOR:1.54; 95%:1.27–1.87), secondary education (AOR:2.34; 95% CI:1.70–3.23), higher education (AOR:2.92; 95% CI:1.90–4.50), access to media (AOR: 1.44; 95% CI:1.20–1.76), being rich (AOR: 1.52; 95%CI:1.12–2.07), andrichest (AOR: 1.67;95%CI:1.15–2.44), known the place of HIV testing (AOR: 4.95; 95% CI:3.44–7.11), discriminatory attitude to PLHIV (AOR: 1.47; 95%CI:1.23–1.76), being khat chewer(AOR: 1.60;95%CI:1.11–2.31), and alcohol drinker (AOR: 1.55; 95% CI:1.27–1.90).

Conclusion

It is possible to conclude that being urban resident, attending education (primary, secondary, higher), media access, improved wealth index, knowing the places for HIV testing, chewing khat, drinking alcohol, and having 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.

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

Data

The current study uses secondary data from 2016 Ethiopia Demographic and Health Survey (EDHS). A detailed description of the study design and methodology of the 2016 is found elsewhere (13). A nationally representative sample was obtained based on a two-stage cluster sampling. The first and second stages involved the selection of the clusters and households in each cluster, respectively. Further, stratification by rural-urban areas was taken into account. This study was based on data from the Woman’s Questionnaire, which was administered to all women aged 15–49 in the selected households. The analytic sample for the current study consisted of married women aged 15–49 years (n = 9602).

Outcome of interest: Premarital HIV testing

The main outcome of interest was self-reported history of premarital HIV testing among married women (yes/no). The independent variables were selected based on literature review which deemed to be the factors associated with premarital HIV testing and includes age, education status, type of residence, occupation, wealth index, media access, knowing the places for HIV testing, comprehensive knowledge about HIV, discriminatory attitude to PLHIV, khat chewing, and alcohol drinking.

Comprehensive knowledge about HIV/AIDS was defined based on a widely used measure where each woman was asked whether or not she agreed or disagreed with the following five items: (1) Consistent use of condoms during sexual intercourse can reduce the chance of getting HIV; (2) having just one uninfected faithful partner can reduce the chance of getting HIV; (3) Healthy-looking person can have HIV; (4) HIV can be transmitted by mosquito bites; and (5) a person can become infected by sharing food with a person who has HIV. An additive summary score was created and which was then dichotomized to create a binary variable with 0 indicating at least one incorrect response and 1 to indicate correct response to five items.

Media exposure was defined based on response to how often respondents read a newspaper, listened to the radio, or watched television. Those who responded at least once a week to any of these sources were considered to have access to media/media exposure.

Discriminatory attitudes towards people living with HIV (PLHIV) was defined based on the response to two items: (1)Would not buy fresh vegetables from a shopkeeper or vendor if they knew that person had HIV (yes/no); (2)Children living with HIV should not be allowed to attend school with children who do not have HIV(yes/no). Respondents having discriminatory attitudes towards PLHIV are those who responded yes for the above questions otherwise not.

Statistical analysis

The data were analyzed by using Statistical Package for Social Science (SPSS) version 20. All statistical procedures incorporated complex sampling design analysis applied in the 2016 EDHS. Frequencies and weighted percentage of study variables were calculated. Rao–Scott chi-square test was used to examine the relationship between premarital HIV testing and each of the independent variables. Multivariate logistic regression analysis was performed to control confounders and to identify independent predictors about premarital HIV testing. All independent variables were entered in the multivariate logistic regression model irrespective of the p-values in the bivariate analysis. Adjusted odds ratio (AOR) with 95% confidence interval was used to declare statistically significant associations.

Ethics approval and consent to participate

Ethical clearance for the study is not required since it is secondary data analysis from EDHS 2016 data base. The researchers have received the survey data from USAID–DHS program and then the researchers of this study have maintained the confidentiality of the data.

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).

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

Variables Category Overall Premarital HIV testing p-value
No Yes
n(wt.%) n (wt. %) n (wt. %)
Residence Urban 2369(15.8) 1109 (9.1) 1260(37.1) p<0.001
Rural 7233(84.2) 6033(90.9) 1200(62.9)
Age 15–19 641(5.7) 433(5.1) 208(7.5) p<0.001
20–24 1725(16.5) 1091(14.0) 634(24.6)
25–29 2189(23.5) 1470(21.1) 719(31.1)
30–34 1814(20.1) 1355(20.5) 459(19)
35–39 1536(15.8) 1289(17.7) 247(9.8)
40–44 1006(10.5) 889(12.4) 117(4.6)
45–49 691(7.8) 615(9.2) 76 (3.4)
Educational status No education 5625(61.8) 4948(70.4) 677(34.8) p<0.001
Primary 2621(28.1) 1708(25.0) 916(37.8)
Secondary 839(6.2) 338(3.1) 501(15.8)
Higher 517(3.9) 151(1.5) 366(11.5)
Occupation Unemployed 5273(52.0) 4117(53.7) 1156(46.7) p<0.001
Agricultural 1890(23.5) 1580(25.4) 310(17.6)
Non-agricultural 2439(24.5) 1445(20.9) 994(35.7)
Access to media No 5799(62.2) 5025(69.6) 774(38.6) p<0.001
Yes 3803(37.8) 2117(30.4) 1686(61.4)
Wealth index Poorest 2880(19.2) 2598(22.3) 282(9.3) p<0.001
Poorer 1474(20.4) 1248(22.8) 226(12.7)
Middle 1342(20.3) 1083(21.7) 259(18.7)
Richer 1289(19.6) 983(19.6) 306(19.6)
Richest 2617(20.5) 1230(13.5) 1387(42.5)
Comprehensive knowledge about HIV No 9396(96.8) 6974(96.5) 2422(97.5) 0.132
Yes 206(3.2) 168 (3.5) 38 (2.5)
Know the places to HIV testing No 1872(25.7) 1789(32.6) 83 (5.7) p<0.001
Yes 6810(74.3) 4470(67.4) 2340 (94.3)
Discriminatory attitude No 6521(74.2) 5463(81.1) 1058 (52.4) p<0.001
Yes 3081(25.8) 1679(18.9) 1402 (47.6)
Chewing khat No 8493(85.2) 6336(84.8) 2156(86.6)  0.406
Yes 1109(14.8) 805(15.2) 304(13.4)
Alcohol drinking No 6651(65.4) 5232(68.2) 1419(56.9)  p<0.001
Yes 2951(34.6) 1910(31.8) 1041(43.1)
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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).

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

Variables Category Premarital HIV testing COR(95%CI) AOR(95%CI)
No Yes
n (wt. %) n (wt. %)
Residence Urban 1109 (9.1) 1260 (37.1) 5.89(4.72–7.35) 1.81(1.31–2.50)*
Rural 6033 (90.9) 1200 (62.9) Ref Ref
Age 15–19 433 (5.1) 208 (7.5) Ref Ref
20–24 1091 (14.0) 634 (24.6) 1.19(0.91–1.56) 0.87(0.63–1.20)
25–29 1470 (21.1) 719 (31.1) 1.00(0.76–1.31) 0.74(0.53–1.03)
30–34 1355 (20.5) 459 (19) 0.63(0.47–0.83) 0.48(0.32–0.70)
35–39 1289 (17.7) 247 (9.8) 0.37(0.27–0.52) 0.26(0.18–0.39)
40–44 889 (12.4) 117(4.6) 0.25(0.17–0.36) 0.17(0.10–0.28)
45–49 615 (9.2) 76 (3.4) 0.24(0.16–0.39) 0.18(0.01–0.34)
Educational status No education 4948 (70.4) 677(34.8) Ref Ref
Primary 1708 (25.0) 916(37.8) 3.06(2.58–3.63) 1.54(1.27–1.87)*
Secondary 338 (3.1) 501(15.8) 10.2(7.77–13.3) 2.34(1.70–3.23)*
Higher 151 (1.5) 366(11.5) 15.7(11.0–22.3) 2.92(1.90–4.50)*
Occupation Unemployed 4117 (53.7) 1156(46.7) Ref Ref
Agricultural 1580(25.4) 310(17.6) 0.79(0.65–0.98) 0.98(0.77–1.22)
Non-agricultural 1445(20.9) 994(35.7) 1.96(1.59–2.41) 0.97(0.79–1.19)
Access to media No 5025(69.6) 774(38.6) Ref Ref
Yes 2117(30.4) 1686(61.4) 3.64(3.06–4.32) 1.44(1.20–1.76)*
Wealth index Poorest 2598(22.3) 282(9.3) Ref Ref
Poorer 1248(22.8) 226(12.7) 1.34(1.02–1.76) 1.05(0.77–1.42)
Middle 1083(21.7) 259(18.7) 1.74(1.32–2.30) 1.26(0.94–1.71)
Richer 983(19.6) 306(19.6) 2.40(1.85–3.13) 1.52(1.12–2.07)*
Richest 1230(13.5) 1387(42.5) 7.54(5.71–9.94) 1.67(1.15–2.44)*
Comprehensive knowledge about HIV No 6974(96.5) 2422(97.5) Ref Ref
Yes 168 (3.5) 38 (2.5) 0.70(0.44–1.11) 1.27(0.80–2.02)
Know place to HIV testing No 1789(32.6) 83 (5.7) Ref Ref
Yes 4470(67.4) 2340 (94.3) 7.94(5.58–11.3) 4.95 (3.44–7.11)*
Discriminatory attitude No 5463(81.1) 1058 (52.4) Ref Ref
Yes 1679(18.9) 1402 (47.6) 3.90(3.29–4.61) 1.47 (1.23–1.76)*
Chewing khat No 6336(84.8) 2156(86.6) Ref Ref
Yes 805(15.2) 304(13.4) 0.86(0.61–1.22) 1.60 (1.11–2.31)*
Alcohol drinking No 5232(68.2) 1419(56.9) Ref Ref
Yes 1910(31.8) 1041(43.1) 1.62(1.34–1.96) 1.55 (1.27–1.90)*
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Ref- reference category AOR: Adjusted Odds ratio; COR: Crude Odds Ratio; * P-value < 0.05

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

S1 Checklist. STROBE statement—checklist of items that should be included in reports of cross-sectional studies.

(DOC)

Click here for additional data file. (152.5KB, doc)

Acknowledgments

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

Data Availability

For this analysis, we used the USAID–DHS program 2016 Ethiopian demographic and health survey data set. To request the same or different data for another purpose, a new research project request should be submitted to the DHS program here: https://dhsprogram.com/data/Access-Instructions.cfm. The DHS Program will normally review all data requests within 24 – 48 hours (during working days) and provide notification if access has been granted, or if additional project information is needed before access can be granted. After receiving permission, the researcher can login and select the specific data in the format they prefer.

Funding Statement

The author(s) received no specific funding for this work

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Decision Letter 0

Benn Sartorius

15 Apr 2020

PONE-D-20-03022

Factors associated with premarital HIV testing among married women in Ethiopia.

PLOS ONE

Dear Mr Ahmed,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by May 30 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

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Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Benn Sartorius, PhD

Academic Editor

PLOS ONE

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1. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

https://www.unaids.org/en/regionscountries/countries/ethiopia

https://www.benthamopen.com/FULLTEXT/TOAIDJ-10-34

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

2. Please refrain from stating p values as 0.000, either report the exact value or employ the format p<0.001.

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Please ensure that the revised manuscript is sent for a full professional English proofread.

Please include a completed STROBE checklist as part of the supplementary material for this article.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is an important topic and the analysis is solid. The manuscript, however, needs extensive editing for English. It is not publishable in its current state.

Other concerns to address:

• Include the URL of where the original data can be accessed as per PLOS ONE guidelines

• Add background information about premarital HIV testing. Is it required? Is it encouraged? If so, by whom, how and to what extent? In general, what percent of women undergo premarital HIV testing, and what percent of men (to compare)? Is premarital HIV testing an important imperative of the Ministry of Health?

• Add information about gender-related factors in Ethiopia. While HIV prevalence is higher for women, what gender-related factors account for that? Are women more likely to be tested than men? Are women more at risk of contracting HIV due to gender-normative behavior?

• The Discussion section should be fleshed out more. For example, testing rates are higher among urban residents (it appears that part of your paragraph is missing). Could this be because they have better/closer/easier access to testing facilities? Is stigma lower in urban areas leading more women to be tested? How common is khat-chewing, in general, in Ethiopia? How common is it among women, compared to men? More context needs to be provided. Why is it a social activity? Why do people, particularly women, chew khat? Relatedly, how common is alcohol consumption among women in Ethiopia? Where is the Gambela region referenced in the Discussion section? And, your explanation as to why Gambela is different is unclear (English needs editing) – not sure what you’re trying to say. While fleshing out this section, include how the findings are relevant to more literature.

• Your conclusion states that rural residents were positively associated with HIV testing, while throughout the paper, you state it is urban residents. Review paper carefully for consistency (cleaning up the English will help with clarity). Can you offer concrete ideas for policymakers? How to target poor or uneducated women, etc.?

Reviewer #2: Thank you for the opportunity to review this manuscript. I believe the manuscript has the potential to contribute to the body of literature related to HIV testing in both rural Africa. I think the essence of your argument based on your findings is that people are understanding their risks and are going for testing. This however, is not clear in the arguments that you make. And so in terms of how you then phrase your argument, it would appear that going for testing is a bad thing which I don't believe is what you intend.

The discussion section is relatively short and void of the substance I was looking for in my review. For instance, what distinguishes urban dwellers from rural dwellers when it comes to HIV testing based on your findings? The conclusion was also not adequately developed.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 Aug 3;15(8):e0235830. doi: 10.1371/journal.pone.0235830.r002

Author response to Decision Letter 0

14 May 2020

Thank you very much for PLOS one editorial office, academic editors, as well as reviewers of this manuscript entitled with factors associated with premarital HIV testing among married women in Ethiopia for their astonished effort.

The written documents below explained point by point response for respective editors and reviewers

Academic editor’s comments and respective author response

Editors comment 1. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

https://www.unaids.org/en/regionscountries/countries/ethiopia

https://www.benthamopen.com/FULLTEXT/TOAIDJ-10-34

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

Author response: based on the comments, the authors modified the overlapped text in the manuscript.

Editors comment 2. Please refrain from stating p values as 0.000, either report the exact value or employ the format p<0.001.

Author response: all p-value result in the manuscript which have a value of 0.000 were corrected as p<0.001.

Editors comment 3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Author response: For this analysis, we used the USAID–DHS program 2016 Ethiopian demographic and health survey data set. To request the same or different data for another purpose, a new research project request should be submitted to the DHS program here: https://dhsprogram.com/data/Access-Instructions.cfm. The DHS Program will normally review all data requests within 24 – 48 hours (during working days) and provide notification if access has been granted, or additional project information is needed before access can be granted. After receiving permission, the researcher can login and select the specific data in the format they prefer.

Editors comment 4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Author response: the corresponding author linked his ORCID to editorial manager.

Editors comment 5. Your ethics statement must appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please also ensure that your ethics statement is included in your manuscript, as the ethics section of your online submission will not be published alongside your manuscript.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Author Response: the ethics statement is moved in the methods section of the manuscript based on the comments.

Additional Editor Comments (if provided):

Editors comment : Please ensure that the revised manuscript is sent for a full professional English proofread.

Author response: revised manuscript was sent for full professional English for proof read by English language expert.

Editor comment: Please include a completed STROBE checklist as part of the supplementary material for this article.

Author response: STROBE checklist as part of the supplementary material for this article was attached.

Reviewer 1 comments and respective author response

This is an important topic and the analysis is solid. The manuscript, however, needs extensive editing for English. It is not publishable in its current state.

Reviewer comment 1: Include the URL of where the original data can be accessed as per PLOS ONE guidelines

Author response: For this analysis, we used the USAID–DHS program 2016 Ethiopian demographic and health survey data set. To request the same or different data for another purpose, a new research project request should be submitted to the DHS program here: https://dhsprogram.com/data/Access-Instructions.cfm. The DHS Program will normally review all data requests within 24 – 48 hours (during working days) and provide notification if access has been granted, or additional project information is needed before access can be granted. After receiving permission, the researcher can login and select the specific data in the format they prefer.

Reviewer comment 1: Add background information about premarital HIV testing. Is it required? Is it encouraged? If so, by whom, how and to what extent? In general, what percent of women undergo premarital HIV testing, and what percent of men (to compare)? Is premarital HIV testing an important imperative of the Ministry of Health?

Author response: Background information about premarital HIV testing is included in the revised manuscript. According to EDHS 2016 report, 24.5 % of married women age 15-49 ever tested before getting married or living with a partner but the men data about premarital HIV testing is not found for comparison. The ministry of health has accepted premarital 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 and included in the revised manuscript.

Reviewer comment 2: Add information about gender-related factors in Ethiopia. While HIV prevalence is higher for women, what gender-related factors account for that? Are women more likely to be tested than men? Are women more at risk of contracting HIV due to gender-normative behavior?

Author response: information about gender-related factors affecting women to be at risk for HIV is included in the background. For instance, women are particularly vulnerable to HIV infection because of increased biologic susceptibility to HIV transmission through heterosexual sexual contact .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.

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. The above information’s were narrated and included in the introduction section of the manuscript.

Reviewer comment 3: The Discussion section should be fleshed out more. For example, testing rates are higher among urban residents (it appears that part of your paragraph is missing). Could this be because they have better/closer/easier access to testing facilities? Is stigma lower in urban areas leading more women to be tested? How common is khat-chewing, in general, in Ethiopia? How common is it among women, compared to men? More co ntext needs to be provided. Why is it a social activity? Why do people, particularly women, chew khat? Relatedly, how common is alcohol consumption among women in Ethiopia? Where is the Gambela region referenced in the Discussion section? And, your explanation as to why Gambela is different is unclear (English needs editing) – not sure what you’re trying to say. While fleshing out this section, include how the findings are relevant to more literature.

Author response: The discussion part is well narrated based on the comment which is provided for the authors. Considering residence, women who were residing in urban area have higher odds to undertake premarital HIV testing. The reason for this may be better availability and accessibility of HIV testing facilities in urban settings. Considering alcohol and khat chewing, according to EDHS 2016 report, the proportion of women who consumed alcohol and chewed chat in Ethiopia in the last 30 days was 50% and 65 %, respectively. As well, the present study revealed that premarital HIV testing was higher among khat chewer and alcohol drinker 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.

Regarding the Gambela region, it is one of 9 regions found in Ethiopia. The explanation for the discrepancy may be due to sample size variation, in which the current study was done based on nationally representative data. The study done in Gambela was region specific, which have small sample size. The above information is included more in the revised manuscript attached.

Reviewer comment 4: Your conclusion states that rural residents were positively associated with HIV testing, while throughout the paper, you state it is urban residents. Review paper carefully for consistency (cleaning up the English will help with clarity). Can you offer concrete ideas for policymakers? How to target poor or uneducated women, etc.?

Author response: the authors amended the conclusions based on the result consistently.

Regarding poor or uneducated women, the Ethiopian government needs to step up efforts to expand education for all Women.

Reviewer #2 comments and respective author response:

Reviewer comment 1: Thank you for the opportunity to review this manuscript. I believe the manuscript has the potential to contribute to the body of literature related to HIV testing in both rural Africa. I think the essence of your argument based on your findings is that people understand their risks and are going for testing. This however, is not clear in the arguments that you make. And so in terms of how you then phrase your argument, it would appear that going for testing is a bad thing which I don't believe is what you intend.

Author response: Generally, premarital testing is the best solution for prevention, care, treatment, and support services. 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. the above amended argument is included in the revised manuscript attached.

Reviewer comment 2: The discussion section is relatively short and void of the substance I was looking for in my review. For instance, what distinguishes urban dwellers from rural dwellers when it comes to HIV testing based on your findings? The conclusion was also not adequately developed.

Author response: The discussion part is well narrated based on the comment which is provided for the authors. Considering residence, women who were residing in urban area have higher odds to undertake premarital HIV testing. The reason for this may be better availability and accessibility of HIV testing facilities in urban settings. The conclusion is adequately developed based on the comments and incorporated in the revised manuscript.

Attachment

Submitted filename: response to reviewers.docx

Click here for additional data file. (29.9KB, docx)

Decision Letter 1

Benn Sartorius

8 Jun 2020

PONE-D-20-03022R1

Factors associated with premarital HIV testing among married women in Ethiopia.

PLOS ONE

Dear Dr. Ahmed,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 23 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Benn Sartorius, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: As per PLOS ONE instructions, the authors need to "Describe where the data may be found in

full sentences." They provide this information in their response to the reviewer's comments, but it is not provided in the article submission. The manuscript continues to require editing for English.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 Aug 3;15(8):e0235830. doi: 10.1371/journal.pone.0235830.r004

Author response to Decision Letter 1

10 Jun 2020

Thank you very much for PLOS one editorial office, academic editors, as well as reviewers of this manuscript entitled with factors associated with premarital HIV testing among married women in Ethiopia for their astonished effort.

The written documents below explained point by point response for respective editors and reviewers

Reviewer 1 comments for authors:

As per PLOS instructions the authors need to “describe where the data maybe found in full sentences” they provide this information in their response to the reviewer’s comments, but it is not provided in the article submission”. The manuscript continues to require to editing for English.

Author response: For this analysis, we used the USAID–DHS program 2016 Ethiopian demographic and health survey data set. To request the same or different data for another purpose, a new research project request should be submitted to the DHS program here: https://dhsprogram.com/data/Access-Instructions.cfm. The DHS Program will normally review all data requests within 24 – 48 hours (during working days) and provide notification if access has been granted, or additional project information is needed before access can be granted. After receiving permission, the researcher can login and select the specific data in the format they prefer. The above information is included and attached in the revised manuscript.

The English language, grammar and spelling errors were corrected by linguist.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (22.1KB, docx)

Decision Letter 2

Benn Sartorius

24 Jun 2020

Factors associated with premarital HIV testing among married women in Ethiopia.

PONE-D-20-03022R2

Dear Dr. Ahmed,

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

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Acceptance letter

Benn Sartorius

30 Jun 2020

PONE-D-20-03022R2

Factors associated with premarital HIV testing among married women in Ethiopia.

Dear Dr. Ahmed:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Benn Sartorius

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. STROBE statement—checklist of items that should be included in reports of cross-sectional studies.

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    Data Availability Statement

    For this analysis, we used the USAID–DHS program 2016 Ethiopian demographic and health survey data set. To request the same or different data for another purpose, a new research project request should be submitted to the DHS program here: https://dhsprogram.com/data/Access-Instructions.cfm. The DHS Program will normally review all data requests within 24 – 48 hours (during working days) and provide notification if access has been granted, or if additional project information is needed before access can be granted. After receiving permission, the researcher can login and select the specific data in the format they prefer.

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