Do men face greater barriers to accessing HIV testing services than women? Might HIV self-testing be the answer? Evidence from a longitudinal survey in east Zimbabwe (2018–2023)

HIV testing is crucial for prevention and treatment, yet barriers may disproportionately affect men in some sub-Saharan African settings. HIV self-testing (HIVST) may offer a promising solution, but its uptake remains under-explored. This study examines sex-specific barriers, HIV testing trends, and HIVST uptake in Manicaland, Zimbabwe, across three survey rounds pre-, during-, and post-COVID-19. We conducted longitudinal surveys 2018-2019 (pre- COVID-19), 2021 (during COVID-19), 2022-2023 (post-COVID-19), across six socio-economic zones (tea estates, rural villages, forestry areas, towns, roadside settlements, and urban areas) in eastern Zimbabwe. The study employed an open cohort design with repeated cross-sections, complemented by a sub-analysis among repeat participants to assess robustness. Data on socio-demographic characteristics, HIV testing, perceived barriers, and HIVST awareness and usage were analysed using generalized linear mixed-effects models. Men consistently had lower odds of HIV testing than women (2022-2023, aOR=0.74, 95% CI:0.67-0.81, P < 0.001). Barriers to HIV testing peaked during COVID-19 (2021), with men reporting three to five times higher barriers than women, including "judgmental staff" (24.5% vs. 4.7%, P = 0.005) and "lack of privacy" (21.5% vs. 5.1%, P = 0.032). Rural residents had reduced testing odds post-COVID-19 (aOR=0.82, 95% CI:0.69-0.99, P = 0.034). Although HIVST awareness increased, particularly among men compared to women, (66.7% vs 58.5%, aOR=2.21, 95% CI:2.09-2.33, P < 0.001), usage remained low (5.9%, vs 9.8%). Men report substantially greater barriers to HIV testing in Zimbabwe, exacerbated during the COVID-19 and are now further threatened by cuts to HIV funding. Although HIVST awareness expanded, its low uptake among men highlights the need for improved linkage-to-care mechanisms and tailored outreach such as peer-led distribution models.