This study analyses in-depth the uptake of HTC services among youth in Zambia, using nationally representative population-based survey data. We demonstrate an increase in uptake of HTC between 2007 and 2018, from 45–92% among pregnant women, 10–58% among non-pregnant women, and from 10–49% among men. Government health centres became the primary source of HIV testing by 2018, performing around 60% of all tests among youth. The percentage of tests delivered through mobile clinics almost doubled in all groups between 2013 and 2018 and accounted for one-third of all tests among adolescent boys. Multivariate analysis conducted for men and non-pregnant women showed higher odds of testing among young adults than adolescents (aOR = 1.55 among men and aOR = 1.74 among women). Circumcision and in a union were associated with higher odds of testing among men; whereas higher education and not reporting HIV-related stigma were predictors of testing among women. Inequity analyses mainly found an improvement in testing coverage in each sub-group of all inequality qualifiers by 2018, although the absolute difference in coverage was widened between the sub-groups for both genders. Education-based inequity was substantially increased among women than men by 2018.
The trend observed in this study for HTC uptake among youth demonstrates a considerable improvement over time in Zambia. Among pregnant women, the achievement could be related to the integration into ANC services since 2005 of a program of prevention of mother to child transmission of HIV (PMTCT), intensively promoted among pregnant women to ensure almost universal access to HTC around 2013 (39,40). The great level of attendance to ANC services among pregnant Zambian women was reported by the 2007 DHS (97% of women with at least one ANC visit) and maintained in 2013-14 and 2018 (roughly 98% for both reports); and was likely a contributing factor for inclusion of young women regardless of their age (41–43).
Regarding men, the promotion of couple HIV counselling and testing (CHCT) among partners of women attending ANC might be a factor to consider, especially considering that multivariate analysis in our study showed a high odds of testing among men in a union (44–46). In our results the voluntary medical male circumcision (VMMC) as part of the main predictors of HIV testing among young men suggests a potential contribution of the VMMC campaigns launched in 2012 in Zambia, and which reached more than 400,000 men by 2013 (47,48). Its scale-up in 2016, mainly through the mobile clinics, might explain the increase in the proportion of this source of delivery as reflected in our results for adolescent boys in 2018 (32% of testing through MC). The increasing proportion of HIV tests offered through MC observed in the study reflects an attempt of the Zambian government to reach underserved and hard-to-reach youth. In addition to the latter, other community-based strategies that are specific to youth should be explored given their promising results, such as adolescent-focused case finding implemented in Kenya and home-based HTC (49,50). HIV self-testing (HST) is also part of interventions in Zambia and has shown some acceptance and the potential to improve access to HIV testing (51–54). However, our study found that HST was unknown to most youth (85% and 80% among women and men, respectively). Its promotion, together with other community-based approaches, is to be encouraged given their potential to increase testing coverage, overcome stigma barriers, and contribute to reducing risky sexual behaviour (55–59). Concerns regarding their linkage to care for HIV positive cases should be adequately addressed if chosen to be implemented at a large scale.
The positive changes in testing uptake highlighted above among men and non-pregnant women have also been accompanied by a constant gap in the trend of HIV testing coverage between genders, with men being generally less well covered than women. Similar differences among youth were reported in Nigeria, Mozambique, and Uganda (60,61). The persistence of higher testing rates among non-pregnant women compared to men may be due to their higher demand of HTC services, caused by a greater perception of HIV risk resulting from their vulnerability and frequent exposures to sexual intercourse with older partners with whom they may have less control over condom use (8,62). Women of reproductive age are also generally reported to use primary healthcare more often than men, either for themselves or for their children (63,64). As a result, non-pregnant women remain more likely to be suggested an HIV test whenever they interact with health services as part of provider-initiated counselling and testing (PICT), which is widely implemented in government health facilities in Zambia (24,47,65). Moreover, it is possible that existing interventions that target youth, such as youth-friendly services (YFS), might be much more women-specific (66,67). Indeed, it has been shown that norms related to masculinity bring men to consider sexual health as a woman's domain, and therefore believe that it would be inappropriate for them (68). A recent scoping review focusing on the sub-Sahara African (SSA) region highlighted several other barriers to uptake of HTC among men that might be important to consider even for youth (69,70). Among the most common, we find poor knowledge of HIV, fear of testing positive, lack of confidentiality, and other aspects related to the quality of services. Therefore, increasing uptake of testing among young men will require the implementation of interventions that are young men-driven, needs-based, and beneficiary responsive, including implementation of decentralised service delivery models that capture young men in their safe spaces.
Our results showed adolescent girls (non-pregnant) and boys having a lower HIV testing uptake by 2018 (46% and 38%, respectively), compared to young adults. The persistence of this age-based gap in the trend analysis was observed in both multivariate and inequity analysis among both non-pregnant women and men. The proportions achieved in testing coverage among adolescents in 2018 are still far from the testing targets set by the Zambian Ministry of Health for this year (70% and 50% for adolescent girls and boys, respectively) (8). A recent study in Zambia and several other countries from the SSA region have also reported lower odds of testing among adolescents (19,32,60,61). Most supported the fact that older age is likely to confer more sexual experience and better knowledge of HIV, which may accordingly improve the perception of the risk and affect the need for HIV testing (19,71,72). Other barriers specific to adolescents include the legal age of consent to HIV testing, stigma, and sanctioning of sexual activity in adolescents; and are important to be highlighted to ensure that they are targets of future interventions that aim to improve coverage of testing among adolescents in Zambia (20,73,74). The ongoing mobilization in Zambia to revise the legal age of consent, currently at 16 years old, needs to be further supported and accelerated (8,66). Lowering the age of consent below 16 years old is associated with increased testing for adolescents (11% increase in national testing coverage, 95%CI:7.2–14.8%), as suggested in a systematic review that included several high burden countries (75,76).
Of the other determinants analysed, this study found strong evidence of higher odds of HIV testing among the most educated women, consistent with other studies on youth in the SSA region (19,32,60). The education-based inequity widened in the last survey, mostly among non-pregnant women, indicating the need to reach the least educated youths. Other sub-groups of disadvantaged young people who were identified from the inequity analysis require continual attention to ensure improvement of the testing coverage among youth in Zambia.
The results from this study suggest some critical actions from programme implementers and researchers to ensure better access to HTC for youth in Zambia. These include the scaling-up of mobile testing and strengthening of alternative community-based approaches such as HIV self-testing, which has shown some acceptance and potential to clients who are less easy to reach through the government health facilities. The development of gender-sensitive HTC services and less coercive strategies to sustain the gain in testing uptake among men in a union are also important to consider. Finally, the warning about barriers associated with the access to sexual health and HIV services through YFS in a recent study from Brazil (77), and the scarcity of evidence supporting the progress made since their introduction in Zambia, suggest that more research will help to demonstrate their contribution and yield.