Heri et al.

BMC Public Health (2021) 21:456

https://doi.org/10.1186/s12889-021-10472-x

RESEARCH ARTICLE Open Access

Changes over time in HIV testing and

counselling uptake and associated factors
among youth in Zambia: a cross-sectional
analysis of demographic and health surveys
from 2007 to 2018
Aimé Bitakuya Heri1, Francesca L. Cavallaro2, Nurilign Ahmed3, Maurice Mubuyaeta Musheke4 and
Mitsuaki Matsui1*

Abstract
Introduction: Zambia is among the countries with the highest HIV burden and where youth remain disproportionally
affected. Access to HIV testing and counselling (HTC) is a crucial step to ensure the reduction of HIV transmission. This
study examines the changes that occurred between 2007 and 2018 in access to HTC, inequities in testing uptake, and
determinants of HTC uptake among youth.
Methods: We carried out repeated cross-sectional analyses using three Zambian Demographic and Health Surveys
(2007, 2013–14, and 2018). We calculated the percentage of women and men ages 15–24 years old who were tested for
HIV in the last 12 months. We analysed inequity in HTC coverage using indicators of absolute inequality. We performed
bivariate and multivariate logistic regression analyses to identify predictors of HTC uptake in the last 12 months.
Results: HIV testing uptake increased between 2007 and 2018, from 45 to 92% among pregnant women, 10 to 58%
among non-pregnant women, and from 10 to 49% among men. By 2018 roughly 60% of youth tested in the past 12
months used a government health centre. Mobile clinics were the second most common source reaching up to 32%
among adolescent boys by 2018. Multivariate analysis conducted among men and non-pregnant women showed higher
odds of testing among 20–24 year-olds than adolescents (aOR = 1.55 [95%CI:1.30–1.84], among men; and aOR = 1.74
[1.40–2.15] among women). Among men, being circumcised (aOR = 1.57 [1.32–1.88]) and in a union (aOR = 2.44 [1.83–
3.25]) were associated with increased odds of testing. For women greater odds of testing were associated with higher
levels of education (aOR = 6.97 [2.82–17.19]). Education-based inequity was considerably widened among women than
men by 2018.
(Continued on next page)

* Correspondence: [email protected]
1
Department of Global Health, Nagasaki University School of Tropical
Medicine and Global Health, Sakamoto 1-12-4, Nagasaki 852-8523, Japan
Full list of author information is available at the end of the article

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Heri et al. BMC Public Health (2021) 21:456 Page 2 of 18

(Continued from previous page)

Conclusion: HTC uptake among Zambian youth improved considerably by 2018 and reached 65 and 49% tested in the
last 12 months for women and men, respectively. However, achieving the goal of 95% envisioned by 2020 will require
sustaining the success gained through government health centres, and scaling up the community-led approaches that
have proven acceptable and effective in reaching young men and adolescent girls who are less easy to reach through
the government facilities.
Keywords: HIV/AIDS, HTC, HIV testing, 90–90-90, Youth, Adolescents, Sub-Saharan Africa, Zambia, Demographic
health survey

Background point of this cascade of HIV care and the means through
HIV/AIDS remains a leading cause of death in low- and which the first step of the 90–90-90 UNAIDS goal can
middle-income countries (LMICs), with around 663,000 be achieved [18–20]. Unfortunately, the use of HTC ser-
deaths estimated in 2019 [1, 2]. In the sub-Sahara African vices has generally been reported to be low among youth
region, home to more than two-thirds (25.7 million) of in Zambia, and several barriers to accessing these ser-
people living with HIV globally, HIV/AIDS is the fourth vices have been highlighted [21–24]. In alignment with
leading cause of death [2]. The remarkable scale-up of ac- the UNAIDS fast-track strategy, the Zambian govern-
cess to HIV prevention and care services made in the past ment launched the HTC Implementation Plan (2014–
two decades, through multiple global health initiatives 16), which aimed to achieve by 2015 50% HTC coverage
such as the Global Fund to Fight Tuberculosis, HIV/AIDS, among adults for testing and receipt of the results in the
and Malaria (GFATM), and the United States President’s last 12 months, to guarantee that the country remains
Emergency Plan for AIDS Relief (PEPFAR) [3], has led to on track with the 2020 targets [25]. The ongoing current
a significant reduction in morbidity and mortality due to National AIDS Strategic Framework (NASF) 2017–2021
HIV/AIDS in affected populations [2]. Despite the overall remained aligned with the UNAIDS 90–90-90 global
progress, only minor declines in new HIV infections have strategy and integrated the priority given to adolescents
been observed among young people in high-burden coun- and young people [10]; such that the related HTC guide-
tries, especially for adolescent girls and young women [4, lines recommended for adolescents (10–19 years) and
5]. Youth (15–24 years) still account for over 30% of new adults who are sexually active or with unknown HIV sta-
HIV infections each year globally [6]. tus to undertake a serological HIV test at first contact
Zambia faces a generalised HIV epidemic with an esti- with health services, 3 months later if they were negative
mated prevalence of 11% among adults (15–49 years), for the first test, and repeat the test every 6 months [26,
which ranks it among the ten most affected countries 27].
globally [7, 8]. Among 48,000 estimated new infections To our knowledge, no study has investigated
in 2018, 39% were youth; of which more than two-thirds changes in HTC uptake among youth in Zambia after
were women [9]. National data show that around 90% of the launch of the 90–90-90 fast track targets and
these HIV infections are the result of unprotected het- youth-specific global initiatives (“ALL IN Initiative”
erosexual intercourse [10]. Individual and contextual and “THREE fast-track”), which were launched to
drivers are thought to be among the main contributors boost the HIV response toward this population [28,
of transmission including biological, behavioural, cul- 29]. Moreover, the uncertainty around achieving the
tural, socio-economic, and legal factors [10–14]. HIV 2020 goals for HIV/AIDS-related morbidity and mor-
prevention programs that comprehensively address these tality among youth reflects the challenges in accessing
drivers are required to achieve substantial change in the HIV prevention and treatment services and highlights
incidence of infection, with a cascade HIV care approach the importance of understanding who is, and who is
being key to the reduction of HIV transmission [15, 16]. not accessing the first step of the cascade of HIV care
In 2014, UNAIDS launched a fast-track global strategy - HTC - and associated factors, to help refine control
to end the HIV epidemic by 2030, central to which is strategies and maximise the impact of future interven-
the 90–90-90 cascade goals; namely, aiming to ensure tions [6].
that 90% of people living with HIV know their status, The objectives of this study were to examine changes
90% of those in HIV care are initiated on antiretroviral in uptake of HTC among youth between 2007 and 2018,
therapy (ART), and 90% of those on ART achieve viral to explore inequity in testing uptake over time, and to
load suppression by 2020 [17]. HIV testing and counsel- identify the determinants of HTC among young women
ling (HTC) services are therefore critical for the reduc- and men ages 15–24 years-old in Zambia.
tion of new infections because they constitute the entry
Heri et al. BMC Public Health (2021) 21:456 Page 3 of 18

Methods Data analysis

Data source and study population For each survey we calculated the percentage of respon-
This study used three datasets from the 2007, 2013–14, dents tested for HIV in the last 12 months who received
and 2018 Zambian Demographic Health Surveys (DHS). results; for adolescents (15–19), and young (20–24)
The Zambia Statistics Agency conducts these nationally women and men separately. To examine the extent of an
representative, population-based surveys using a strati- antenatal care (ANC) session as a contributing factor in
fied two-stage cluster sampling method [7, 24]. In this higher testing rates among women, we separated them
study, we included all women and men respondents ages into non-pregnant and pregnant groups. The testing up-
15–24 years old, regardless of reported sexual activity. take for pregnant women considered those who had a
birth in the last 12 months and received their test as part
of ANC. The source of HTC (in the last 12 months) was
Outcome variable also described for each survey and each age group of
The primary outcome of interest was respondents women and men, separately. The numbers of annual
reporting that they had been tested for HIV in the last tests conducted through each testing source were esti-
12 months and received the results. mated by multiplying the percentage of tests reported
per source multiplied by the estimated population of
young women and men obtained from the World Bank
Determinants of HIV testing population projections [37]; separately for adolescents
Potential determinants of HIV testing and counselling and young adults of each gender.
were selected based on Andersen’s behavioural model We examined changes in inequity in HIV testing
which suggests three factors influencing utilisation of a coverage from 2007 to 2018 separately among men and
health service [30, 31]; specifically, (i) predisposing fac- non-pregnant women. We used the Equiplot graph sug-
tors in any condition that can enhance the risk of en- gested by the International Center for Equity in Health
gaging in unprotected sexual behavior, such as age and (ICEH) to illustrate changes across time points for in-
education; (ii) enabling factors that would increase equalities related to age, residence, education level, and
chances of greater access to HTC, such as wealth and household wealth [32, 38]. The mean coverage difference
urban residence; and (iii) required factors which would from the best-performing region was also calculated to
affect a perceived need for HTC, such as knowledge of show regional disparities in testing coverage across time
HIV or being sexually active. On this basis, we identified points [39]. We restricted the analysis of inequity and
available determinants in the DHS, shown in Fig. 1 (a predictors of HTC uptake among women to those non-
full list and definitions are shown in Supplementary pregnant, to avoid bias in the estimate of HIV testing
Table S1) [21, 32–36]. coverage due to high rates observed through ANC.

Fig. 1 Adapted Andersen Behavioural Model of utilization of HIV testing and counselling services
Heri et al. BMC Public Health (2021) 21:456 Page 4 of 18

Potential determinants (listed in Fig. 1) of HTC uptake tested at a GHC in 2018. GHCs accounted for a much
were examined using the most recent survey dataset smaller percentage among men in 2007 but increased
(2018). We first described respondent characteristics, considerably in 2013, and by 2018 became the source for
then conducted bivariate analyses to identify those asso- more than 50% of HIV tests among men. Moreover, the
ciated with the primary outcome; specifically, HIV test- percentage getting tested in mobile clinics (MC) almost
ing in the last 12 months with receipt of results. After doubled in all four groups between 2013 and 2018,
checking for collinearity and excluding variables with reaching 32% among adolescent boys. The increase in
missing values for the outcome, all variables associated the percentage of youth tested in either GHCs or MCs
with the primary outcome (with p < 0.05) were consid- masks considerable increases in the absolute number of
ered for inclusion in the multivariate logistic regression tests performed through these sources, due to the overall
models. The main models were run separately for men increase in the percentage of youth, as shown in Fig. 3b.
and non-pregnant women. Considering that 90% of HIV For GHCs the estimated number of tests performed for
infections are reported to be transmitted through het- youth increased substantially from roughly 163,000 in
erosexual intercourse in Zambia [10], a sub-group ana- 2007 to 1.3 million in 2018. For MC sources, the overall
lysis restricted to men and non-pregnant women estimated number of tests reached approximately 400,
reported being sexually active was also conducted to 000 in 2018 compared to 41,000 in 2007.
identify specific determinants associated with HTC up-
take in this population. Determinants of HIV testing uptake in the 2018 DHS
STATA SE version 16.1 (Stata Corporation, Ltd. Characteristics of the target population in the 2018 DHS
Texas, USA) was used for analysis, and all analyses con- dataset are shown in Table 1.
sidered clustering, weighting, and stratification using the In the multivariate models, the ages 20–24 were com-
svyset command. monly associated with high odds of HIV testing among
both non-pregnant women (adjusted odds ratio = 1.74,
Results 95%CI:1.40–2.15) and men (aOR = 1.55, 95%CI:1.30–
Changes in HIV testing uptake 1.84) (Tables 2 and 3). Among women the odds of test-
Overall, an improvement in HIV testing was observed ing increased with the level of education attained (aOR =
between 2007 and 2018, with the percentage tested and 6.97; 95%CI:2.82–17.19, for higher education compared
receiving the results in the last 12 months increasing to no education). Among men high HIV testing uptake
from 17 to 65% among young women, and from 10 to was mainly predicted by being circumcised (aOR = 1.57;
49% among young men (Fig. 2a). These increases, ob- 95%CI:1.32–1.88) and currently being in a union (aOR =
served in both genders and age groups (ages 15–19 and 2.46, 95%CI:1.85–3.28, compared to never in union).
20–24), were more pronounced between the period Among men and non-pregnant women who reported
2007–2013 than 2013–2018, and the absolute increase previous sexual experience, condom use at last inter-
was higher among women than men (Fig. 2b). The test- course was not associated with HIV testing uptake
ing rate among pregnant women, tested as part of ANC, among women but was a predictor of testing among
increased considerably from 2007 to 2013 and nearly men (aOR = 1.64, 95%CI: 1.32–2.04) (Tables S2 and S3
reached universal coverage for both age groups, with al- in SM). Other predictors of testing were like the main
most no change between 2013 and 2018. Figure 2b also models, except for not reporting HIV-related stigma
shows that HIV testing uptake among non-pregnant manifestation which was associated with higher odds of
women was much lower in all age groups than among testing among non-pregnant sexually active women
women who received a test as part of ANC. Moreover, (aOR = 1.59, 95%CI:1.14–2.21, compared to those
women not recently pregnant had almost the same test- reporting about stigma) (Tables S2); while having a dis-
ing coverage as men between 2007 and 2013, for both criminatory attitude was no longer a predictor for
age groups. Nevertheless, a small difference between among men.
genders was noted from 2013 to 2018 within each age
group, and more pronounced among young adults. Inequity in HIV testing uptake
We analysed inequities in HIV testing uptake for a test
Source of HIV test taken and results received in the last 12 months for age,
Figure 3a shows the proportions of HIV tests received residence, education level, household wealth, and regions
through each testing source between 2007 and 2018. at each time point among men and young non-pregnant
Government health centres (GHC) accounted for more women. The results suggested an overall improvement
than half of HIV tests for adolescent girls and young in testing coverage between 2007 and 2018 in each sub-
women in 2007, and their proportion increased over group for all inequality qualifiers (Fig. 4). However, by
time, with more than 60% in each age group getting 2018 the absolute inequity in coverage widened between
Heri et al. BMC Public Health (2021) 21:456 Page 5 of 18

a.
100

80
Percent tested

60

40

20

0
2007 2013-14 2018
Year

Women (15-24) Men (15-24)

Error bars:
Women (25-49) Men (25-49) 95% CI

b.
100

80
Percent tested

60

40

20

0
2007 2013-14 2018
Year

Pregnant women (15-19) Non-pregnant women (15-19) Men (15-19)

Error bars:
Pregnant women (20-24) Non-pregnant women (20-24) Men (20-24) 95% CI

Fig. 2 Changes in HIV testing uptake in Zambia, from 2007 to 2018: a. Among adults and youth tested in the last 12 months and receiving the
result, b. among youth tested in the last 12 months and receiving the result

sub-groups for both genders. Less well covered were regions increased among women (increase in the
those age 15–19 years-old, living in rural areas, less edu- mean difference from the best-covered region from
cated, and the poorest (Figs. 4a-d). Education-based in- 4% in 2007 to 17% in 2018) (Fig. 5). Among men,
equity was more considerable by 2018 among women however, an opposite trend was observed between
(54% absolute difference between no education and 2007 and 2018; specifically, a reduction in the mean
higher education) than men (31%) (Fig. 4c). Regarding difference from the best-covered region from 21% in
regions, by 2018 the disparities in testing coverage across 2007 to 9% in 2018.
Heri et al. BMC Public Health (2021) 21:456 Page 6 of 18

a.
100

80
Proportion of test

60

40

20

0
2007 2013/14 2018 2007 2013/14 2018 2007 2013/14 2018 2007 2013/14 2018
(N=212) (N=1387) (N=1613) (N=320) (N=1932) (N=2090) (N=109) (N=792) (N=1026) (N=157) (N=1137) (N=1229)
Adolescent girls 15-19 Women 20-24 Adolescent boys 15-19 Men 20-24

Government Hospital Government Health Center Private health hacility Mission health facility

Stand-alone VCT Center Mobile Clinic Community-based delivery Others

b.
800000

600000
Estimated number of tested

400000

200000

0
2007 2013/14 2018 2007 2013/14 2018 2007 2013/14 2018 2007 2013/14 2018
Adolescent girls 15-19 Women 20-24 Adolescent boys 15-19 Men 20-24

Fig. 3 Changes in the source of reception of HIV tests between 2013 and 14 and 2018, for tests conducted in the last 12 months. a. The
proportion of tests conducted through each source, b. estimated number of youths tested through each source of testing

Discussion mobile clinics almost doubled in all groups between 2013

This study analyses in-depth the uptake of HTC services and 2018 and accounted for one-third of all tests among
among youth in Zambia, using nationally representative adolescent boys. Multivariate analysis conducted for men
population-based survey data. We demonstrate an in- and non-pregnant women showed higher odds of testing
crease in uptake of HTC between 2007 and 2018, from among young adults than adolescents (aOR = 1.55 among
45 to 92% among pregnant women, 10 to 58% among men and aOR = 1.74 among women). Circumcision and in
non-pregnant women, and from 10 to 49% among men. a union were associated with higher odds of testing among
Government health centres became the primary source of men, whereas higher education and not reporting HIV-
HIV testing by 2018, performing around 60% of all tests related stigma were predictors of testing among non-
among youth. The percentage of tests delivered through pregnant sexually active women. Inequity analyses mainly
Heri et al. BMC Public Health (2021) 21:456 Page 7 of 18

Table 1 Respondent characteristics of young women (N = 5799) and men (N = 4846), Zambia 2018 DHS
Characteristics Women Men
N Percent (%) 95% CI N Percent (%) 95% CI
Age
15–19 3112 52.3 [50.8–53.9] 2852 57.8 [55.9–59.3]
20–24 2687 47.7 [46.1–49.2] 1994 42.2 [40.4–44.1]
Education level
No education 237 3.6 [2.9–4.4] 133 3.0 [2.3–4.0]
Primary 2313 39.0 [37.0–41.0] 1933 38.2 [36.0–40.4]
Secondary 3118 54.8 [52.8–56.8] 2666 55.9 [53.9–57.8]
Higher 131 2.6 [1.9–3.5] 114 2.9 [2.1–3.9]
Household wealth quintile
Poorest 1186 17.9 [16.4–19.6] 849 15.1 [13.6–16.8]
Poorer 1132 17.5 [16.0–19.2] 961 17.3 [15.6–19.0]
Middle 1153 18.2 [16.5–20.1] 1073 20.8 [18.9–22.8]
Richer 1103 22.3 [19.5–25.4] 936 22.8 [19.2–26.7]
Richest 1225 24.1 [21.2–27.3] 1027 24.0 [20.8–27.7]
Relationship status
Never in union 3681 63.1 [60.8–65.3] 4296 89.1 [87.8–90.3]
Currently in union 1879 32.7 [30.5–35.0] 514 10.2 [9.1–11.4]
Formerly in union 239 4.2 [3.6–4.9] 36 0.7 [0.5–1.0]
Residence
Urban 2335 46.0 [43.1–48.9] 1812 44.1 [40.7–47.4]
Rural 3464 54.1 [51.2–57.0] 3034 56.0 [52.6–59.3]
Region
Central 612 8.9 [7.9–9.9] 533 8.9 [7.9–10.1]
Copperbelt 683 16.2 [13.8–19.0] 558 15.3 [13.3–17.5]
Eastern 661 12.0 [10.6–13.5] 574 13.1 [11.7–14.7]
Luapula 599 7.8 [6.8–9.0] 530 8.1 [7.1–9.4]
Lusaka 688 18.6 [16.3–21.1] 547 17.5 [15.2–20.2]
Muchinga 501 5.6 [4.8–6.7] 435 5.6 [4.9–6.3]
Northern 542 8.0 [7.0–9.1] 422 7.6 [6.4–9.1]
North western 485 5.9 [4.7–7.5] 391 5.3 [4.4–6.5]
Southern 572 11.1 [9.0–13.7] 489 12.8 [9.5–17.2]
Western 456 5.9 [5.1–6.8] 367 5.6 [4.7–6.6]
Ever had sex
No 1741 30.2 [28.4–32.0] 1732 36.8 [34.9–38.7]
Yes 4058 69.9 [68.0–71.7] 3114 63.2 [61.3–65.1]
b
Age at first sexual intercourse
Before 16 years 1740 41.8 [39.7–43.8] 1425 44.1 [41.7–46.4]
At 16 years and above 2318 58.3 [56.2–60.3] 1689 55.9 [53.6–58.3]
Number of sexual partners in the last 12 months
None/never had sex 2354 40.2 [38.2–42.3] 2384 50.3 [48.3–52.3]
One 3350 58.1 [56.1–60.1] 1934 39.1 [37.2–41.1]
Two or more 95 1.7 [1.3–2.1] 528 10.6 [9.4–11.8]
Heri et al. BMC Public Health (2021) 21:456 Page 8 of 18

Table 1 Respondent characteristics of young women (N = 5799) and men (N = 4846), Zambia 2018 DHS (Continued)
Characteristics Women Men
N Percent (%) 95% CI N Percent (%) 95% CI
Condom used during last sexual intercourseb
No 3429 84.1 [82.5–85.6] 2119 67.4 [65.2–69.5]
Yes 629 15.9 [14.4–17.5] 995 32.6 [30.5–34.8]
Heard about STI
No 115 1.8 [1.5–2.3] 43 0.8 [0.6–1.2]
Yes 5684 98.2 [97.7–98.5] 4803 99.2 [98.8–99.4]
History of STI
No 5735 99.0 [98.6–99.3] 4692 97.0 [96.3–97.6]
Yes 64 1.0 [0.7–1.4] 154 3.0 [2.4–3.7]
Heard about AIDS
No 189 3.0 [2.5–3.7] 76 1.5 [1.2–2.0]
Yes 5610 97.0 [96.3–97.5] 4770 98.5 [98.0–98.9]
Reported stigma
No 888 15.5 [14.1–17.0] 517 9.3 [8.3–10.5]
Yes 4048 69.6 [67.7–71.3] 3765 79.4 [77.7–80.9]
Don’t know 863 14.9 [13.7–16.3] 564 11.3 [10.1–12.7]
Discriminatory attitudes
No 3966 69.5 [67.9–71.1] 3401 70.1 [65.3–71.9]
Yes 1833 30.5 [28.9–32.1] 1445 29.9 [28.1–31.8]
Comprehensive knowledge of HIV
No 3269 55.2 [53.1–57.3] 2802 57.7 [55.8–59.6]
Yes 2530 44.8 [42.7–47.0] 2044 42.3 [40.4–44.2]
Knowledge of a place to get HIV testa
No 417 6.8 [6.0–7.7] 389 7.9 [6.9–8.9]
Yes 5382 93.2 [92.3–94.0] 4457 92.1 [91.1–93.1]
HIV Self testing
Never heard of HIV self-test Kit 4908 85.4 [83.7–87.0] 3926 80.3 [78.4–82.1]
Has tested with HIV self-test Kit 105 2.6 [2.0–3.5] 89 2.5 [1.8–3.4]
Knows self-test kits but never tested with 597 12.0 [10.8–13.2] 755 17.2 [15.7–18.9]
Circumcised
No 2952 62.6 [60.4–64.7]
Yes 1894 37.4 [35.3–39.6]
Exposure to television
Not at all 3582 56.7 [53.8–59.6] 2424 45.6 [42.9–48.3]
Less than once a week 341 6.0 [5.2–6.9] 565 11.9 [9.9–14.3]
At least once a week 1876 37.3 [34.6–40.1] 1857 42.5 [39.8–45.3]
Exposure to radio
Not at all 3307 55.2 [53.1–57.3] 1766 34.6 [32.5–36.8]
Less than once a week 721 13.6 [12.4–14.8] 697 15.0 [13.6–16.6]
At least once a week 1771 31.2 [29.3–33.1] 2383 50.4 [48.0–52.7]
Use of internet
Not at all 5123 87.3 [85.6–88.7] 3709 73.8 [71.5–76.1]
Less than once a week 118 2.1 [1.7–2.6] 234 5.3 [4.5–6.3]
Heri et al. BMC Public Health (2021) 21:456 Page 9 of 18

Table 1 Respondent characteristics of young women (N = 5799) and men (N = 4846), Zambia 2018 DHS (Continued)
Characteristics Women Men
N Percent (%) 95% CI N Percent (%) 95% CI
At least once a week 218 4.1 [3.4–4.9] 457 9.6 [8.4–11.0]
Almost everyday 340 6.5 [5.5–7.7] 446 11.2 [9.5–13.2]
Owns a mobile phone
No 3471 56.8 [54.6–58.9] 2313 46.1 [43.8–48.5]
Yes 2328 43.2 [41.1–45.4] 2533 53.9 [51.6–56.2]
HIV test in the last 12 months and received the result
No 2096 34.8 [33.1–36.6] 2591 51.2 [48.4–54.0]
Yes 3703 65.2 [63.4–67.0] 2255 48.8 [46.0–51.6]
a
Comprehensive knowledge is a composite of 4 questions to assess respondent understanding of HIV transmission (whether people reduce their chances of
getting the AIDS virus by having just one uninfected sex partner who has no other partners and if a healthy-looking person can have AIDS) and prevention
(whether a person can get the AIDS virus from mosquito bites and if a person can get the AIDS virus by sharing food with a person who has AIDS)
b
The frequency and percentage for the age at first sexual intercourse and use of condom are restricted to respondents who report prior sexual intercourse

found an improvement in testing coverage in each sub- and hard-to-reach youth. In addition to the latter, other
group of all inequality qualifiers by 2018, although the community-based strategies that are specific to youth
absolute difference in coverage was widened between the should be explored given their promising results, such as
sub-groups for both genders. Education-based inequity was adolescent-focused case finding implemented in Kenya
substantially increased among women than men by 2018. and home-based HTC [48, 49]. HIV self-testing (HST) is
The trend observed in this study for HTC uptake also part of interventions in Zambia and has shown some
among youth demonstrates a considerable improvement acceptance and the potential to improve access to HIV
over time in Zambia. Among pregnant women, the testing [50–53]. However, our study found that HST was
achievement could be related to the integration into unknown to most youth (85 and 80% among women and
ANC services since 2005 of a program of prevention of men, respectively). Its promotion, together with other
mother to child transmission of HIV (PMTCT), inten- community-based approaches, is to be encouraged given
sively promoted among pregnant women to ensure al- their potential to increase testing coverage, overcome
most universal access to HTC around 2013 [40, 41]. The stigma barriers, and contribute to reducing risky sexual
great level of attendance to ANC services among preg- behaviour [54–58]. Concerns regarding their linkage to
nant Zambian women was reported by the 2007 DHS care for HIV positive cases should be adequately ad-
(97% of women with at least one ANC visit) and main- dressed if chosen to be implemented at a large scale.
tained in 2013–14 and 2018 (roughly 98% for both re- The positive changes in testing uptake highlighted
ports); and was likely a contributing factor for inclusion above among men and non-pregnant women have also
of young women regardless of their age [7, 24, 42]. been accompanied by a constant gap in the trend of HIV
Regarding men, the promotion of couple HIV counsel- testing coverage between genders, with men being gen-
ling and testing (CHCT) among partners of women at- erally less well covered than women. Similar differences
tending ANC might be a factor to consider, especially among youth were reported in Nigeria, Mozambique,
considering that multivariate analysis in our study showed and Uganda [59, 60]. The persistence of higher testing
a high odds of testing among men in a union [43–45]. In rates among non-pregnant women compared to men
our results the voluntary medical male circumcision may be due to their higher demand of HTC services,
(VMMC) as part of the main predictors of HIV testing caused by a greater perception of HIV risk resulting
among young men suggests a potential contribution of the from their vulnerability and frequent exposures to sexual
VMMC campaigns launched in 2012 in Zambia. These intercourse with older partners with whom they may
campaigns reached over 400,000 men by 2013, and in- have less control over condom use [10, 61]. Women of
cluded HIV testing and other preventive services in reproductive age are also generally reported to use pri-
addition to circumcision [46, 47]. Its scale-up in 2016, mary healthcare more often than men, either for them-
mainly through the mobile clinics, might explain the in- selves or for their children [62, 63]. As a result, non-
crease in the proportion of this source of delivery as pregnant women remain more likely to be suggested an
reflected in our results for adolescent boys in 2018 (32% HIV test whenever they interact with health services as
of testing through MC). The increasing proportion of HIV part of provider-initiated counselling and testing (PICT),
tests offered through MC observed in the study reflects an which is widely implemented in government health facil-
attempt of the Zambian government to reach underserved ities in Zambia [26, 46, 64]. Moreover, it is possible that
Heri et al. BMC Public Health (2021) 21:456 Page 10 of 18

Table 2 Determinants of HIV testing uptake among non-pregnant women ages 15–24, Zambia 2018 DHS (N = 4198)
Respondent characteristics N HTC coverage (%) Crude OR(95% CI) P-value Adjusted OR(95% CI) P-value
Age < 0.001 < 0.001
15–19 2484 45.8 1 1
20–24 1714 74.4 3.44 [2.98–3.98] 1.74 [1.40–2.15]
Education level < 0.001 < 0.001
No education 145 22.9 1 1
Primary 1521 47.0 3.00 [1.89–4.75] 3.14 [1.94–5.08]
Secondary 2418 65.5 6.41 [3.98–10.32] 5.52 [3.30–9.25]
Higher 114 77.3 11.49 [5.14–25.68] 6.97 [2.82–17.19]
Household wealth quintile < 0.001 0.04
Poorest 719 48.5 1 1
Poorer 730 50.9 1.10 [0.88–1.38] 0.99 [0.76–1.29]
Middle 790 56.3 1.37 [1.08–1.74] 1.02 [0.76–1.37]
Richer 858 68.4 2.30 [1.74–3.04] 1.41 [0.96–2.09]
Richest 1101 59.3 1.55 [1.23–1.96] 0.90 [0.59–1.38]
Relationship status < 0.001 0.04
Never in union 3185 53.0 1 1
Currently in union 850 73.5 2.46 [2.03–2.99] 1.33 [0.99–1.79]
Formerly in union 163 73.1 2.42 [1.58–3.68] 1.70 [1.04–2.78]
Residence < 0.001 0.23
Urban 1915 63.3 1 1
Rural 2283 52.5 0.64 [0.54–0.76] 0.85 [0.65–1.11]
Region < 0.001 < 0.001
Central 445 57.3 0.85 [0.62–1.16] 1.10 [0.78–1.54]
Copperbelt 549 61.3 1 1
Eastern 419 53.4 0.72 [0.52–1.01] 1.11 [0.76–1.62]
Luapula 414 41.5 0.45 [0.34–0.60] 0.66 [0.48–0.90]
Lusaka 560 63.8 1.11 [0.82–1.51] 1.00 [0.71–1.40]
Muchinga 363 41.7 0.45 [0.31–0.67] 0.68 [0.47–0.99]
Northern 371 46.1 0.54 [0.37–0.79] 0.90 [0.58–1.41]
North western 362 58.8 0.90 [0.62–1.32] 1.07 [0.73–1.58]
Southern 406 67.1 1.29 [0.91–1.82] 1.44 [0.98–2.11]
Western 309 73.0 1.71 [1.18–2.47] 2.48 [1.63–3.77]
Number of sexual partners < 0.001 < 0.001
None 2255 45.5 1 1
One 1861 72.6 3.17 [2.72–3.70] 2.13 [1.74–2.61]
Two or more 82 67.2 2.45 [1.37–4.40] 1.61 [0.79–3.31]
History of STI 0.006 0.16
No 4161 57.9 1 1
Yes 37 87.1 4.90 [1.60–15.03] 2.63 [0.68–10.16]
Reported stigma < 0.001 < 0.001
No 607 63.2 1.08 [0.87–1.34] 1.26 [0.98–1.61]
Yes 2937 61.3 1 1
Don’t know 654 39.0 0.40 [0.32–0.52] 0.55 [0.42–0.72]
Heri et al. BMC Public Health (2021) 21:456 Page 11 of 18

Table 2 Determinants of HIV testing uptake among non-pregnant women ages 15–24, Zambia 2018 DHS (N = 4198) (Continued)
Respondent characteristics N HTC coverage (%) Crude OR(95% CI) P-value Adjusted OR(95% CI) P-value
Discriminatory attitudes 0.01 0.12
No 2957 59.7 1 1
Yes 1241 54.1 0.80 [0.67–0.95] 1.16 [0.96–1.39]
Comprehensive knowledge of HIV < 0.001 0.18
No 2311 53.1 1 1
Yes 1887 63.8 1.56 [1.32–1.83] 1.13 [0.95–1.35]
Exposure to television 0.007 0.17
Not at all 2368 55.8 1 1
Less than once a week 257 53.6 0.91 [0.69–1.22] 0.72 [0.51–1.01]
At least once a week 1573 61.5 1.27 [1.07–1.50] 0.88 [0.67–1.16]
Exposure to radio 0.003 0.21
Not at all 2311 56.1 1 1
Less than once a week 537 55.6 0.98 [0.76–1.25] 0.91 [0.69–1.18]
At least once a week 1350 62.3 1.29 [1.09–1.53] 1.13 [0.92–1.40]
Owns a mobile phone < 0.001 < 0.001
No 2400 45.5 1 1
Yes 1798 72.6 3.17 [2.71–3.70] 1.88 [1.52–2.33]
Use of internet < 0.001 0.24
Not at all 3609 56.0 1 1
Less than once a week 100 55.0 0.96 [0.60–1.54] 0.60 [0.34–1.05]
At least once a week 186 73.1 2.14 [1.42–3.21] 1.26 [0.80–1.98]
Almost everyday 303 72.2 2.04 [1.55–2.69] 0.98 [0.69–1.40]

existing interventions that target youth, such as youth- the testing targets set by the Zambian Ministry of Health for
friendly services (YFS), might be much more women- this year (70 and 50% for adolescent girls and boys, respect-
specific [65, 66]. Indeed, it has been shown that norms ively) [10]. A recent study in Zambia and several other
related to masculinity bring men to consider sexual countries from the SSA region have also reported lower
health as a woman’s domain, and therefore believe that odds of testing among adolescents [21, 33, 59, 60]. Most
it would be inappropriate for them [67]. A recent scop- supported the fact that older age is likely to confer more
ing review focusing on the sub-Sahara African (SSA) re- sexual experience and better knowledge of HIV, which may
gion highlighted several other barriers to uptake of HTC accordingly improve the perception of the risk and affect the
among men that might be important to consider even need for HIV testing [21, 60, 70]. Other barriers specific to
for youth [68, 69]. Among the most common, we find adolescents include the legal age of consent to HIV testing,
poor knowledge of HIV, fear of testing positive, lack of stigma, and sanctioning of sexual activity in adolescents; and
confidentiality, and other aspects related to the quality are important to be highlighted to ensure that they are
of services. Therefore, increasing uptake of testing targets of future interventions that aim to improve coverage
among young men will require the implementation of of testing among adolescents in Zambia [22, 71, 72]. The
interventions that are young men-driven, needs-based, ongoing mobilization in Zambia to revise the legal age of
and beneficiary responsive, including implementation of consent, currently at 16 years old, needs to be further sup-
decentralised service delivery models that capture young ported and accelerated [10, 65]. Lowering the age of consent
men in their safe spaces. below 16 years old is associated with increased testing for
Our results showed adolescent girls (non-pregnant) and adolescents (11% increase in national testing coverage,
boys having a lower HIV testing uptake by 2018 (46 and 95%CI:7.2–14.8%), as suggested in a systematic review that
38%, respectively), compared to young adults. The persist- included several high burden countries [73, 74].
ence of this age-based gap in the trend analysis was observed Of the other determinants analysed, having reported
in both multivariate and inequity analysis among both non- HIV-related stigma was associated with lower odds of
pregnant women and men. The proportions achieved in HTC among non-pregnant sexually active women. The
testing coverage among adolescents in 2018 are still far from negative impact of stigma has been noted by several
Heri et al. BMC Public Health (2021) 21:456 Page 12 of 18

Table 3 Determinants of HIV testing uptake among men ages 15–24, Zambia 2018 (N = 4846)
Respondent characteristics N HTC coverage (%) Crude OR(95% CI) P value Adjusted OR(95% CI) P value
Age < 0.001 < 0.001
15–19 2852 37.5 1 1
20–24 1994 64.2 2.98 [2.58–3.45] 1.55 [1.30–1.84]
Education level < 0.001 < 0.001
No education 133 37.8 1 1
Primary 1933 37.1 0.97 [0.59–1.61] 1.02 [0.68–1.51]
Secondary 2666 56.4 2.13 [1.33–3.40] 1.51 [1.01–2.26]
Higher 114 68.8 3.63 [1.98–6.65] 1.41 [0.74–2.71]
Household wealth quintile 0.001 < 0.001
Poorest 849 39.8 1 1
Poorer 961 43.4 1.16 [0.93–1.44] 1.23 [0.95–1.59]
Middle 1073 49.7 1.49 [1.20–1.86] 1.36 [1.03–1.79]
Richer 936 56.8 1.99 [1.38–2.87] 1.37 [0.99–1.90]
Richest 1027 50.0 1.52 [1.21–1.90] 0.78 [0.53–1.15]
Relationship status < 0.001 < 0.001
Never in union 4296 45.8 1 1
Currently in union 514 74.0 3.37 [2.60–4.37] 2.46 [1.85–3.28]
Formerly in union 36 65.1 2.21 [0.97–5.04] 1.78 [0.74–4.27]
Residence < 0.001 0.06
urban 1812 54.6 1 1
rural 3034 44.2 0.66 [0.52–0.83] 0.72 [0.52–1.01]
Region < 0.001 0.002
Central 533 52.1 1.13 [0.84–1.51] 1.44 [1.00–2.06]
Copperbelt 558 49.2 1 1
Eastern 574 49.1 1.00 [0.74–1.34] 1.41 [0.97–2.05]
Luapula 530 39.8 0.68 [0.50–0.92] 0.96 [0.67–1.38]
Lusaka 547 52.4 1.12 [0.84–1.54] 1.10 [0.79–1.53]
Muchinga 435 33.3 0.51 [0.35–0.76] 0.76 [0.49–1.20]
Northern 422 41.6 0.73 [0.53–1.03] 1.12 [0.77–1.64]
North western 391 44.8 0.84 [0.60–1.17] 0.75 [0.51–1.10]
Southern 489 56.4 1.34 [0.70–2.54] 1.39 [0.75–2.58]
Western 367 55.1 1.27 [0.93–1.73] 1.45 [0.98–2.13]
Ever had sex < 0.001 0.14
No 1732 34.0 1 1
Yes 3114 57.4 2.62 [2.27–3.01] 1.19 [0.95–1.50]
Number of sexual partners < 0.001 < 0.001
None 2384 37.1 1 1
One 1934 61.2 2.67 [2.30–3.09] 1.79 [1.41–2.27]
Two or more 528 58.4 2.37 [1.84–3.06] 1.38 [0.99–1.91]
History of STI 0.26
No 4692 48.6 1 –
Yes 154 54.1 1.25 [0.85–1.82] –
Heri et al. BMC Public Health (2021) 21:456 Page 13 of 18

Table 3 Determinants of HIV testing uptake among men ages 15–24, Zambia 2018 (N = 4846) (Continued)
Respondent characteristics N HTC coverage (%) Crude OR(95% CI) P value Adjusted OR(95% CI) P value
Circumcised < 0.001 < 0.001
No 2952 43.8 1 1
Yes 1894 57.2 1.72 [1.46–2.02] 1.58 [1.32–1.89]
Reported stigma < 0.001 < 0.001
No 517 40.6 0.64 [0.50–0.81] 0.65 [0.50–0.84]
Yes 3765 51.8 1 1
Don’t know 564 34.3 0.49 [0.40–0.59] 0.61 [0.49–74]
Discriminatory attitudes < 0.001 0.02
No 3401 52.3 1 1
Yes 1445 29.8 0.63 [0.53–0.73] 0.80 [0.67–0.97]
Comprehensive knowledge of HIV < 0.001 0.14
No 2802 44.8 1 1
Yes 2044 54.2 1.46 [1.28–1.66] 1.13 [0.96–1.33]
Owns a mobile phone < 0.001 0.002
no 2313 36.8 1
yes 2533 59.0 2.47 [2.10–2.89] 1.32 [1.11–1.57]
Use of internet < 0.001 < 0.001
Not at all 3709 43.5 1 1
Less than once a week 234 57.8 1.78 [1.32–2.39] 1.41 [1.02–1.94]
At least once a week 457 63.0 2.21 [1.69–2.87] 1.53 [1.13–2.08]
Almost everyday 446 66.9 2.62 [2.04–3.37] 1.76 [1.32–2.35]
Exposure to television < 0.001 0.07
Not at all 2424 42.7 1 1
Less than once a week 565 57.9 1.85 [1.30–2.61] 1.38 [1.05–1.82]
At least once a week 1857 52.7 1.50 [1.29–1.73] 1.08 [0.85–1.38]
Exposure to radio < 0.001 0.04
Not at all 1766 43.9 1 1
Less than once a week 697 48.6 1.21 [1.00–1.47] 0.86 [0.69–1.07]
At least once a week 2383 52.2 1.40 [1.22–1.59] 1.12 [0.94–1.34]

other authors and remains a challenge for any HIV pro- The results from this study suggest some critical ac-
gram [75, 76]. However, it should be recognized that tions from programme implementers and researchers to
the scaling up of HIV prevention and treatment ensure better access to HTC for youth in Zambia. These
services, especially in a universal ‘test and treat’ ap- include the scaling-up of mobile testing and strengthen-
proach, could help reduce HIV-related stigma in the ing of alternative community-based approaches such as
community through several pathways and improve ac- HIV self-testing, which has shown some acceptance and
cess to these services [77, 78]. We also found strong potential to clients who are less easy to reach through
evidence of higher odds of HIV testing among the the government health facilities. The development of
most educated women, consistent with other studies gender-sensitive HTC services and less coercive strat-
on youth in the SSA region [21, 33, 59]. The egies to sustain the gain in testing uptake among men in
education-based inequity widened in the last survey, a union are also important to consider. Finally, the
mostly among non-pregnant women, indicating the warning about barriers associated with the access to sex-
need to reach the least educated youths. Other sub- ual health and HIV services through YFS in a recent
groups of disadvantaged young people who were iden- study from Brazil [79], and the scarcity of evidence sup-
tified from the inequity analysis require continual at- porting the progress made since their introduction in
tention to ensure improvement of the testing coverage Zambia, suggest that more research will help to demon-
among youth in Zambia. strate their contribution and yield.
Heri et al. BMC Public Health (2021) 21:456 Page 14 of 18

Fig. 4 Changes in inequities of testing uptake among men and young non-pregnant women tested and receiving the results in the past 12 months,
between 2007 and 2018. a. age-based inequalities, b. residence-based inequalities, c. education-based inequalities, d. wealth-based inequalities
Heri et al. BMC Public Health (2021) 21:456 Page 15 of 18

Fig. 5 Changes in testing coverage among men and non-pregnant women tested and receiving results in the past 12 months, between 2007
and 2018. Region-based inequalities

Conclusion Africa; STI: Sexually transmitted infection; UNAIDS: Joint United Nations
Overall, the improvement observed in HTC among programme on HIV/AIDS; UNICEF: United Nations children’s fund;
VCT: Voluntary counselling and testing; VMMC: Voluntary medical male
Zambian youth is encouraging, with 65% of women and circumcision; YFS: Youth-friendly services
49% of men knowing their status, although it is still far
from the 95% goal envisioned by the UNAIDS in 2030. Supplementary Information
Therefore, renewed efforts are needed to close the gaps The online version contains supplementary material available at https://doi.
observed among men in general, non-pregnant and less org/10.1186/s12889-021-10472-x.
educated adolescent girls, and young women. Sustaining
Additional file 1: Table S1. Details on variables used for the analysis;
the gains obtained from existing HTC services by ad- Table S2. Determinants of HIV testing uptake among sexually active
dressing barriers such as stigma and offering gender and non-pregnant young women aged 15–24, Zambia 2018 DHS (N = 2457);
adolescent-sensitive services is required, in addition to and Table S3. Determinants of HIV testing uptake among sexually active
young men aged 15–24, Zambia DHS 2018 (N = 3114).
the scaling up of most effective community-based testing
approaches. Despite the hope stemming from the recent
Acknowledgments
mobilization to prioritize adolescent health in the coun- We thank the DHS Program for providing access to the Zambian
try, much attention should be invested in rigorously Demographic Health surveys. A.B.H is benefited by a scholarship from the
tracking progress in access to HIV prevention and care Ministry of Education, Culture, Sports, Science and Technology (MEXT) of
Japan for his doctoral training at Nagasaki University. The first author wishes
services to ensure the reach, effectiveness, and sustain- to thank Associate Professor Lenka Benova for her contributions in the
ability of implemented strategies, as well as headway to- development of this study. We would like also to thank Dr. Thomas
ward ensuring that youth live free of HIV and can Templeton (http://templetoncopyediting.com) for English language editing.
contribute to the prosperity of the country.
Authors’ contributions
A.B.H. designed the research idea and protocol, conducted data analysis, and
Abbreviations prepared the manuscript. F.L.C. and M.M. provided input on the study
AGAPE: Adolescent girls accessing prevention and education; design, contributed to the data analysis, the interpretation of the results, as
AGYW: Adolescent girls and young women; AIDS: Acquired immune well as the revision of the manuscript. N.A. and M.M.M. contributed
deficiency syndrome; ANC: Antenatal care; aOR: Adjusted odds ratio; substantially to the interpretation of results and finalization of the
CI: Confidence interval; CHCT: Couple HIV counselling and testing; manuscript. All authors have read and approved the final manuscript.
cOR: Crude odds ratio; DHS: Demographic and health survey; DREA
MS: Determined, resilient, empowered, AIDS-free, mentored, and safe; GFAT Funding
M: Global fund to fight tuberculosis, HIV/AIDS and malaria; GHC: Government This study did not receive funding.
health centres; HIV: Human immunodeficiency virus; HTC: HIV testing and
counselling; HST: HIV self-testing; LMIC: Low- and middle-income countries; Availability of data and materials
NASF: National AIDS strategic framework; MC: Mobile clinic; PEPFAR: United Required permission was obtained from the DHS programme to access the
States president’s emergency plan for AIDS relief; PICT: Provider-initiated data analysed for this study. All data and DHS-related materials used are
counselling and testing; SM: Supplementary materials; SSA: Sub-Saharan available from the website: https://dhsprogram.com/.
Heri et al. BMC Public Health (2021) 21:456 Page 16 of 18

Declarations 11. McKinnon LR, Karim QA. Factors driving the HIV epidemic in southern
Africa. Curr HIV/AIDS Rep. 2016;13(3):158–69.
Ethics approval and consent to participate 12. Mojola SA, Wamoyi J. Contextual drivers of HIV risk among young African
The DHS program obtained ethical approval from institutional review boards women. J Int AIDS Soc. 2019;22(Suppl 4):e25302.
at Inner City Fund (ICF) International Inc. and the Tropical Diseases Research 13. Saul J, Bachman G, Allen S, Toiv NF, Cooney C, Beamon T. The DREAMS
Centre (TDRC) in Zambia. At the beginning of each survey, every participant core package of interventions: a comprehensive approach to preventing
was informed that participation in the survey is completely voluntary, the HIV among adolescent girls and young women. PLoS One. 2018;13(12):
participant has rights to skip any questions and stop the interview any time, e0208167.
and the information in this survey is strictly confidential. For each survey, 14. Abdool Karim Q, Baxter C, Birx D. Prevention of HIV in adolescent girls and
respondents were asked to provide written informed consent before Young women: key to an AIDS-free generation. J Acquir Immune Defic
interview; and data collectors were trained on ethical issues. This study was a Syndr. 2017;75:S17–26.
secondary analysis of data with no identifying information, and therefore did 15. Miller WC, Lesko CR, Powers KA. The HIV care cascade: simple concept,
not require ethical approval from Nagasaki University. This study was complex realization. Sex Transm Dis. 2014;41(1):41–2.
complied with Ethical Guidelines for Medical and Health Research Involving 16. Mugavero MJ, Amico KR, Horn T, Thompson MA. The state of engagement
Human Subjects jointly issued from the Ministry of Education, Culture, Sports, in HIV care in the United States: from cascade to continuum to control. Clin
Science and Technology and the Ministry of Health, Labor and Welfare in Infect Dis. 2013;57(8):1164–71.
2017 in Japan. We also received an authorization to use the Zambian dataset 17. Joint United Nations Programme on HIV/AIDS (UNAIDS). 90–90–90 - An
from the DHS Program. ambitious treatment target to help end the AIDS epidemic. Geneva:
UNAIDS; 2014.
Consent for publication 18. Govindasamy D, Ferrand RA, Wilmore SM, Ford N, Ahmed S, Afnan-Holmes
Not applicable. H, et al. Uptake and yield of HIV testing and counselling among children
and adolescents in sub-Saharan Africa: a systematic review. J Int AIDS Soc.
Competing interests 2015;18(1):20182.
The authors declare that they have no competing interests. 19. The INSIGHT START Study Group. Initiation of antiretroviral therapy in early
asymptomatic HIV infection. N Engl J Med. 2015;373:795–807.
Author details 20. Wong VJ, Murray KR, Phelps BR, Vermund SH, McCarraher DR. Adolescents,
1
Department of Global Health, Nagasaki University School of Tropical young people, and the 90–90–90 goals: a call to improve HIV testing and
Medicine and Global Health, Sakamoto 1-12-4, Nagasaki 852-8523, Japan. linkage to treatment. AIDS. 2017;31:S191–4.
2
Institute of Child Health, University College London, 30 Guilford St, Holborn, 21. Mwaba K, Mannell J, Burgess R, Sherr L. Uptake of HIV testing
London WC1N 1EH, UK. 3Faculty of Public Health and Policy, London School among 15–19-year-old adolescents in Zambia. AIDS Care. 2020;
of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. 32(sup2):183–92.
4 22. Qiao S, Zhang Y, Li X, Menon JA. Facilitators and barriers for HIV-testing in
Centre for Infectious Disease Research in Zambia, Plot # 34620, Off Alick
Nkhata Road, Lusaka, Zambia. Zambia: a systematic review of multi-level factors. PLoS One. 2018;13(2):
e0192327.
Received: 25 December 2020 Accepted: 19 February 2021 23. Ministry of Health, Zambia. Zambia Population-based HIV Impact
Assessment (ZAMPHIA) 2016: Final Report. Lusaka: Ministry of Health; 2019.
24. Central Statistical Office (CSO) [Zambia], Ministry of Health (MOH) [Zambia],
References and ICF International. Zambia Demographic and Health Survey 2013–14.
1. Global health estimates: Leading causes of death. Geneva: World Health Rockville, Maryland, USA: Central Statistical Office, Ministry of Health, and ICF
Organization; 2020. https://www.who.int/data/gho/data/themes/mortality-a International; 2014.
nd-global-health-estimates/ghe-leading-causes-of-death. Accessed 10 Dec 25. Republic of Zambia. HIV Testing and Counselling Implementation Plan
2020. (2014–2016). Lusaka: National HIV/AIDS/STI/TB Council; 2015.
2. HIV/AIDS Key facts. Geneva: World Health Organization; 2020. https://www. 26. Ministry of Health Zambia. Zambia consolidated guidelines for treatment
who.int/news-room/fact-sheets/detail/hiv-aids. Accessed 10 Dec 2020 and prevention of HIV infection. Lusaka: National HIV/AIDS/STI/TB Council;
3. Bernstein M, Sessions M. A trickle or a Flood: Commitments and 2017.
Disbursement for HIV/AIDS from the Global Fund, PEPFAR, and the World 27. Ministry of Health Zambia. Zambia consolidated guidelines for HIV
Bank’s Multi-country AIDS program (MAP). In: HIV/AIDS monitor. Center for treatment and prevention 2018. Lusaka: National HIV/AIDS/STI/TB Council;
Global Development. 2007. https://www.cgdev.org/publication/trickle-or- 2018.
flood-commitments-and-disbursement-hivaids-global-fund-pepfar-and- 28. Joint United Nations Programme on HIV/AIDS (UNAIDS). A super fast-track
world-banks. Accessed 15 Oct 2020. framework for ending aids in children, adolescents, and young women by
4. UNAIDS, WHO, UNICEF. UNAIDS, UNICEF and WHO urge countries in 2020. UNAIDS. 2016. https://free.unaids.org/. Accessed 18 Mar 2020.
western and central Africa to step up the pace in the response to HIV for 29. Joint United Nations Programme on HIV/AIDS (UNAIDS). All In initiative for
children and adolescents. In: Press release. Geneva: UNAIDS; 2019. https:// adolescents. Geneva: UNAIDS; 2015.
www.unaids.org/en/resources/presscentre/pressreleaseandstatementa 30. Andersen R, Newman JF. Societal and individual determinants of medical
rchive/2019/january/20190116_PR_WCA_children_adolescents. Accessed 22 care utilization in the United States. Milbank Q. 2005;83(4):1–28.
Oct 2020 31. Andersen RM. Revisiting the behavioral model and access to medical care:
5. Children, HIV and AIDS: The world today and in 2030. New York: UNICEF; does it matter? J Health Soc Behav. 1995;36(1):1–10.
2018. https://data.unicef.org/resources/children-hiv-and-aids-2030/. Accessed 32. Barros AJD, Victora CG. Measuring coverage in MNCH: determining and
22 Oct 2020. interpreting inequalities in coverage of maternal, newborn, and child health
6. Joint United Nations Programme on HIV/AIDS (UNAIDS). Start Free Stay Free interventions. PLoS Med. 2013;10(5):e1001390.
AIDS Free - 2019 report. Geneva: UNAIDS; 2019. 33. Bekele YA, Fekadu GA. Factors associated with HIV testing among young
7. Zambia Statistics Agency, Ministry of Health (MOH) Zambia, and ICF. Zambia females; further analysis of the 2016 Ethiopian demographic and health
Demographic and Health Survey 2018. Lusaka, Zambia,and Rockville, survey data. PLoS One. 2020;15(2):e0228783.
Maryland, USA: Zambia Statistics Agency, Ministry of Health, and ICF; 2019. 34. Lakhe NA, Diallo Mbaye K, Sylla K, Ndour CT. HIV screening in men and
8. AIDSinfo. Geneva: UNAIDS; 2020. http://aidsinfo.unaids.org/. Accessed 28 women in Senegal: coverage and associated factors; analysis of the 2017
Mar 2020. demographic and health survey. BMC Infect Dis. 2020;20:1.
9. Joint United Nations Programme on HIV/AIDS (UNAIDS). Zambia. In: 35. Menna T, Ali A, Worku A. Factors associated with HIV counseling and testing
Country factsheets. UNAIDS. 2019. https://www.unaids.org/en/ and correlations with sexual behavior of teachers in primary and secondary
regionscountries/countries/zambia. Accessed 21 Apr 2020. schools in Addis Ababa, Ethiopia. HIVAIDS (Auckl). 2015;7:197–208.
10. National HIV/AIDS/STI/TB Council Zambia. National AIDS Strategic Framework 36. Yaya S, Olarewaju O, Oladimeji KE, Bishwajit G. Determinants of prenatal
(NASF) 2017-2021. Lusaka: National HIV/AIDS/STI/TB Council; 2017. care use and HIV testing during pregnancy: a population-based, cross-
Heri et al. BMC Public Health (2021) 21:456 Page 17 of 18

sectional study of 7080 women of reproductive age in Mozambique. BMC standard clinic referral: a multisite, open-label, randomised controlled trial in
Pregnancy Childbirth. 2019;19:354. South Africa and Uganda. Lancet HIV. 2016;3(5):e212–20.
37. World Bank. Population estimates and projections, DataBank. 2020. https:// 55. Chamie G, Clark TD, Kabami J, Kadede K, Ssemmondo E, Steinfeld R, et al. A
databank.worldbank.org/source/population-estimates-and-projections. hybrid mobile HIV testing approach for population-wide HIV testing in rural
Accessed 11 Jul 2020. East Africa: an observational study. Lancet HIV. 2016;3(3):e111–9.
38. Equiplot. International Center for Equity in Health, Pelotas. https://www. 56. Coates TJ, Kulich M, Celentano DD, Zelaya CE, Chariyalertsak S, Chingono A,
equidade.org/equiplot. Accessed 8 Dec 2020. et al. Effect of community-based voluntary counselling and testing on HIV
39. World Health Organization. Handbook on health inequality monitoring: with incidence and social and behavioural outcomes (NIMH project accept; HPTN
a special focus on low- and middle-income countries. Geneva: World Health 043): a cluster-randomised trial. Lancet Glob Health. 2014;2(5):e267–77.
Organization; 2013. 57. Feyissa GT, Lockwood C, Munn Z. The effectiveness of home-based HIV
40. Herlihy JM, Hamomba L, Bonawitz R, Goggin CE, Sambambi K, Mwale J, counseling and testing on reducing stigma and risky sexual behavior
et al. Integration of PMTCT and antenatal services improves combination among adults and adolescents: a systematic review and meta-analyses. JBI
antiretroviral therapy uptake for HIV-positive pregnant women in southern Database Syst Rev Implement Rep. 2015;13(6):318–72.
Zambia: a prototype for option B+? J Acquir Immune Defic Syndr. 2015; 58. Sharma M, Ying R, Tarr G, Barnabas R. Systematic review and meta-analysis
70(4):e123–9. of community and facility-based HIV testing to address linkage to care gaps
41. Muyunda B, Mee P, Todd J, Musonda P, Michelo C. Estimating levels of HIV in sub-Saharan Africa. Nature. 2015;528(7580):S77–85.
testing coverage and use in prevention of mother-to-child transmission 59. Ajayi AI, Awopegba OE, Adeagbo OA, Ushie BA. Low coverage of HIV
among women of reproductive age in Zambia. Arch Public Health. 2018; testing among adolescents and young adults in Nigeria: implication for
76(1):80. achieving the UNAIDS first 95. PLoS One. 2020;15(5):e0233368.
42. Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases 60. Asaolu IO, Gunn JK, Center KE, Koss MP, Iwelunmor JI, Ehiri JE. Predictors of
Research Centre (TDRC), University of Zambia, and Macro International Inc. HIV testing among youth in sub-Saharan Africa: a cross-sectional study.
Zambia Demographic and Health Survey 2007. Calverton, Maryland, USA: PLoS One. 2016;11(10):e0164052.
CSO and Macro International Inc.; 2009. 61. Nwachukwu CE, Odimegwu C. Regional patterns and correlates of HIV
43. Musheke M, Bond V, Merten S. Couple experiences of provider-initiated voluntary counselling and testing among youths in Nigeria. Afr J Reprod
couple HIV testing in an antenatal clinic in Lusaka, Zambia: lessons for Health. 2011;15(2):131–46.
policy and practice. BMC Health Serv Res. 2013;13:97. 62. Cleary PD, Mechanic D, Greenley JR. Sex differences in medical care
44. Wall KM, Kilembe W, Nizam A, Vwalika C, Kautzman M, Chomba E, et al. utilization: an empirical investigation. J Health Soc Behav. 1982;23(2):106–19.
Promotion of couples’ voluntary HIV counselling and testing in Lusaka, 63. Yeatman S, Chamberlin S, Dovel K. Women’s (health) work: a population-
Zambia by influence network leaders and agents. BMJ Open. 2012;2(5): based, cross-sectional study of gender differences in time spent seeking
e001171. health care in Malawi. PLoS One. 2018;13(12):e0209586.
45. Inambao M, Kilembe W, Canary LA, Czaicki NL, Kakungu-Simpungwe M, 64. Topp SM, Chipukuma JM, Chiko MM, Wamulume CS, Bolton-Moore C, Reid
Chavuma R, et al. Transitioning couple’s voluntary HIV counseling and SE. Opt-out provider-initiated HIV testing and counselling in primary care
testing (CVCT) from stand-alone weekend services into routine antenatal outpatient clinics in Zambia. Bull World Health Organ. 2011;89(5):328–335A.
and VCT services in government clinics in Zambia’s two largest cities. PLoS 65. UNAIDS, UNICEF. All in to end the adolescent AIDS epidemic — a progress
One. 2017;12(10):e0185142. report. Geneva: UNAIDS; 2016.
46. Zambia. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva. 66. Ministry of Community Development Zambia. National Standards and
2017. https://data.theglobalfund.org/investments/location/ZMB. Accessed 9 guidelines for youth friendly health services. Lusaka: Ministry of Community
Nov 2020. Development; 2015.
47. Hensen, B. Increasing men's uptake of HIV-testing in sub-Saharan Africa: a 67. Kolundzija A. Annotated bibliography: gender norms and youth-friendly
systematic review of interventions and analyses of population-based data sexual and reproductive health services. London: ALIGN; 2019.
from rural Zambia. PhD thesis, London School of Hygiene & Tropical 68. Hlongwa M, Mashamba-Thompson T, Makhunga S, Hlongwana K. Barriers to
Medicine; 2016. DOI: https://doi.org/https://doi.org/10.17037/PUBS.02531234 HIV testing uptake among men in sub-Saharan Africa: a scoping review. Afr
48. Kose J, Tiam A, Ochuka B, Okoth E, Sunguti J, Waweru M, et al. Impact of a J AIDS Res. 2020;19(1):13–23.
comprehensive adolescent-focused case finding intervention on uptake of 69. Musheke M, Merten S, Bond V. Why do marital partners of people living
HIV testing and linkage to care among adolescents in Western Kenya. J with HIV not test for HIV? A qualitative study in Lusaka, Zambia. BMC Public
Acquir Immune Defic Syndr. 2018;79(3):367–74. Health. 2016;16(1):882.
49. Shanaube K, Schaap A, Chaila MJ, Floyd S, MacKworth-Young C, Hoddinott 70. Peltzer K, Matseke G. Determinants of HIV testing among young people
G, et al. Community intervention improves knowledge of HIV status of aged 18–24 years in South Africa. Afr Health Sci. 2013;13(4):1012–20.
adolescents in Zambia: findings from HPTN 071-PopART for youth study. 71. Chanda MM, Perez-Brumer AG, Ortblad KF, Mwale M, Chongo S,
AIDS. 2017;31:S221–32. Kamungoma N, et al. Barriers and facilitators to HIV testing among Zambian
50. Bwalya C, Simwinga M, Hensen B, Gwanu L, Hang’andu A, Mulubwa C, et al. female sex Workers in Three Transit Hubs. AIDS Patient Care STDs. 2017;
Social response to the delivery of HIV self-testing in households: 31(7):290–6.
experiences from four Zambian HPTN 071 (PopART) urban communities. 72. Chikwari CD, Dringus S, Ferrand RA. Barriers to, and emerging strategies for,
AIDS Res Ther. 2020;17(1):32. HIV testing among adolescents in sub-Saharan Africa. Curr Opin HIV AIDS.
51. Hatzold K, Gudukeya S, Mutseta MN, Chilongosi R, Nalubamba M, Nkhoma 2018;13(3):257–64.
C, et al. HIV self-testing: breaking the barriers to uptake of testing among 73. Fox K, Ferguson J, Ajose W, Singh J, Marum E, Baggaley R. Adolescent
men and adolescents in sub-Saharan Africa, experiences from STAR consent to testing: a review of current policies and issues in sub-Saharan
demonstration projects in Malawi, Zambia and Zimbabwe. J Int AIDS Soc. Africa. In: HIV and Adolescents: Guidance for HIV Testing and Counselling
2019;22(S1):e25244. and Care for Adolescents Living with HIV. Geneva: World Health
52. Mulubwa C, Hensen B, Phiri MM, Shanaube K, Schaap AJ, Floyd S, et al. Organization; 2013. Annex. p. 15.
Community based distribution of oral HIV self-testing kits in Zambia: a 74. McKinnon B, Vandermorris A. National age-of-consent laws and adolescent
cluster-randomised trial nested in four HPTN 071 (PopART) intervention HIV testing in sub-Saharan Africa: a propensity-score matched study. Bull
communities. Lancet HIV. 2018;6(2):e81–92. World Health Organ. 2019;97(1):42–50.
53. Zanolini A, Chipungu J, Vinikoor MJ, Bosomprah S, Mafwenko M, Holmes 75. Gesesew HA, Tesfay Gebremedhin A, Demissie TD, Kerie MW, Sudhakar M,
CB, et al. HIV self-testing in Lusaka Province, Zambia: acceptability, Mwanri L. Significant association between perceived HIV related stigma and
comprehension of testing instructions, and individual preferences for self- late presentation for HIV/AIDS care in low and middle-income countries: a
test kit distribution in a population-based sample of adolescents and adults. systematic review and meta-analysis. PLoS One. 2017;12(3):e0173928.
AIDS Res Hum Retrovir. 2018;34(3):254–60. 76. Hargreaves JR, Krishnaratne S, Mathema H, Lilleston PS, Sievwright K,
54. Barnabas RV, van Rooyen H, Tumwesigye E, Brantley J, Baeten JM, van Mandla N, et al. Individual and community-level risk factors for HIV stigma
Heerden A, et al. Uptake of antiretroviral therapy and male circumcision in 21 Zambian and south African communities: analysis of data from the
after community-based HIV testing and strategies for linkage to care versus HPTN071 (PopART) study. AIDS. 2018;32(6):783–93.
Heri et al. BMC Public Health (2021) 21:456 Page 18 of 18

77. Camlin CS, Charlebois ED, Getahun M, Akatukwasa C, Atwine F, Itiakorit H,

et al. Pathways for reduction of HIV-related stigma: a model derived from
longitudinal qualitative research in Kenya and Uganda. J Int AIDS Soc. 2020;
23(12):e25647.
78. Chan BT, Tsai AC, Siedner MJ. HIV treatment scale-up and HIV-related stigma
in sub-Saharan Africa: a longitudinal cross-country analysis. Am J Public
Health. 2015;105(8):1581–7.
79. Pastrana-Sámano R, Heredia-Pi IB, Olvera-García M, Ibáñez-Cuevas M, Castro
FD, Hernández AV, et al. Adolescent friendly services: quality assessment
with simulated users. Rev Saúde Pública. 2020;54:36.

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