Correlates of couples HIV testing and counseling and reported interpersonal barriers to uptake among adolescents and young adults: results from two population-based surveys conducted in Malawi and Zambia

BACKGROUND: Most HIV seroconversions in sub-Saharan Africa occur among adolescents and young adults (AYA, aged 15-24) in heterosexual serodiscordant primary partnerships. Thus, couples HIV testing and counseling (CHTC) is a promising modality to reduce transmission. However, CHTC uptake remains low as partnerships involving AYA tend to be novel and emerging during these formative developmental stages, making CHTC especially challenging. We evaluated correlates of CHTC uptake and age- and gender-specific interpersonal barriers to CHTC.
METHODS: We conducted a pooled analysis using data from Malawi's (2015-2016) and Zambia's (2016) Population-based HIV Impact Assessments, two nationally-representative household surveys. To identify correlates of CHTC with a primary partner, we used multivariable logistic regression. To characterize barriers to CHTC uptake, we used chi-squared tests to determine gender- and age-related differences.
RESULTS: Among 7227 AYA, 37% (2678/7227) engaged in CHTC; of which, most were female (55%), aged 20-24 (63%), and Malawian (54%). CHTC correlates (Figure 1) included female gender (Ref: male; aOR:1.96 [1.65-2.33]), 20-24 years (Ref. 15-19; aaOR:1.39 [1.16-1.67]), Zambian (Ref: Malawian; aOR:2.33 [1.95-2.78]), ever-married/cohabited status (Ref: never; aOR:3.13 [2.51-3.91]), urban setting (Ref: rural; aOR:0.72 [0.56-0.89]), having a partner living with HIV (Ref: HIV-negative; aOR: 0.59 [0.37-0.93]), and not knowing partner's HIV status (Ref: HIV- negative; aOR:0.01 [0.01-0.02]). Reasons for non-engagement varied by gender and age (p<0.001). Males and individuals aged 15-19 were more likely to report an unofficial partnership with their primary partner or never discussing CHTC, while females and individuals aged 20-24 years were more likely to report partner refusal.


CONCLUSIONS: In 2016, CHTC uptake was relatively common among Zambian and Malawian AYA, contradicting reports of low utilization. To build on the positive foundation and amplify CHTC uptake, efforts to develop effective, acceptable interventions targeting men, adolescents, and interpersonal barriers, such as status disclosure and communication, are needed.