Predictors of testing history and new HIV diagnosis among adult outpatients seeking care for symptoms of acute HIV infection in coastal Kenya: a cross-sectional analysis of intervention participants in a stepped-wedge HIV testing trial

Globally, an estimated one in five people living with HIV (PLWH) are unaware of their HIV status [1]. Within Eastern and Southern Africa, groups that have gaps in terms of access to and uptake of HIV testing services (HTS) include key populations, partners of PLWH, men and young people [1]. The UNAIDS 2020 report highlights sex disparities in the HIV epidemic, with new infections decreasing more rapidly among women than among men and boys globally [2]. In Eastern and Southern Africa, despite a larger burden of women infected with HIV compared to men, testing rates, treatment coverage and viral suppression were higher among women, resulting in lower AIDS-related mortality rates among women compared to men in 2019 [2].

Several factors are associated with a lower likelihood of HIV testing in studies conducted in sub-Saharan Africa (SSA) including younger age (adolescents), male sex, less than primary education, lower socioeconomic status and having multiple sexual partners [3]. Masculine norms influence men’s engagement in the HIV care continuum in SSA, including HIV testing [4], clinic attendance, ART initiation and treatment continuation [5, 6]. Additional problems contributing to low HIV test uptake among men include stigma, discrimination and low risk perception, often leading to diagnosis with advanced disease and delays in care linkage [4, 5, 7‐13]. Amongst women, HIV testing has largely been integrated within antenatal care (ANC) services and has led to greater test coverage for women, with an estimated 60.7% of women in SSA receiving HIV testing as part of ANC [14].

Kenya has an estimated 1.3 million PLWH, with a national HIV prevalence of 4.9% in 2018, higher among women than men (6.6% vs. 3.1%); in the same year, 36,000 new HIV infections were estimated [15]. An estimated 62% of all new infections were among young people aged 15–29 years, with 15–24-year-olds contributing 42% in 2020 [16]. Kenya’s HIV testing policies are geared towards attainment of the 2020 UNAIDS first 90 goal (i.e., that 90% of PLWH be aware of their status): in 2018, 79.5% of Kenyan PLWH were aware of their status, 82.7% among women and 72.6% among men [15]. By 2019, an estimated 90% of PLWH knew their status [17]. With the new UNAIDS goals to diagnose 95% of all PLWH by 2030, additional interventions are needed [18]. Gender-targeted interventions are critical to address the sex disparities in the HIV epidemic.

Kenyan national HTS guidelines recommend annual HIV testing for the general population and quarterly testing amongst those at increased risk of HIV acquisition [19]. With provider initiated testing and counselling (PITC) accounting for the majority (77%) of more than 13 million tests performed in Kenya in 2017–2018 [20], health facilities are an important site for intensified HIV testing. Using data obtained from the intervention phase of a stepped-wedge trial evaluating opt-out HIV-1 nucleic acid (NA) testing among young adult patients seeking care who met criteria for acute HIV infection (AHI) risk [21], we assessed HIV testing history and new HIV diagnoses among male and female patients aged 18–39 years presenting at six outpatient clinics, evaluating factors associated with each outcome separately for men and for women.

We evaluated factors associated with HIV test coverage and new HIV diagnosis among male and female adult outpatients aged 18–39 seeking care for symptoms of infectious illness at six health facilities in coastal Kenya. Our study highlights sex differences in the uptake of HIV testing, with more men than women reporting never having tested (16.8% vs 5.6%) and more women than men reporting on-time testing (53.3% vs 42.4%). Among both men and women, young, single individuals with no children were less likely to have tested. Associations between sexual behaviours (e.g., multiple partners, concurrency, IPV) and HIV testing were evident among women, but no associations between sexual behaviour and HIV testing were found among men. In contrast, never testing for HIV prior to the study was associated with a fivefold increased odds of a new HIV diagnosis relative to on-time testing among men. Among men, a new HIV diagnosis was associated with reporting symptoms that started > 14 days ago, while fever was associated with a new diagnosis among women, suggesting earlier care-seeking by women in this population. Of note, both AHI cases were diagnosed among women. These findings point to a need for greater engagement of both men and women in the study area in HIV testing and prevention measures.

Gender norms have been shown to influence engagement in the HIV care continuum [4, 5]. Men have traditionally viewed health facilities as feminine spaces, with fear of embarrassment and showing weakness when seen seeking treatment, which has often led to delayed linkage to care. These effects have been compounded by HIV-associated stigma and fear that HIV would compromise a man’s ability to work and their role as a provider or lead to an early death, affecting their willingness to test for HIV and engage in HIV prevention methods [4, 5, 7]. Interestingly in our study, men who reported more than one sexual partner in the past 6 weeks were more likely to have ever tested for HIV, reflecting engagement with HTS among those with risky sexual practices. Despite a relatively high proportion of men who had never tested before in our study, all enrolled participants (613 males) accepted HIV testing when presenting for health care due to symptoms. Indeed, in the observational phase of the present study, we demonstrated high acceptability of HIV testing among men (~ 93.0%) in our target population [29]; similar findings have been documented in other parts of SSA [8]. This suggests missed opportunities for facility-based testing of symptomatic men in our setting that could be addressed with targeted interventions.

Structural barriers contribute to low testing and linkage rates among men in Kenya and other SSA settings. These barriers include labour opportunities requiring extended absence from households, long wait times and inconvenient clinic hours incompatible with work schedules, leading some men to assume their HIV status by proxy, adopting their wives’ HIV status as their own [7, 9, 12]. In our study, men who reported casual labour were more likely to test late relative to those reporting full employment, suggesting constraints on their ability to test. While HIV testing outside of facilities (e.g., community, mobile HIV testing and counseling, home-based testing) is acceptable to men and can achieve higher test coverage [12, 30], facility-based PITC such as in the current study or facility-based self-testing as carried out in a recent study in Malawi [31] could decrease missed opportunities, inform clinical decision-making, and identify HIV-positive men earlier in the course of disease.

We found that women were more likely to be on-time testers and to have ever tested for HIV compared to men. However, despite high HIV test coverage among women in Kenya and other settings in SSA through ANC and sexual reproductive health services [7, 15, 30, 32, 33], young (18–24 years), single, unemployed women and those who were childless were more likely to have never tested in our study. This is of concern, as young women aged 15–24 years made up a third of new adult infections and 10% of total AIDS-related deaths in Kenya in 2017 [34]. Interventions to increase HTS uptake and prompt linkage to care or prevention services among youth are needed, even though testing yield (i.e., HIV test positivity) will be low in these groups. Studies in western Kenya demonstrated increased HTS coverage could be attained among adolescent girls and young women through mobile, home- or community-based and oral self-testing approaches [35].

We found that female participants engaging in riskier behaviours (i.e., multiple sexual partners, concurrency) had a lower likelihood of late retesting, suggesting a realistic assessment of their potential risk of HIV infection. Interestingly, we found that sexually active women whose last sexual encounter was with a regular partner were almost 3 times as likely to have never tested for HIV compared to those whose last sexual encounter was with a spouse. This could be due to a tendency to wait for marriage to test, or a fear of their partner’s negative reaction or rejection if women test positive [36]. Our data also showed that women who had ever experienced IPV (25% of total) were more likely to retest late. Experiences with violence can undermine condom negotiation, HIV testing and linkage to care if positive [36, 37]. Despite the integration of HTS in Gender Based Violence (GBV) services in Kenya [19], more efforts are needed to ensure engagement in the HIV care continuum among women experiencing IPV. Multi-pronged programmes aimed at increasing GBV awareness, addressing cultural norms and strengthening community responses have been beneficial in other SSA settings [38], and could be helpful for Kenyan women, along with greater access to education and employment opportunities that lead to women’s empowerment.

Our study enrolled symptomatic adults 18–39 years presenting for primary care to detect acute and chronic HIV infection, with most new diagnoses among late retesters occurring among women and a large number of diagnoses among young women aged 18–29. Both AHI cases were diagnosed in women, and women reporting fever as a symptom had increased odds of a new HIV diagnosis. This underscores the importance of HIV testing among patients, especially women, presenting to care with symptoms of AHI [27]. Among men, whose symptoms had often lasted longer than those of women, we only diagnosed chronic HIV infection. Our findings underscore the importance of prompt HIV testing among patients presenting with symptoms of AHI, which clearly provides benefits with respect to earlier HIV diagnosis and prompt linkage to care and treatment. In Kenya, PITC constitutes majority of HIV testing conducted yet remains incompletely implemented: during the observation phase of the Tambua Mapema Plus study, only 1 in 4 symptomatic patients 18–39 years seeking care were offered an HIV test (29). Scaling up PITC, addressing the barriers to its implementation, and increasing knowledge and awareness of retesting recommendations may further reduce the sex disparities in HIV test such as those documented in this study.

Our study has some limitations. First, we relied on self-reported HIV testing status and sexual behaviour, which may have been influenced by social desirability. Second, our study was conducted among adults aged 18–39 years seeking care at six health facilities in coastal Kenya who were at increased risk for of AHI based on a risk score algorithm. These results may not be generalizable to patients presenting for other reasons (e.g., trauma, hypertension), to symptomatic patients in other regions in Kenya, or to populations beyond our target age group. Third, we stratified the study population by sex, which reduced power but highlighted important differences between men and women. Despite these limitations, our study provides useful insights on the correlates of late retesting and never testing for HIV, and of new HIV diagnosis, among men and women seeking care for symptoms compatible with AHI or other acute infectious illnesses. Diagnostic evaluations in this population are important for clinical management, and as such, this population should be of high priority for HIV testing strategies.

Our study evaluated the correlates of testing history and new HIV diagnosis among adults aged 18–39 years seeking care for symptoms of an acute infectious illness who met our risk score criteria. Our findings underscore the importance of facility-based HIV testing among adults presenting with symptoms of AHI, in order to avoid diagnostic delays and facilitate early linkage to HIV care and treatment. Our stratified analysis approach highlights the need for sex-targeted interventions. Approaches focused on scaling up provider-initiated HIV testing and improving HIV test uptake among key patient groups such as men who have never tested for HIV, and young, single men and women are needed. Opt-out HIV testing strategies that take into account HIV testing history (never testing or late retesting) could decrease time to diagnosis, greatly improve knowledge of HIV status and lead to better clinical outcomes. Addressing differences in HIV test uptake by men and women is key for achieving the UNAIDS 95–95-95 goals.