Uptake and correlates of HIV testing among men in Malawi: evidence from a national population–based household survey

Malawi is making progress in the fight against HIV: The HIV prevalence for adult population aged 15–49 has declined over the past 5 years, from 10.6% in 2010 to 8.8% in 2016 [1]. New HIV infections have also dramatically declined from 98,000 new infections in 2005 to 36,000 in 2016 [2]. However, these estimates are still unacceptably high, and Malawi needs to make significant improvements to achieve the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90-90 targets by 2020, which include 90% of people with HIV knowing their status, 90% of all people diagnosed with HIV infection receive sustained antiretroviral therapy (ART) and 90% of those on treatment being virally suppressed [3]. In order to reach the UNAIDS 90–90–90 targets it is critical that HIV testing services (HTS) be strategically expanded to diagnose many people living with HIV.

HIV testing is an essential strategy for reducing HIV related morbidity, mortality and may improve patient outcomes [4‐6]. The World Health Organisation (WHO) and Centre for Disease Control (CDC) recognise HIV testing as a critical gateway to prevention of HIV transmission, treatment, care and other support services [7, 8] . HIV testing empowers individuals and couples to adopt measures to avoid the transmission or acquisition of HIV infection [9]. Besides, HIV testing provides access to HIV prevention services, including prevention of mother-to-child transmission (PMTCT) and male circumcision [10]. Furthermore, knowledge of HIV status is a necessary step for initiation of ART and also serves as the basis for accessing care as well as emotional support that enable individuals to cope with HIV–related anxiety and increasing motivation to avoid risky behaviours [11, 12].

Malawi has been implementing rapid HIV testing services since early 2000. The services are provided free of charge in public health facilities and some private clinics/hospitals [13]. Despite the availability of free HIV testing services, there has been low uptake of HIV testing services among men in Malawi. A recent Malawi population–based HIV impact assessment (MPHIA) estimates that 35% of men in Malawi have never tested for HIV [14]. Men are a key population disproportionately affected by HIV and represent an important group to engage in HIV testing and prevention services. Besides, men in Malawi are regarded as key decision–makers in the families and might influence the control of economic resources that are significant for HIV prevention and care. Thus, a better understanding of the factors influencing the uptake of HIV testing in this population is required to inform the development of strategies to scale up HIV testing among men in Malawi, and ultimately, prevent HIV infection and promote timely linkage to HIV treatment and care. For instance, this might highlight the specific categories of men who need to be targeted with more efforts in order to improve HIV testing uptake. Elsewhere, studies have found a positive association between the likelihood of men having tested for HIV and older age, marital status, higher income as well as higher educational [15‐18]. To date, there have been no studies that have investigated the predictors of HIV testing among men in Malawi. Therefore, the aim of this study was to investigate factors associated with lifetime HIV testing among men in Malawi using a nationally representative sample.

The study findings demonstrate that over two–third (69.9%) of men in Malawi had been tested for HIV. The results highlight that several socio–demographic, behavioral and health service related factors influence the uptake of HIV testing services among men in Malawi. In particular, participants’ age was an important factor associated with HIV testing in this study. Men who were aged 20 years or older were more likely to have had HIV testing compared to adolescent men (15–19 years). This finding is in accordance with a recent study in Haiti which revealed that older men were more likely to have been tested for HIV than men aged 15 to 19 years [24]. Similarly, a study in South Africa reported that young males were less likely to be tested for HIV than order males [25]. The low uptake of HIV testing among adolescent men observed in this study could be attributed to a number of factors. Adolescent men may have low HIV–related knowledge as well as limited access to health care services including HIV testing services. For instance, a report by UNICEF reveals that only 32% of boys aged 15–19 years in sub–Saharan Africa know how HIV is transmitted and how it can be prevented [26]. Furthermore, men aged 15 to 19 years might have low engagement of sexual behaviours, therefore perceive themselves as having a lower risk of HIV, which in turn contributes to low uptake of HIV testing among this age group. Fear and stigma surrounding HIV and HIV testing in healthcare facilities may also prevent adolescent men from getting tested for HIV in Malawi. Thus, program planners need to develop and design effective programs, policies, and strategies that target adolescent men in Malawi.

The present study demonstrated that having higher educational level was associated with ever being tested for HIV. Educated men might have higher levels of exposure to HIV/AIDS–related information, better knowledge of the advantages of HIV testing as well as ability to make good decision to go for HIV testing than their uneducated counterparts. Other studies conducted elsewhere have also shown that having higher educational status was associated with ever being tested for HIV [17, 19, 27, 28]. These results highlight the importance of providing health education to men with low level or no education. Promotion of education among men is also a potential strategy to increase HIV testing among men in Malawi.

Region of residence was also associated with ever being tested for HIV even after adjusting for other variables. We observed that men residing in central and southern region were less likely to test for HIV than those from northern region. Similar findings have also been reported in other studies conducted in Ethiopia and Mozambique, where regional variations in uptake of HIV testing was observed [27, 29]. Cultural values and lifestyle differences across the regions could partly explain the observed differences in HIV testing. Moreover, regional differences in availability and access to HIV testing services as well as HIV/AIDS–related information could also be the reasons for the observed regional disparities in the uptake of HIV testing. Therefore, there is a need to expand HIV testing services to central and southern region to reach more men.

The results further indicate that HIV testing among men was positively associated with marital status. Men who were married and formerly married were more likely to have been tested for HIV than men who were never married. The possible explanation for this association is that the ministry of health in Malawi encourages male involvement in reproductive health and other care services. As a result, men may have opportunity of being tested for HIV because of frequent interaction with the health care providers when they accompany their partners to the clinic than their unmarried counterparts. Moreover, men are also likely to undergo for HIV testing when they are planning for marriage to know their HIV sero–status than those who have never been married. This result is consistent with the findings of previous studies conducted in Kenya and Mozambique [29, 30].

This study revealed that being covered by health insurance was associated with increased likelihood of HIV testing among Men in Malawi. This finding concurs with the results of a previous study in Haiti which reported that men who had health insurance were likely to have been tested for HIV compared to those who had no health insurance [24]. The most plausible explanation for this relationship is that men with health insurance tend to have access to regular health care and screenings including HIV testing than those who do not have health insurance. Besides, increased use of health care services by men with insurance also increases their chances of being offered the test through frequent encounters with health care providers. Therefore, there is a need to promote interventions such as free community based HIV testing programs to reach men with no health insurance in order to increase HIV testing among men in Malawi.

While the body of existing evidence suggests that key socio–demographic factors such as wealth index, area of residence and religion are associated with HIV testing [28, 31, 32], this study found contrary results. These variables were strongly associated with HIV testing in bivariate analyses; however, in the multivariable model the results modified and were all not significantly associated with HIV testing. These conflicting results could possibly be due to different sample size, study participants and setting as well as the differences in the definition of ‘HIV testing’ adopted by the studies. Further exploration of the role of these factors in uptake of HIV testing among men in Malawi is recommended.

It is imperative that our results be interpreted under a set of limitations. First, the study was limited to only the variables collected in the MDHS. As such, other important variables (such as substance use and sexual orientation) that may affect HIV testing but were not available in MDHS could not be examined. Second, the cross-sectional nature of MDHS limits the capacity to draw any causal inferences. Third, assessment of the outcome variable and some of the covariates was based on self-reported, thereby potentially introducing social desirability bias in participants’ responses. Furthermore, the present study assessed the lifetime occurrence of HIV testing by the participants. It did not focus on recent HIV test seeking behaviour (i.e., last 3 months, last 6 months, last 12 months). It is therefore possible that HIV testing happened before the exposure status. Finally, the outcome measure ‘ever been tested for HIV’, while being useful indicator to assess the overall uptake of HIV testing services, does not assess whether the participants who took HIV test received the results of their test or not. Taking an HIV test without knowing the ‘results of the test’ might not have implication for HIV prevention. Further research is needed to complement the findings of the current study by addressing the above limitations.

Despite these limitations, this study is the first to analyze the correlates of HIV testing among men in Malawi using a nationally representative sample. Given the representativeness of our sample, the current findings are generalizable to the entire country.

This paper provides nationally representative statistics related to HIV testing among men aged 15–54 years in Malawi. The findings suggest the need for health policy makers as well as other stakeholders to sustain current efforts to target younger unmarried men aged 15–19, men with low level or no education and expand HIV testing services to the central and southern regions of Malawi. Targeting the undiagnosed men living with HIV in a timely manner is a crucial and necessary step not only for achieving the UNAIDS’ 90–90-90 targets but for individuals to benefit from antiretroviral treatment and to sustainably reduce population–level HIV transmission.