Research Article: Facilitators and barriers for HIV-testing in Zambia: A systematic review of multi-level factors

Date Published: February 7, 2018

Publisher: Public Library of Science

Author(s): Shan Qiao, Yao Zhang, Xiaoming Li, J. Anitha Menon, Marcel Yotebieng.


It was estimated that 1.2 million people live with HIV/AIDS in Zambia by 2015. Zambia has developed and implemented diverse programs to reduce the prevalence in the country. HIV-testing is a critical step in HIV treatment and prevention, especially among all the key populations. However, there is no systematic review so far to demonstrate the trend of HIV-testing studies in Zambia since 1990s or synthesis the key factors that associated with HIV-testing practices in the country. Therefore, this study conducted a systematic review to search all English literature published prior to November 2016 in six electronic databases and retrieved 32 articles that meet our inclusion criteria. The results indicated that higher education was a common facilitator of HIV testing, while misconception of HIV testing and the fear of negative consequences were the major barriers for using the testing services. Other factors, such as demographic characteristics, marital dynamics, partner relationship, and relationship with the health care services, also greatly affects the participants’ decision making. The findings indicated that 1) individualized strategies and comprehensive services are needed for diverse key population; 2) capacity building for healthcare providers is critical for effectively implementing the task-shifting strategy; 3) HIV testing services need to adapt to the social context of Zambia where HIV-related stigma and discrimination is still persistent and overwhelming; and 4) family-based education and intervention should involving improving gender equity.

Partial Text

HIV/AIDS continues to be one of the world’s major public health issues, with sub-Saharan Africa being the most affected region. In 2015, it was estimated that 36.7 million people were living with HIV/AIDS, of which 25.5 million were living in sub-Saharan Africa, especially in eastern and southern Africa [1]. Zambia, a landlocked country in sub-Saharan Africa, has been heavily hit by the HIV epidemic since the late 1980s. The HIV prevalence rates peaked to 28% in the late 1990s, and it declined to 13.5% in 2009 [2]. By 2015, it was estimated that 1.2 million people were living with HIV/AIDS in Zambia [3]. An HIV prevalence of 12.9% among adults aged 15–49 years old makes Zambia one of top 10 countries with the highest HIV prevalence in the world [3]. Fighting against the HIV/AIDS epidemic for over thirty years, Zambia has developed and implemented diverse programs to prevent new infections and improve HIV treatment for those infected [3]. The scale-up of HIV-testing service is one effective national strategies to halt the epidemic.

Initial searches generated 1,819 records and retained 594 records after exclusion of duplicates (Fig 1). The two researchers conducted a three-step citation screening. At the stage of title review, 544 studies were not directly relevant to HIV testing programs in Zambia, leaving 50 for further examination. During the abstract screening process, 10 additional studies were excluded because they did not fit the inclusion criteria. Four of the eleven were cost-effective analysis studies, and six did not focus on factors associated with HIV testing. Forty studies were used for full-text review, excluding 14 that did not fit the inclusion criteria. Three of the 14 exclusions were non-empirical studies, nine did not focus on factors associated with HIV testing, and two were poster presentations. A hand search was conducted within the references of the remaining articles, finding six articles that fit the inclusion criteria. A total of 32 articles were identified as eligible for inclusion.

The rapid growth of empirical studies on HIV-testing in Zambia since 1999 reflects the scale-up of HIV-testing service and national level efforts in combating HIV/AIDS epidemic in Zambia. Along with evolving practices of promoting HIV-testing, the existing literature demonstrates five characteristics. The first is that geographic distributions of the study sites have expanded from urban to rural areas, from Lusaka to other provinces. The second characteristic is that study settings have turned into various formats with the increasing engagement of local communities. The third characteristic is that target populations covered by the studies have become diverse in gender, age and social roles. The forth characteristic shows that, the approaches of HIV-testing service have been diversified adapting to various clients and settings with applications of novel testing techniques. Finally, the past decade witnessed a growing number of longitudinal studies and intervention studies.




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