Increasing men's uptake of HIV-testing in sub-Saharan Africa: a systematic review of interventions and analyses of population-based data from rural Zambia

Men's uptake of HIV-testing and counselling services across sub-Saharan Africa is inadequate relative to universal access targets. A better understanding of the effectiveness of available interventions to increase men’s HIV-testing and of men’s HIV-testing behaviours is required to inform the development of strategies to increase men’s levels and frequency of HIV-testing. My thesis aims to fill this gap. To achieve this, I combine a systematic review of randomised trials of interventions to increase men’s uptake of HIV-testing in sub-Saharan Africa with analyses of two population-based surveys from Zambia, through which I investigate the levels of and factors associated with HIV-testing behaviours. I also conduct an integrated analyses to explore whether the scale-up of voluntary medical male circumcision (VMMC) services between 2009 and 2013 contributed to increasing men’s population levels of HIV-testing. In the systematic review I find that strategies to increase men's HIV-testing are available. Health facility-based strategies, including reaching men through their pregnant partners, reach a high proportion of men attending facilities, however, they have a low reach overall. Community-based mobile HIV-testing is effective at reaching a high proportion of men, reaching 44% of men in Tanzania and 53% in Zimbabwe compared to 9% and 5% in clinic-based communities, respectively. In the population-based surveys, HIV-testing increased with time: 52% of men evertested in 2011/12 compared to 61% in 2013. Less than one-third of men reported a recent-test in both surveys and 35% multiple lifetime HIV-tests. Having a spouse who ever-tested and markers of socioeconomic position were associated with HIV-testing outcomes and a history of TB with ever-testing. The scale-up of VMMC provided men who opt for circumcision with access to HIV-testing services: 86% of circumcised men ever-tested for HIV compared to 59% of uncircumcised men. However, there was little evidence that VMMC services contributed to increasing HIV-testing among men in this rural Zambian setting. Existing strategies to increase men’s uptake of HIV-testing are effective. Over half the men in two population-based surveys reported ever-testing for HIV in rural Zambia. Nonetheless, some 40% of men never-tested. Men’s frequency of HIV-testing was low relative to recommendations that individuals with continued risk of HIV-infection retest annually for HIV. Innovative strategies are required to provide never-testers with access to available services and to increase men’s frequency of HIV-testing.