The HIV testing gap: poorer and less educated Africans still missing out

28 May 2020

Despite intensified efforts to increase HIV testing in sub-Saharan Africa, poorer and less educated people are still missing out.

Group outside a house in Kenya

An analysis of 32 health and demographic surveys conducted between 2003 and 2016 in 16 African countries has found that poorer and less educated people remain less likely than others to test for HIV, despite efforts since 2008 to increase testing access.

Researchers analysed data from around 537,700 adults (15+) from Cameroon, Côte d’Ivoire, the Democratic Republic of Congo, Ethiopia, Guinea, Kenya, Lesotho, Liberia, Malawi, Mali, Niger, Rwanda, Sierra Leone, Tanzania, Zambia, and Zimbabwe. The data came from surveys conducted between 2003 and 2016, half before 2008.

The study compared trends in the socio-demographics, wealth and education levels of people who reported testing for HIV.

Poorer and less educated people were less likely to test for HIV than others. With some exceptions, HIV testing rates were higher in urban than rural areas. But socioeconomic inequalities in testing persisted, even when this and other variables such as age were accounted for.

Although men and women had similar testing levels before 2008, differences between the sexes emerged after testing efforts intensified. This may be due to the success of prevention of mother-to-child transmission (PMTCT) programmes in Africa, which have been highly successful at increasing HIV testing among women.

For both men and women, relative inequalities in HIV testing (which measures increases in relation to initial levels) decreased after 2008 but remained more pronounced among men than women.

Absolute inequalities in testing (which compares the lowest level to the highest) levelled-off among women after 2008 but increased among men. In the post-2008 surveys, the wealthiest men were roughly 3.6 times more likely to report HIV testing than the poorest men. The wealthiest women were roughly 2.8 times more likely to test than the poorest women. Before 2008, the wealthiest women had been nearly ten times more likely to test for HIV than the poorest.

Before 2008 HIV testing was lowest in Niger at 1% and highest in Zambia at 17%. After 2008, testing uptake was lowest in Guinea at 5% and highest in Lesotho at 53%.

In countries with high HIV prevalence, such as Lesotho and Malawi, the HIV testing gap between the richest and poorest was smaller than in countries with low HIV prevalence, such as Ethiopia and Niger.

Relative inequalities in uptake were more marked in west and central Africa than in eastern and southern Africa after 2008, among both women and men.

The results highlight the need to track progress in HIV testing among specific subgroups. Without better strategies to reach people with lower wealth and education levels, particularly men, millions of people in sub-Saharan Africa will remain unaware of their HIV status.

Written by Hester Phillips