Experiences of testing negative or positive for HIV in Malawi, South Africa, and Zambia: a cross-sectional study

BackgroundHIV testing services (HTS) aim to increase HIV status awareness and serve as the gateway to prevention, care, and treatment. Understanding clients experiences accessing facility-based HTS is important to ensure comprehensive service provision, improve linkage to care, and ultimately contribute to better health outcomes. MethodsWe surveyed a convenience sample of adults presenting for HIV testing at 42 health facilities in Malawi, South Africa, and Zambia between September 2022 and April 2023. A structured questionnaire captured data on HTS history, reasons for testing, services obtained, and offer and uptake of pre-exposure prophylaxis (PrEP) or treatment. Open-ended questions captured participants experiences qualitatively. We report participant characteristics, experiences, and services provided using proportions stratified by country and HIV test result and summarize emergent themes from qualitative responses. ResultsWe enrolled 1,142 clients who presented for facility-based HIV testing (324 from Malawi, 389 from South Africa, 429 from Zambia). Of these, 32%, 24%, and 34% tested positive for HIV in Malawi, South Africa, and Zambia, respectively. Although most participants had tested for HIV prior to the current test, this proportion varied by country and current test result but was substantially lower for positive testers (64%, 66%, and 71% for Malawi, South Africa and Zambia) than for negative testers (82%, 88%, and 86%, respectively). Over a third of those who tested positive for HIV at this test had never previously tested for HIV. Among participants who tested positive, ill health was most frequently reported as the reason for testing; negative testers most often reported testing voluntarily (for their own information). Most participants reported being tested by lay counselors and receiving counseling before and after testing. Most participants who tested positive reported receiving ART initiation services, but fewer than a third in Malawi and South Africa and 39% in Zambia said they received adherence counselling. The proportion of those testing negative who were offered PrEP varied across the three countries, ranging from 27% of females in Malawi to 53% of females in Zambia. Participants in all three countries reported high satisfaction with the HTS services received and many qualitatively described high quality counseling, feelings of encouragement, and kind, warm treatment by providers. ConclusionWhile HIV testing clients in Malawi, South Africa, and Zambia were generally satisfied with their testing experiences, we identified opportunities for improvement in HTS services. ART adherence counseling was not universally provided, and prevention services were not offered to most negative testers. Of concern are the large proportion of positive testers who had never been tested before and self-reported testing because of ill health, which may indicate late presentation for testing. Emphasis on comprehensive linkage to services should be prioritized for all clients presenting for HIV testing. Statements and DeclarationsWe have no financial or non-financial competing interests to disclose.