Who Gets Missed? Inequities in Antenatal HIV Testing in Zambia Despite Routine Screening Policies.

BackgroundAlthough substantial advances have been made in eliminating mother-to-child HIV transmission in sub-Saharan Africa, significant disparities in antenatal HIV testing by socioeconomic status and geographic location continue. This study examined predictors of HIV testing during pregnancy among women in Zambia, with a focus on equity-related factors. MethodsThis study utilized data from the 2007, 2013-2014, and 2018 rounds of the Zambia Demographic and Health Surveys, which are nationally representative household surveys. Eligible participants were women aged 15-49 who reported a live birth in the five years preceding the survey and received at least one antenatal care visit during that pregnancy. We applied survey-adjusted logistic regression models to analyze time trends and identify key sociodemographic factors associated with HIV testing uptake. We also conducted stratified analyses by urban-rural residence. ResultsHIV testing among women who attended antenatal care and had recent births rose from 87% in 2007 to 95% in 2018. However, persistent disparities were observed. Women with no education, in the poorest wealth quintile, or residing in rural areas were significantly less likely to be tested. In multivariable models, education and wealth were strong predictors of testing uptake. Stratified models revealed that education and wealth gradients were steeper in rural than urban areas. ConclusionWhile Zambia has made major gains in antenatal HIV testing coverage, persistent inequities remain among the poorest, least educated, and rural-dwelling women. To close these gaps, national policy should prioritize community-based testing integrated within ANC services, expand the use of mobile clinics in rural areas, and implement peer-led education initiatives targeting underserved populations. These equity-focused strategies are essential to achieving universal HIV testing in pregnancy and advancing Zambias PMTCT and 95-95-95 goals.