Social inequality and HIV-testing

Abstract

Abstract The plan to increase HIV testing is a cornerstone of the international health strategy against the HIV/AIDS epidemic, particularly in sub-Saharan Africa. This paper highlights a problematic aspect of that plan: the reliance on clinic- rather than home-based testing. First, drawing on DHS data from across Africa, we demonstrate the substantial differences in socio-demographic and economic profiles between those who report having ever had an HIV test, and those who report never having had one. Then, using data from a random household survey in rural Malawi, we show that substituting home-based for clinic-based testing may eliminate this source of inequality between those tested and those not tested. This result, which is stable across modeling frameworks, has important implications for accurately and equitably addressing the counseling and treatment programs that comprise the international health strategy against AIDS, and that promise to shape the future trajectory of the epidemic in Africa and beyond. Even as vastly increased funding for HIV has become available, those most vulnerable to HIV and its impact continue to receive the least access to HIV prevention, care and treatment services. (UNAIDS Reference Group on HIV and Human Rights 2007:1) 1. Introduction Over the last several years, dramatic increases in funding for AIDS and substantial reductions in the price of ART have promised to transform the life-prospects of HIV+ individuals in poor countries. In all but a handful of countries, this promise has yet to be realized, especially in sub-Saharan Africa (SSA). The main reason is that HIV-testing regimes, the critical gateway (Rennie and Behets 2006) to treatment and counseling, remain mired in two distinct problems. The first, the generally low testing prevalence across the continent, is widely recognized. As shown in Table 1, which uses data from Demographic and Health Surveys administered in the field in 26 SSA countries, only 16 percent of respondents report ever having had an HIV test (column 3). This is in spite of the much larger percentage who both declare their willingness to have an HIV test (column 4), and who know where they can get one (column 5). It is also in spite of recent increases in testing. In 10 of these countries, for example, people have been asked whether they have had an HIV test in two discrete survey waves (administered on the average in 2000 and 2005). During the five years that separate those waves the percentage of 15 to 49 year olds who claimed to have been tested increased from 10.9 to 26.3 percent. The second problem with the contemporary HIV-testing regime is related to inequalities within a given country. This can express itself in one of two ways. The first is differences across spatial boundaries, which in most SSA settings also signal ethnic and political boundaries. The second is differences across social boundaries, represented in the simplest terms by individuals' socio-demographic and economic characteristics. This second type of within-country inequality is the focus of this article. In the first of three main sections we use DHS data from across SSA in order to highlight the scale of within-country differences in HIV testing, that is, the extent to which HIV testees' socio-demographic and economic characteristics differ from those of their untested counterparts. In the second section we briefly review three key institutional responses to HIV testing problems: the expansion of clinic-based Voluntary Counseling and Testing (VCT); the substitution of opt-out testing for traditional VCT approaches; and the emergence of home-based testing. Finally, in the third section, this time drawing on survey data collected in Malawi, we evaluate whether home-based HIV testing has a stronger or weaker association with households' socio-demographic and economic characteristics than clinic-based testing. In other words, we use the available evidence to identify whether moving HIV testing out of clinics would make the HIV testing process more equitable between different social groups. …