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Who Has Yet to Test? A Risk Score for Predicting Never Having Tested for Human Immunodeficiency Virus Among Women and Men in Rural Malawi

Harrington, Bryna J., PhD*; Turner, Abigail Norris, PhD†‡§; Chemey, Elly, MBA§; Esber, Allahna, PhD; Kwiek, Jesse, PhD†¶; Norris, Alison H., MD, PhD‡§

Sexually Transmitted Diseases: June 2019 - Volume 46 - Issue 6 - p 416–421
doi: 10.1097/OLQ.0000000000000989
Original Studies

Background Human immunodeficiency virus (HIV) status awareness is important for preventing onward HIV transmission, and is one of the Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 goals. Efforts to scale up HIV testing have generally been successful, but identifying at-risk individuals who have never tested for HIV—a population necessary to reach improved HIV status awareness—remains challenging.

Methods Using data from a community-based cohort of people living in rural central Malawi, we identified demographic, socioeconomic, and sexual health correlates of never having tested for HIV. Correlates were assigned values from the logistic regression model to develop a risk score that identified who had never tested for HIV.

Results Among 1310 ever sexually active participants, 7% of the women and 13% of the men had never tested for HIV. Of those who had tested for HIV, about 30% had tested more than 12 months ago. For women, younger age and poorer sexual health knowledge were correlated with never having tested for HIV, and the c-statistic for the risk score was 0.83. For men, their partner having not tested for HIV, low socioeconomic status, and poor sexual health knowledge were correlated with never testing for HIV (c-statistic, 0.81). Among those with a score of 3 or greater, the sensitivity and specificity for never having tested for HIV were 81% and 77% for women, and 82% and 66% for men, respectively.

Conclusions About 10% of participants had never tested for HIV. This risk score could help health professionals to identify never testers to increase HIV status awareness in line with 90-90-90 goals.

About 10% of research participants in rural Malawi had never tested for human immunodeficiency virus. A risk score using demographic and sexual health knowledge variables may help identify who has never tested.

From the *Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC;

Department of Internal Medicine,

College of Public Health, The Ohio State University, Columbus, OH;

§Child Legacy International, Umoyo wa Thanzi Research Program, Lilongwe, Malawi; and

Department of Microbiology, The Ohio State University, Columbus, OH

Conflicts of interest: none declared.

A version of this analysis was presented at the International Society for Sexually Transmitted Diseases Research Meeting in Brisbane, Australia.

The authors also gratefully acknowledge Dr. John Phuka's contributions to the study's design. The authors acknowledge the following research funding: Institute for Population Research [NICHD P2C-HD058484], the OSU Center for Clinical and Translational Science [NCATS UL1TR001070, KL2TR001068, and TL1TR001069], the OSU Public Health Preparedness for Infectious Diseases program; the UNC Medical Scientist Training Program [grant T32GM008719], the NIMH individual fellowship [F30MH111370], and the NIH Fogarty International Center Grant [R25TW009340]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding sources had no role in the study design, data collection and analysis, interpretation of results, or preparation of the article for publication.

Correspondence: Bryna J. Harrington, PhD, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 2101 McGavran-Greenberg Hall CB#7435, Chapel Hill, NC 27599. E-mail:

Received for publication September 1, 2018, and accepted January 26, 2019.

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