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

Background Although 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.

This 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.

HIV 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.

While 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 Zambia’s PMTCT and 95–95–95 goals. Competing Interest Statement The authors have declared no competing interest. Clinical Trial N/A Funding Statement This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study used publicly available, de-identified secondary data from the DHS Program. Ethical clearance for DHS data collection was obtained from the DHS Program and relevant national bodies. No further ethical approval was required for this secondary analysis. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Footnotes Email: nan53{at}georgetown.edu, whitesonmbele{at}gmail.com, azielynmutiibwa{at}gmail.com, hm896{at}georgetown.edu, linda.siachalinga{at}griffithuni.edu.au Data Availability The datasets used in this study are publicly available via the DHS Program website: