title: Frequency of HIV-testing and factors associated with multiple lifetime HIV-testing among a rural population of Zambian men.
abstract: BACKGROUND
  Across sub-Saharan Africa, men's levels of HIV-testing remain inadequate relative to women's. Men are less likely to access anti-retroviral therapy and experience higher levels of morbidity and mortality once initiated on treatment. More frequent HIV-testing by men at continued risk of HIV-infection is required to facilitate earlier diagnosis. This study explored the frequency of HIV-testing among a rural population of men and the factors associated with more frequent HIV-testing.
  
  
  METHODS
  We conducted a secondary analysis of a population-based survey in three rural district in Zambia, from February-November, 2013. Households (N = 300) in randomly selected squares from 42 study sites, defined as a health facility and its catchment area, were invited to participate. Individuals in eligible households were invited to complete questionnaires regarding demographics and HIV-testing behaviours. Men were defined as multiple HIV-testers if they reported more than one lifetime test. Upon questionnaire completion, individuals were offered rapid home-based HIV-testing.
  
  
  RESULTS
  Of the 2376 men, more than half (61%) reported having ever-tested for HIV. The median number of lifetime tests was 2 (interquartile range = 1-3). Just over half (n = 834; 57%) of ever-testers were defined as multiple-testers. Relative to never-testers, multiple-testers had higher levels of education and were more likely to report an occupation. Among the 719 men linked to a spouse, multiple-testing was higher among men whose spouse reported ever-testing (adjusted prevalence ratio = 3.02 95% CI: 1.37-4.66). Multiple-testing was higher in study sites where anti-retroviral therapy was available at the health facility on the day of a health facility audit. Among ever-testers, education and occupation were positively associated with multiple-testing relative to reporting one lifetime HIV-test. Almost half (49%) of ever-testers accepted the offer of home-based HIV-testing.
  
  
  CONCLUSIONS
  Reported HIV-testing increased among this population of men since a 2011/12 survey. Yet, only 35% of all men reported multiple lifetime HIV-tests. The factors associated with multiple HIV-testing were similar to factors associated with ever-testing for HIV. Men living with HIV were less likely to report multiple HIV-tests and employment and education were associated with multiple-testing. The offer of home-based HIV-testing increased the frequency of HIV-testing among men.
  
  
  CONCLUSIONS
  Although men's levels of ever-testing for HIV have increased, strategies need to increase the lifetime frequency of HIV-testing among men at continued risk of HIV-infection.
authors.affiliation: Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. Bernadette.hensen@lshtm.ac.uk.
authors.forename: B
authors.initials: B
authors.lastname: Hensen
authors.affiliation: MRC Tropical Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK. james.lewis@lshtm.ac.uk.
authors.forename: J J
authors.initials: JJ
authors.lastname: Lewis
authors.affiliation: MRC Tropical Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK. ab@zambart.org.zm.|ZAMBART Project, Ridgeway Campus, University of Zambia, Nationalist Road, Lusaka, Zambia. ab@zambart.org.zm.
authors.forename: A
authors.initials: A
authors.lastname: Schaap
authors.affiliation: ZAMBART Project, Ridgeway Campus, University of Zambia, Nationalist Road, Lusaka, Zambia. Margaret@zambart.org.zm.
authors.forename: M
authors.initials: M
authors.lastname: Tembo
authors.affiliation: University College London and Institute for Fiscal Studies, London, UK. m.vera@ucl.ac.uk.
authors.forename: M
authors.initials: M
authors.lastname: Vera-Hernández
authors.affiliation: Department of Public Health, University of Zambia School of Medicine, Lusaka, Zambia. wmutale@yahoo.com.
authors.forename: W
authors.initials: W
authors.lastname: Mutale
authors.affiliation: MRC Tropical Epidemiology Group, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK. Helen.Weiss@lshtm.ac.uk.
authors.forename: H A
authors.initials: HA
authors.lastname: Weiss
authors.affiliation: Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. James.hargreaves@lshtm.ac.uk.
authors.forename: J
authors.initials: J
authors.lastname: Hargreaves
authors.affiliation: Global Women's Health Division, Department of Obstetrics & Gynecology; Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA. jeffrey_stringer@med.unc.edu.
authors.forename: Jsa
authors.initials: J
authors.lastname: Stringer
authors.affiliation: ZAMBART Project, Ridgeway Campus, University of Zambia, Nationalist Road, Lusaka, Zambia. Helen@zambart.org.zm.|Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK. Helen@zambart.org.zm.
authors.forename: H
authors.initials: H
authors.lastname: Ayles
mesh_terms: D015492:AIDS Serodiagnosis / Q000706:statistics & numerical data*; D000328:Adult; D016000:Cluster Analysis; D005191:Family Characteristics; D015658:HIV Infections / Q000175:diagnosis* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D015995:Prevalence; D012424:Rural Population / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D055815:Young Adult; D015024:Zambia / Q000453:epidemiology