Who gets missed in Zambia's antenatal HIV testing? Persistent inequities despite routine screening policies in Zambia

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. We examined predictors of HIV testing during pregnancy among women in Zambia, with a focus on equity-related factors, utilizing 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 (ANC) 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. The study sample consisted of 4047 participants in 2007, 9190 in 2013/2014 and 7245 in 2018. Self-reported 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, approaches shown in other sub-Saharan African settings to improve testing uptake among underserved women. These equity-focused strategies are essential to achieving universal HIV testing in pregnancy and advancing Zambia's PMTCT and 95-95-95 goals.