HIV Testing Uptake in a Sexual and Reproductive Health Service for Youth and Impact on Population-Level Prevalence of Undiagnosed HIV in Zimbabwe

Purpose: High rates of undiagnosed HIV persist among youth. We investigated the uptake of HIV testing within community-based integrated HIV and sexual and reproductive health (SRH) services, and the impact on population-level prevalence of undiagnosed HIV in Zimbabwe. Methods: A cluster randomized trial (CHIEDZA) was conducted in three provinces (Harare, Bulawayo, and Mashonaland East) with 8 clusters/province randomized 1:1 to integrated HIV/SRH services for youth aged 16–24 years or to routine existing services for 30 months, followed by a population-level outcome survey. HIV testing uptake within CHIEDZA services, prevalence of population-level undiagnosed HIV, and individual- and community-level factors associated with undiagnosed HIV were assessed. Results: Overall, 29,827/35,446 (84%) youth who accessed CHIEDZA took up HIV testing, with 92% (27,339/29,827) testing at their first eligible visit. Notably, 98% and 93% of females and males took up another service alongside HIV testing. In the outcome survey, HIV prevalence was 7% (n = 1,226/17,554), of whom 576 (47%) were undiagnosed. There was no difference in prevalence of undiagnosed HIV by trial arm (49% intervention; 45% control). Individual-level factors associated with being undiagnosed were male sex, higher education, no HIV testing history, and inconsistent condom use. Community-level factors associated with undiagnosed HIV were unavailability of SRH services and testing drives, and harmful social norms. Discussion: Although community-based integrated HIV/SRH achieved high HIV testing uptake, there was no impact on population-level prevalence of undiagnosed HIV. Concerted efforts are needed to identify and reach those at highest risk, and to address structural factors and prevalent social norms.