Improved HIV testing coverage after scale-up of antiretroviral therapy programs in urban Zambia: Evidence from serial hospital surveillance

Background: We evaluated changing HIV testing coverage and prevalence rates before and after expanding city-wide antiretroviral therapy (ART) programs in Lusaka, Zambia. Methods: We conducted serial cross-sectional surveys on the University Teaching Hospital medical ward to assess HIV prevalence among inpatients of unknown status in 2003 and 2006. Willing participants received counseling and dual HIV rapid tests. We compared the proportion of inpatients receiving their test results in 2003 (off-the-ward testing) to 2006 (on-the-ward). Results: In 2003, none of 103 inpatients knew their HIV status or took ART; 99.0% (102/103) agreed to testing. In 2006, 49.3% (99 of 201) patients knew they were HIV-infected and were on ART; of those with unknown status, 98.0% (100/102) agreed to testing. In 2003, only 54.9% (56/102) received posttest counseling and 98.2% (55/56) learned their status. In 2006, 99.0% (99/100) received post-test counseling and 99.1% (98 of 99) learned their status. In 2003, 62.8% (64 of 102) of status- unknown inpatients who agreed to testing were seropositive by dual rapid test, compared to 48.0% (48 of 100) of status-unknown inpatients in 2006. When including inpatients who already knew their seropositive status plus those unknowns who tested seropositive, the proportion of inpatients that was seropositive in 2006 was 73.1% (147 of 201), higher than in 2003. Conclusions: After ART program expansion, inpatients in 2006 were far more likely than their 2003 counterparts to know their HIV status and to be taking ART. In both years, 63-73% of medical inpatients were HIV-infected and 98.5% of inpatients agreed to testing. On-the-ward testing in 2006 avoided the 2003 problem of patient discharge before learning of their test results. Hospital-based HIV testing is an essential clinical service in high prevalence settings and can serve further as a surveillance system to help track the community impact of outpatient AIDS services in Africa.