The high prevalence of HIV/AIDS among young people in sub-Saharan Africa [36
] has stimulated research and programmatic efforts to understand and address their sexual and reproductive health. In this study, we drew on data collected in two urban slum settlements in Nairobi City to 1) explore the linkages between young people's sociodemographic characteristics, HIV-related psychosocial attributes, and HIV testing behavior; and 2) investigate the reasons young people give for getting (or not getting) tested for HIV.
The bivariate analyses revealed the theoretically-expected association between HIV testing and the HBM-based constructs of HIV/AIDS knowledge, perceived susceptibility to HIV, level of anxiety about getting infected with HIV and attitudes towards condom use for HIV prevention. However, in the multivariable models only attitudes towards condom use was significantly associated with HIV testing among females. We note that we used a less exhaustive set of measures since this study was not designed as a test for HBM. Nonetheless, some of our findings do lend some support for the model. For example, at the bivariate level, we observed that, for females, youth who perceived that they were at some risk for HIV were more likely to have ever been tested. This echoes the voices of tested youth in the two slum settlements, majority of whom stated that they had been tested because they were concerned about their HIV status. Denison and colleagues [18
] in their study of youth aged 16-19 years in Ndola, Zambia also found that not wanting to be worried and wanting to know one's status were frequent reasons for willingness to be tested for HIV.
Of concern, however, is that among young people who had never been tested and were sexually experienced, close to two-fifths stated that they had not been tested because they were not at risk. Similar results were noted in a study conducted by Merchan-Hamann and colleagues [37
] in Brazil where the most common reason given by sexually experienced adolescents for not testing was that they were not at risk for HIV or that they trusted their sexual partner. Given that condom use among young people in Nairobi is relatively low even in instances where young people have multiple sexual partnerships [6
], being sexually experienced presents high risk for HIV infection. These results suggest that the educational campaign aimed at getting young people to understand that having unprotected sex is a risk factor for HIV infection, irrespective of what partners one is involved with, is not getting through to many young people. Thus, programmatic efforts to enable young people to accurately assess their levels of risk based on prior behavior may lead to increased use of HCT services. However these findings also underscore the need for alternative approaches beyond VCT, which "typically serve the 'worried well'" [38
] (p. 861), such as routine provider-initiated testing.
We observed significant gender differences in factors associated with HIV testing among youth in slum settlements. In particular, we found that young females are more likely to be required or offered an HIV test than are males, and that a substantial proportion of females who reported an HIV test were tested because they were pregnant. These findings are not surprising, given the widespread promotion of PMTCT interventions in the region [39
]. Previous studies among Kenyan [19
] and South African [40
] youth have also shown that HIV testing among females is highly associated with pregnancy status. Targeting pregnant youth for HIV testing is important in preventing pediatric HIV/AIDS and provides a potentially important avenue to reach partners of pregnant youth. Farquhar and colleagues' [41
] study on antenatal couple counseling in Kenya highlights potential benefits of partner participation in adoption of preventive strategies and women's uptake of PMTCT services. In this respect, the Kenya Ministry of Health's guidelines for PMTCT services in Kenya [42
] emphasize the need for partner involvement in PMTCT services. Nevertheless, it is important that HIV testing interventions target both males and females who may not be reached through PMTCT initiatives [35
]. As noted by MacPhail and colleagues [40
] in their study among youth in South Africa, a large proportion of young people visit health care facilities for various health services. Thus, drawing on the relative success of PMTCT services in increasing HIV testing rates among pregnant female youth, routine provider-initiated testing and counseling among all clients visiting medical facilities may provide an important avenue to increase HIV status awareness particularly for young men and non-pregnant women. Previous studies have shown the feasibility of provider-initiated HIV testing programs in limited resource-settings [43
Study findings suggest that there are substantial differences in HIV testing rates between the two slum settlements with males in Viwandani being more likely to have ever been tested than their peers in Korogocho and females in Viwandani being more likely than females in Korogocho to have requested an HIV test relative to being required to have one. Preliminary unpublished data from a recent study conducted in these two slum settlements [45
] shows that 41% of the 160 clinics and health centers in Korogocho surveyed in 2008 provided HCT services. In Viwandani, 34% of the 134 clinics offered HCT services. However, the same data showed that a greater proportion of health facilities in Viwandani (56%) than Korogocho (34%) had staff qualified to provide HCT services. These data suggest that in practice, residents of Viwandani may have a relative advantage in accessing HIV testing services. Given the high prevalence of HIV/AIDS in these urban slum settlements, it is important to ensure that residents have adequate access to HIV prevention and treatment services. Further, we note that although one might expect that majority of youth who request an HIV test would be tested in VCT centers, which are often low cost, we found that substantial proportions of youth who requested an HIV test received their test in other health care facilities. Data from the 2007 Kenya AIDS Indicator Survey [5
] show that only about one-fifth of Kenyan adults get tested in VCT centers or mobile units. We posit that some people may prefer to be tested at a general health center because this offers more privacy. Thus, ensuring that health care facilities in urban slum settlements are equipped with HCT services may increase access to testing services.
Finally, the guidelines issued by the Kenyan Ministry of Health recommend that appropriate counseling should follow all testing [46
]. Yet, we observed that counseling is not enforced universally. Given that those who received counseling were more likely to receive their test results, it is important to take steps to ensure compliance with government policies and guidelines on HIV testing.
Our study findings should be interpreted in light of several limitations. First, the study relied on self-reported data that are subject to response bias. Second, the cross-sectional nature of the study does not allow us to make causal inferences. Finally, the measures of the reasons for being tested or not being tested involved only the main reason in each case. Since individual decision-making surrounding HIV testing is likely to involve many different factors, this may under-represent some important secondary factors that affect health behavior.