HIV Testing, Behavior Change, and the Transition to Adulthood in Malawi

For young adults living in countries with AIDS epidemics, getting an HIV test may influence near-term decisions, such as when to leave school, when to marry, and when to have a first child. These behaviors, which define the transition from adolescence to adulthood, have long-term implications for well-being and directly affect a person's risk of contracting HIV. Using an experimental design embedded in a panel survey from Malawi, this study assesses how HIV voluntary counseling and testing of young adults affects these decisions. The results show a negligible intent-to-treat effect of HIV testing on behaviors. There is some suggestive evidence, however, of a differential response by wealth and by prior beliefs about one's HIV status.

We find little response to an HIV test among our outcomes. We see no impact of the VCT intervention on any of the behaviors by young women. The results for men suggest some slowdown in the transition toward adulthood in response to the VCT intervention as measured by marriage and impregnating a sexual partner. Despite a generalized epidemic, these results are consistent with the high rates of prior testing, the low rates of infectivity among young adults, and the low levels of reported likelihood of infection — characteristics of many settings in sub-Saharan Africa where testing is touted as a means to change behaviors. The majority of young men and women report there is no or little chance they are infected. As such, a test does not offer new information, although it does provide confirmation about one's prior beliefs. We do look for heterogeneity in response to a test through a set of ex post analysis looking at prior beliefs and wealth. These are ex post in the sense that the original study was a randomization without regard to these traits.

The wealth effects differ for women and men. The poorer young women, who assigned some likelihood to being infected before receiving the VCT offer, are less likely to transition into marriage or fertility a year after the intervention. Among the young men, it is the wealthier ones who are less likely to be married or to father—children a year after the VCT offer. This heterogeneity by socioeconomic status can result from the different set of opportunities richer and poorer young adults face and the different expectations they have about their futures. It could also be that testing influences decisions similarly, but because of the different propensities to engage in the different behaviors, independent of testing, we can only observe significant changes in behaviors for some groups.