Addressing the Slow Uptake of HIV Testing in Malawi: The Role of Stigma, Self-efficacy, and Knowledge in the Malawi BRIDGE Project Sima Berendes, MD, MPH Rajiv N. Rimal, PhD This study was carried out to test the hypothesis that HIV-related stigma would function as a barrier to uptake of HIV testing and that knowledge and self-efficacy would serve as facilitators. We also hypothesized that exposure to a behavior-change campaign would be associated with lower levels of stigma and higher levels of knowledge and self- efficacy. We conducted two separate cross-sectional surveys as part of the Malawi BRIDGE Project, including one at baseline in eight districts (n 5 891), and another at mid-term in four districts in Malawi (n 5 881). HIV-related knowledge, self- efficacy, and lack of stigma were positively associated with HIV testing. A positive association was also found between program exposure, on one hand, and knowledge, self-efficacy, and lack of stigma, on the other. These findings suggest that important psycho- social variables are linked with people’s likelihood of HIV testing, and that these variables may be influ- enced by behavior-change programs. (Journal of the Association of Nurses in AIDS Care, 22, 215-228) Copyright Ó 2011 Association of Nurses in AIDS Care Key words: behavior-change program, HIV, HIV testing, self-efficacy, stigma Increasing international efforts aim at improving the uptake of HIV testing (i.e., the willingness to make use of HIV testing services) in response to the alarming rates of HIV transmission (Joint United Nations Programme on HIV [UNAIDS]/World Health Organization [WHO], 2004; Matovu & Makumbi, 2007). This is especially true in sub-Saharan Africa, which remains the epicenter of the epidemic with the highest level of HIV transmission in the world. More than two thirds of all HIV infections and of all estimat- ed AIDS-related deaths occur in this region (UNAIDS/ WHO, 2009). With an estimated HIV prevalence of 12%, Malawi is one of the countries that is most severely affected by the epidemic (United Nations General Assembly Special Session [UNGASS], 2010). Approximately one million Malawians were living with HIV in 2007, and 68,000 people died from AIDS in that year (UNAIDS/United Nations Children’s Fund/WHO, 2008). These numbers are re- flected in the drastic decline of life expectancy, from a projected 54 years without the HIV epidemic to 39 years (Malawi Ministry of Health, 2008). One important component of the response to this disaster has been the introduction of voluntary HIV counseling and testing, which is a critical entry point for both prevention and mitigation programs (Painter, Sima Berendes, MD, MPH, is a post-doctoral research fellow, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland and Liverpool School of Tropical Medicine, University of Liverpool, Liverpool, United Kingdom. Rajiv N. Rimal, PhD, is Associate Professor, Department of Health, Behavior, & Society, Johns Hopkins University, Baltimore, Maryland. JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 22, No. 3, May/June 2011, 215-228 doi:10.1016/j.jana.2010.08.005 Copyright Ó 2011 Association of Nurses in AIDS Care