Using the theory of gender and power (TGP) and data from the Tsogolo la Thanzi (TLT) study, we examined how relationship power shapes young people’s decisions to test for HIV in rural Malawi (N=932), a high-HIV prevalence setting undergoing rapid expansions in testing services. We used generalized estimating equations (GEE) to examine associations among five constructs of relationship power (socioeconomic inequalities, relationship dominance, relationship violence, relationship unity, and mistrust), perceived risk, and receiving an HIV test over a 16-month period. The results indicate that young Malawians are testing for HIV at relatively high rates, repeatedly, and not just during pregnancy. Over the study period, 47.3% of respondents received at least one HIV test outside of TLT (range: 0–4). The GEE analysis revealed that men and women with higher levels of relationship unity were less likely to test for HIV. For men, being a victim of sexual coercion was an additional barrier to testing. Women’s testing decisions were more strongly influenced by perceptions of a partner’s risk for HIV than their own, whereas men relied more on self-assessments. The results highlight that testing decisions are deeply embedded within the relationship context, which should be considered in future HIV testing interventions.

Given the challenges of using condoms (Chimbiri, 2007; Tavory & Swidler, 2009) and the risks of extramarital partnerships (Carpenter, Kamali, Ruberantwari, Malamba, & Whitworth, 1999), it is not surprising that the majority of new HIV infections in sub-Saharan Africa occur within marriage or cohabitation (Dunkle et al., 2008). In response to these challenges, HIV testing and counseling has been promoted as an alternative strategy to reduce HIV transmission through prevention services and timely access to care and treatment (Painter, 2001; VCT Efficacy Group, 2000). Although the availability of HIV testing and counseling has improved throughout the region, many people still do not know their serostatus and may inadvertently transmit the virus to their sexual partners (World Health Organization [WHO], 2007). To date, the majority of research on HIV testing barriers focused on psychosocial factors that occur at the individual level (Obermeyer & Osborn, 2007), even though HIV testing decisions are often made within the broader relationship context.

Failure to consider the interpersonal dimension of HIV testing limits new opportunities to intervene at the couple level and improve uptake of HIV testing services. In this study, we considered whether one relationship dynamic in particular, power, shapes young people’s decisions to test in a high-HIV prevalence community in southern Malawi.