The path to controlling the global HIV/AIDS epidemic and achieving the UNAIDS goals of 90-90-90 is hampered by the need to identifying people living with HIV (PLHIV) through HIV testing and counseling (HTC) services. Improving access to HTC services is important because the early identification of HIV-positive individuals can facilitate their access to and enrollment in life-long HIV prevention and treatment services, which can lead to significant reductions in morbidity and mortality. HTC is also a cornerstone of prevention of mother-to-child (PMTCT) programs and can protect the health of pregnant women and their babies. Yet gaps remain in the uptake of HTC, particularly in sub-Saharan Africa where the more than 50% of PLHIV reside. Compounding this problem, there is a dearth of evidence on key operational challenges and the quality of services administered to people in low- and middle-income countries that may impede the delivery of HTC at health care facilities. This dissertation, which is comprised of two analyses, seeks to help fill that gap.

I examined the association between the regional HTC service environment and recent HIV testing behaviors among adults and the determinants of routine HIV testing in antenatal care (ANC) settings using nationally-representative datasets from East Africa. The first objective of this dissertation was to examine the association between HTC service readiness and HTC standard precautions and uptake in HIV testing and counseling by linking data from the Demographic and Health Survey (DHS) and Service Provision Assessments (SPA) from Kenya, Tanzania and Uganda from 2004-2010. The second objective was to determine the frequency of health care providers routinely offering HTC to pregnant women during ANC visits and the facility- and individual-level characteristics of health care providers offering the HIV test, using data from the Kenya 2010 SPA. These population-based analyses provide insight on the degree and extent of HTC program and policy implementation in East Africa, identify how the service readiness of HTC provided at facilities is associated with health-seeking behaviors on an individual level and help to fill an important knowledge gap in HIV implementation research.