Correlates of HIV status awareness among older adults in Uganda: results from a nationally representative survey

The paper is based on secondary analysis of existing data on persons aged between 45 and 59 years from the Uganda AIDS Indicator Survey (UAIS) conducted between February and September 2011 [21]. The 2011 UAIS was a nationally representative, cross-sectional, household sero-survey from which data of total 2472 persons aged 45 to 59 years was extracted.

The UAIS methodology including the data collection procedures have been previously reported [21]. In brief, the survey used a two-stage, stratified sampling design to provide national estimates from nine sero-survey regions across the country. In the first stage, a total of 470 enumeration areas (EAs) were selected, and from each area, a random sample of 25 households was selected for a total of 11,750 households. Data were collected on household and individual characteristics. Blood samples were obtained from consenting adults for HIV serology. This analysis is based on selected socio-demographic and HIV/AIDS-specific indicators of 2472 sexually active adults aged between 45 and 59 years, for whom complete HIV testing data were available. The selected indicators included prior HIV counseling and testing (HCT) experiences, knowledge of HCT service sites, self-perception of HIV risk, history of sexually transmitted infections (including STIs in the past 12 months), sexual risky behaviors (i.e., multiple sexual partners and condom use at last sex), comprehensive knowledge of HIV/AIDS, age, education level, wealth index, employment status and HIV stigma. These factors were selected because they have been associated with uptake of HCT in previous studies [12‐19].

The primary outcome of this analysis was awareness of HIV status among older Ugandans that were interviewed as part of the 2011 UAIS. In the survey, participants were asked ‘Have you ever been tested to see if you have/do not have the virus that causes AIDS?’ and if they responded in the affirmative, a follow-up question was asked: ‘When was the last time you were tested?’ Individuals were asked if they received the result of their last test and if not, whether or not they were already aware of their HIV status at the time of interview. All those who tested and reported receiving their HIV test results in the past 12 months (regardless of whether it was positive or negative) and those who reported that they were already aware of their HIV positive status at the time of interview were considered to be aware of their HIV status.

For the knowledge of HIV/AIDS, a respondent was considered to have comprehensive knowledge if she or he stated that (1) people can reduce the chances of acquiring HIV by using a condom every time before sex, (2) people can reduce the chance of acquiring HIV by having sex with just one partner who is not infected and who has no other partner; (3) people cannot acquire HIV from mosquito bites; (4) people cannot acquire HIV from sharing food with a person who has it, and that (5) a healthy looking person can have HIV.

Wealth index scores were constructed using household asset data via principal component analysis and categorized into quintiles as described in UDHS 2011 report [21]. An HIV stigma index was created from seven questions reflecting both accepting and negative attitudes about people living with HIV/AIDS. In the survey, the respondents were asked to state yes or no to the following questions: “Would you buy fresh vegetables from a vendor who has the virus that causes AIDS?”; “If a female teacher has the virus that causes AIDS but is not sick, should she be allowed to continue teaching in school?”; “If a family member got infected with the virus that causes AIDS, would you be willing to care for her or him in your own household?”; “If a member of your family got infected with the virus that causes AIDS, would you want it to remain a secret?”. The respondents were also asked to state if they agree or disagree with the following statements: “People with the AIDS virus should be ashamed of themselves” and “people with the AIDS virus should be blamed for bringing the disease into the community”. The responses were appropriately summated and categorized into 0 (“No stigma”), 1–2 (“Low stigma”) and above 3 (“High stigma”). All measures were based on self-reports.

Data were extracted from a sample of 2543 respondents aged 45–59 years, who were sexually active in the past 12 months prior to the survey. Table 1 shows the socio-demographic characteristics of the study sample. Of these, 2472 (97%) had complete data on HIV testing within the 12 months. Of the 2472 respondents, 59% were males; 50% were aged above 49 years; 91% were married or cohabiting; and 88% of the participants were living in rural areas. Further, 23 % had no formal education but majority were employed and notably in the informal agricultural sector.

Almost all participants (2448; 99%) had ever heard of AIDS and identified different preventive measures to HIV acquisition. However, only 35% had comprehensive knowledge of HIV/AIDS. Eleven percent reported to have been involved in high risk sex (sex with a non-cohabiting or non-married partner) while 14% reported multiple sexual partnerships in the past 12 months. At least 65% had some form of stigmatizing attitudes with about 10% classified as having high stigmatizing attitudes (Table 2). Eleven percent reported to have had an STI within the previous 12 months while only 20% of the respondents perceived themselves to be at high risk of acquiring HIV.

Of the 2472, 48% had ever tested and received their HIV test results and 23% tested and received their HIV results in the past 12 months or knew their HIV positive status. Of those who have ever tested, only 48% had a recent test in the past 12 months. At bivariate analysis, sex, age group, education level, religion, wealth index, sexual behavior, having had an STI in the past 12 months, stigma and low comprehensive knowledge of HIV/AIDS were significantly associated with awareness of HIV status in the past 12 months (Tables 1 and 2). Individuals reporting high levels of stigma (20% versus 29% among individuals with no stigma; p-value < 0.001) and those with limited comprehensive knowledge of HIV/AIDS (20% versus 28%; p-value < 0.001) were less likely to be aware of their HIV status. The proportions of those reporting to have received HCT in the past 12 months increased with increasing education levels and increasing wealth index. Marital status, place of residence (rural versus urban) and employment status were not associated with awareness of one’s HIV status.

Results from multivariable analysis are presented in Table 3. Education level, female (sex), risky sexual behavior, stigma and comprehensive knowledge of HIV/AIDS were associated with awareness of HIV status. Women are more likely to be aware of their HIV status than men (adjusted Odds Ratio (AOR) = 1.26; 95% CI: 1.04, 1.53). Individuals who had comprehensive knowledge of HIV/AIDS (AOR = 1.28; 95% CI: 1.04, 1.58) and those reporting multiple sexual partners (i.e. high risk sexual behavior) had higher odds of being aware of their HIV status than their counterparts (AOR = 1.53; 95% CI: 1.11, 2.10) (Table 3). There was an increasing trend towards higher odds of HIV status awareness with increasing levels of education. In particular, individuals with post-secondary education had more than twice the odds of being aware of their HIV status than individuals with no formal education (AOR = 2.10; 95% CI: 1.47, 2.99). A high level of stigma (holding at least three stigmatizing attitudes toward people living with HIV) was negatively correlated with awareness of HIV status (AOR =0.60; 95% CI: 0.45, 0.78).

In general, wealth index had no significant effect on one’s awareness of their current HIV status at multivariate analysis. Whereas, individuals in households in the third wealth quintile had lower odds of being aware of their HIV status, there was no consistency in upward trend or down trend to confirm the effect of wealth index on testing for HIV.