Background
The Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) estimate that the number of people living with HIV or Acquired Immune Defiency Syndrome (AIDS) in 2008 stood at 33 million [
1]. Although sub-Saharan Africa is comprised of only 10% of the world's population, it is home to 67% of all people living with HIV - some 22 million [
1]. In 2007 an estimated 2.7 million people were newly infected [
1]. Declines in adult national prevalence appear to be underway in three sub-Saharan African countries: Kenya, Uganda and Zimbabwe [
2].
Uganda has made remarkable progress in reversing the trend of the HIV/AIDS epidemic in the last two decades. The HIV/AIDS Sero-Behavioral Survey (UHSBS) conducted in 2004/2005 showed a national adult HIV prevalence of 6.4% [
3] for the 15-49 age group, down from a peak of 28% in 1992 [
4]. This achievement has largely been attributed to the ABC strategy (abstinence, be faithful, condom use), treatment of opportunistic infections, prevention of mother-to child transmission of HIV (PMTCT), use of antiretroviral therapy (ART) and HIV counseling and testing [
5]. Recent evidence however suggests that the incidence of HIV is rising among some population sub-groups in Uganda [
6].
HIV Voluntary Counseling and Testing (VCT) is now a key component of national AIDS programmes in sub-Saharan Africa [
7], and is a major component of HIV/AIDS prevention, treatment and care efforts in Uganda [
8]. The UNAIDS in its guidelines on terminology reports that an alternative term for VCT is client initiated testing [
9]. VCT relies mostly on individuals presenting themselves for HIV testing and giving voluntary informed consent [
10]. It is a process whereby individuals or couples undergo pre-test counseling, risk assessment, a same-day rapid HIV test, post-test HIV prevention counseling, and referral for medical and support services by trained counselors [
11]. Matovu et al report that post-test counseling gives high-risk HIV-uninfected individuals the opportunity to change their high-risk behavior and potentially, the behavior of their sex and drug-using partners [
8]. As a result, expansion of VCT services has been advocated for, as a central component of public health efforts to bring down the HIV incidence through reduction in high-risk behaviors [
8].
As access to anti-retroviral treatment is scaled up in countries like Uganda, there is a critical opportunity to simultaneously expand access to HIV prevention, which continues to be the mainstay of the response to the HIV epidemic [
12]. The WHO and UNAIDS report that even in settings where antiretroviral therapy is not yet available, interventions such as co-trimoxazole prophylaxis and antiretroviral prophylaxis for the PMTCT offer significant potential health benefits to individuals and their children [
13].
VCT can be offered through different innovative approaches such as in the work place, in mobile clinics and using the home based model [
13]. VCT services in Uganda are provided through facility based services, stand-alone (freestanding) clinics and mobile outreach programmes. The provision of VCT through a home based approach was initiated in the country as a strategy for improving access to the services. In the facility based model, counseling and testing (CT) services are offered in medical settings (primarily the public sector). However, they may not appeal to groups who often do not go readily to health facilities, such as young people and men. Also, in the presence of competing interests, staff may not be committed to the VCT program [
10]. In quasi-integrated sites, an NGO provides CT in a public sector health facility; both the NGO and the facility contribute to managing the services [
14]. While in the home based model, CT is offered within the home to family members, including children where appropriate [
14]. Home based VCT involves the use of lay counselors or community health workers to provide counseling and testing. The counselors and testers move from door to door, provide pre-test counseling, and take consent from eligible family members [
10]. For this reason, it is sometimes referred to as the family-based model [
14].
Coverage of client-initiated HIV testing and counseling services is inadequate in both high-income and resource-constrained settings [
13]. It has been reported that in developing countries only one out of nine people has access to voluntary counseling and testing [
15]. A survey conducted in Uganda in 2006 shows that the percentage of women and men aged 15-49 who received an HIV test in the last 12 months and who knew their results was 12% [
16].
The uptake of VCT varies according to service delivery model and this is influenced by a number of factors. An annual serosurvey conducted in rural southwestern Uganda reports only 20% of participants had received their HIV results under the existing facility-based system [
17]. In a study cohort in Rakai district, Uganda, uptake of results delivered at home rose from 35% in the first year of the study in 1994-5 to 65% in 1999-2000 [
18]. Were et al also demonstrated that onetime home delivery of HIV results and counseling following community-wide mobilization in Mukono district of Uganda yielded a remarkable 93% uptake [
19].
Some studies have found that acceptance of VCT programs has been poor due to socio-cultural barriers. In Nigeria, women reported reluctance to test because of the discrimination and stigma that is placed upon those who openly acknowledge their HIV status [
20]. A study undertaken in Tanzania reported that socio-demographic factors such as gender and marital status influenced VCT uptake among males and females in different ways concurring partly with what had earlier been established by Matovu et al [
7,
21]. Elsewhere Pool et al report that confidentiality, social stigma and domestic violence reduced acceptance of VCT among rural Ugandan respondents [
22]. Nyanzi-Wakholi et al reported that the decision to take up VCT was postponed until the person or their partner was evidently sick [
23].
Studies undertaken on factors influencing uptake of VCT have mainly dwelt on specific models and there is paucity of literature comparing the facility and home based approaches. This study therefore seeks to compare predictors for uptake of facility and home based VCT in a rural context. Considering that the home based model is being promoted as a strategy for improving access, it is expected that findings from this analysis will provide a basis for a review of the design and implementation of existing models for VCT provision in rural communities of Uganda.
Results
Background characteristics of respondents
A total of 994 respondents were interviewed during the baseline visit. All respondents who were offered either facility based VCT (500) or home based VCT (494) accepted testing and received results. The respondents had a mean age of 32.2 years (SD 10.9) and were mainly female (68 percent). The majority had attended school (78.2 percent) and resided in rural households (62.9 percent). The mean number of years of education completed was 5.5 (SD 4.1). Approximately 61.8 percent were married, 15.7 percent single and 10.7 percent co-habiting.
The background characteristics of the respondents who received VCT through either the facility or home based models are compared in Table
1 below.
Table 1
Comparing background characteristics between facility and home based VCT respondents
Gender | | | |
Male | 138 (28) | 156 (33) | |
Female | 351 (72) | 326 (67) | 0.133+ |
Age: Mean (SD) | 31.8 (11.3) | 32.7 (10.7) | 0.158λ |
Residence | | | |
Trading center | 319 (67) | 32 (7) | |
Rural | 153 (33) | 450 (93) | <0.0001** |
Ever attended school | | | |
Yes | 385 (79) | 374 (77) | |
No | 100 (21) | 112 (23) | 0.351+ |
Years of education Mean (sd) | 5.8 (4.3) | 5.2 (4.0) | 0.014λ* |
Ever married | | | |
Yes | 287 (62) | 336 (75) | |
No | 179 (38) | 112 (25) | <0.001+** |
Monthly income median (mean) | 30,000/= (52,100/=) | 30,000/= (70,900) | - (0.011) |
Age at first sex: Mean (sd) | 18.08 (3.3) | 18.11 (3.4) | 0.916λ |
Had sex in past 12 months | | | |
Yes | 355 (79) | 353 (82) | |
No | 93 (21) | 79 (18) | 0.461+ |
Had VCT in past 12 months | | | |
Yes | 142 (29) | 81 (17) | |
No | 345 (71) | 399 (83) | <0.001+** |
Similar proportions of male and female respondents received either facility (28% and 72%) or home based (33% and 67%) VCT. The mean age and age at first sex debut of the respondents receiving either option did not differ significantly. The respondents differed with regard to residence, mean years of education completed, marital status and mean monthly income. A larger proportion of the respondents who received facility based VCT resided in trading centers (67%) while those who received home based VCT were from more rural (93%) households (p-value < 0.0001). Similar proportions of the respondents who received either facility (79%) or home based (81%) VCT had had sex in the 12 months prior to the study. However, their VCT experience in 12 months prior to the study differed with a higher proportion of respondents who received the facility based service having accessed VCT previously (p-value < 0.0001).
The respondents were asked to give the reasons for accepting to receive either facility or home based VCT models and these are compared in Table
2.
Table 2
Associations between reasons for receiving VCT, presence of STI symptoms, respondents' fear of discrimination, and type of VCT service model
Own past sexual behaviors | 5 (1) | 6 (1) | 0.8 (0.3, 2.7) | |
Partners' past sexual behavior | 9 (2) | 12 (3) | 0.7 (0.3, 1.7) | |
Taking care of people with HIV/AIDS | 7 (1) | 15 (3) | 0.5 (0.2, 1.1) | |
Wanted to know your sero-status | 466 (96) | 312 (66) | 11.6 (7.2, 18.7) | |
Planning for the future | 12 (2) | 17 (4) | 0.3 (0.2, 0.4) | |
Was asked to volunteer for the study | 7 (1) | 200 (42) | 0.02 (0.01, 0.04) | |
STI symptoms for males (present)
|
N = 128 n (%)
|
N = 141 n (%)
| | |
Sores on your penis | 25 (20) | 29 (21) | 0.9 (0.3, 2.7) | |
Discharge from penis | 20 (16) | 18 (13) | 1.2 (0.6, 2.5) | |
Pain or burning on urination | 28 (22) | 23 (17) | 1.4 (0.8, 2.6) | |
Itching | 39 (31) | 29 (21) | 1.7 (0.9, 2.9) | |
STI symptom for females (present)
|
N = 351 n (%)
|
N = 326 n (%)
| | |
Pain or burning on urination | 137 (40) | 81 (31) | 1.5 (1.1, 2.2) | 0.63 (0.46, 0.86) |
Non-traumatic sores or boils | 98 (29) | 67 (25) | 1.2 (0.8, 1.7) | |
Itching | 169 (50) | 91 (34) | 1.9 (1.4, 2.6) | |
Abnormal discharge | 85 (25) | 61 (24) | 1.1 (0.7, 1.6) | |
Discrimination related variable (yes)
|
N = 477 n (%)
|
N = 485 n (%)
| | |
Family will not treat you as a full family member | 235 (51) | 337 (70) | 2.27 (1.74, 2.96) | |
Friends will banish you | 204 (43) | 334 (69) | 3.02 (2.32, 3.94) | 0.39 (0.26, 0.57) |
Community will treat you as an outcast | 169 (36) | 318 (66) | 3.44 (2.64, 4.48) | |
Family will not care for you | 269 (57) | 347 (72) | 1.98 (1.51, 1.60) | 1.78 (1.22, 2.61) |
The respondents who received VCT through the facility based model were more likely to receive the service because they wanted to know their sero-status (OR = 11.6 95% CI = 7.2, 18.7). While those who received home based VCT did so because they wanted to plan for the future (OR = 0.3 95% CI = 0.2, 0.4) or were asked to volunteer for the study (OR = 0.02 95% CI = 0.01, 0.04). The past sexual behavior of the respondents or their partners was not associated with whether they received VCT through either of the models.
STI symptoms and use of VCT services
The respondents were asked to whether they had STI symptoms in the 6 months prior to the study and these were compared with the use of either model of VCT in Table
2.
Among the males, having had an STI in the 6 month period prior to the study was not associated with use VCT services. The female respondents who received VCT through the facility based model were more likely to have had pain or burning on urination and itching around the vagina (OR = 1.5 95% CI = 1.1, 2.2 and OR = 1.9 95% CI = 1.4, 2.6 respectively).
Knowledge on HIV transmission and use of VCT services
The respondents were asked whether each of the items shown in Table
3 was a mode of transmission for HIV. The answers to the questions are shown in Table
3.
Table 3
Knowledge of respondents on transmission of HIV
Working near someone with the AIDS virus | 92.7 |
Eating food cooked by someone who has the AIDS virus | 90.4 |
Sharing plates, forks, or glasses with someone who has the AIDS virus | 76.5 |
Using public toilets | 83.1 |
Injecting drugs with syringes or needles used by someone who has the AIDS virus | 93.6 |
An infant from his/her mother who has the AIDS virus | 83.7 |
Being coughed or sneezed on by someone who has the AIDS virus | 78.4 |
Having sexual intercourse without a condom with someone who has the AIDS | 92.8 |
A baby breast-fed by his/her mother who has the AIDS virus | 87.9 |
Attending school with a child who has the AIDS virus | 91.0 |
Bites by mosquitoes or other insects who have bitten a person who has the AIDS virus | 52.5 |
Sharing a bed with someone who has the AIDS virus | 91.6 |
Only one item (transmission of the AIDS virus by insects) was answered correctly by less than 70 percent of respondents. The median and mean score for knowledge on transmission of HIV for the whole sample was 11.0 and 10.07 (sd 1.9) respectively The mean score for respondents who received facility based VCT was 9.98 while that for those who received home based VCT was 10.15. This difference in mean score was not statistically significant (t test p-value 0.182). However, when the knowledge was classified into "high" and "low", those who had ever attended school were more likely to have a higher level of knowledge on the transmission of HIV (OR = 2.27 95%CI = 1.60, 3.31). The respondents who received home based VCT had a higher knowledge scores than those who received facility based VCT (OR = 0.7 95% CI = 0.49, 0.97).
Risk perception and use of VCT services
Respondents' perceptions about their HIV risk were assessed using a series of questions. They perceived themselves at a "high" risk of; getting infected (84%), already having the HIV virus (74%) and eventually developing AIDS (64%). Risk perception was not associated with level of knowledge on HIV transmission (p-value 0.60). The respondents who received facility based VCT were more likely to have a higher personal risk perception than those who received home based VCT (OR = 2.0 95% CI = 1.3, 3.1).
Discrimination and use of VCT services
The respondents were asked questions to assess their fear of discrimination. The responses are shown in Table
2. Respondents who received home based VCT facility based VCT were more likely to be worried about discrimination (p-value < 0.01).
Multivariate analysis of factors associated with use of VCT services
The factors that were significantly associated with use of VCT services in the unadjusted analysis were fitted into a multivariable logistic regression model with type of VCT model as the outcome. The results are shown in Table
4.
Table 4
Adjusted Odds Ratios from multivariable logistic regression
Residence (trading center or rural) | 0.14 | 0.07, 0.22 | < 0.001 |
Ever married | 2.45 | 1.66, 3.62 | < 0.001 |
Income categorized into poor/non poor | 0.50 | 0.36, 0.69 | < 0.001 |
Female with an STI | 0.63 | 0.46, 0.86 | 0.004 |
Friend will banish you | 0.39 | 0.26, 0.57 | < 0.001 |
Family will not care for you | 1.78 | 1.22, 2.61 | 0.003 |
The residence (aOR = 0.14, 95% CI 0.07, 0.22), marital status (aOR = 2.45, 1.66, 3.62), income (aOR = 0.5, 95% CI 0.36, 0.69), females with an STI symptom (aOR = 0.63, 95% CI 0.46, 0.86), fear that that one would be banished by friends if one had AIDS (aOR = 0.39, 95% CI 0.26, 0.57) and fear that one's family would not look after him/her if he or she had AIDS (aOR = 1.78, 95% CI 1.22, 2.61) were independently associated with type of VCT model.
Discussion
Overall the findings of this study reveal that factors such as residence, marital status, STI symptoms among females, income and fear of discrimination predict uptake of VCT among rural communities. The design of VCT services to improve coverage and utilization should therefore take these factors into consideration.
Consistent with studies conducted elsewhere, the main reason for receiving VCT through either model among the study population was to find out their status as opposed to other reasons such as own or spouse's past sexual behavior [
22,
29,
30]. As demonstrated elsewhere, this may suggest that VCT is feasible and well accepted and may also be a high profile subject among rural communities in south western Uganda [
11,
30].
Respondents' residence was independently associated with utilization of VCT services. As expected, respondents who resided in trading centers were more likely to seek facility based when compared to those who resided outside these trading centers, in a more rural context. This was largely because health facilities are within the vicinity of trading centers.
The findings show that the proportion of respondents who had previously received VCT in the home based group was lower than that in the facility based group (29% and 17% respectively). These findings are consistent with those from studies done elsewhere which show that ease of access contributes to acceptability between clinic-based and household based VCT [
31]. The findings suggest that emphasis should now be placed on improving service coverage by offering VCT services through both models to target the different clusters of rural communities.
The presence of STI symptoms in women was independently associated with the use of VCT services which contrasts findings elsewhere [
7]. The women who utilized facility based VCT were more likely to report having an STI symptom. This suggests that women who receive facility based VCT are more willing to disclose the presence of STI symptoms given that their spouses were not likely to be present. In the home setting, fear of repercussions from their spouses in terms of domestic violence constrains the women to reveal existence of any STI related symptoms. The implication here is the provision of VCT in a home setting is likely to lead to failure or a delay in identification of illnesses that may be risk factors for HIV. The provision of home based VCT should therefore be complemented with an assessment of risk factors for HIV particularly STIs and couples encouraged to subsequently seek appropriate care at a health facility.
In contrast to presence of STI symptoms in women, the high self perceived risk among 60% of the respondents was not independently associated with use of either model of VCT. This was consistent with findings elsewhere in rural Uganda [
21].
The study findings further show that the respondents were worried about discrimination if they contracted the AIDS virus. Worries about one being banished by the community or his/her family not caring once they have the disease were independently associated with use of VCT services. This is consistent with findings from other studies that showed people that people were uncomfortable with home based VCT because of a likelihood of being suspected to have HIV [
11,
18]. These findings underscore the importance of confidentiality in a person's decision to use VCT services. The provision of VCT services through either model should include rigorous campaigns against stigma and discrimination while endeavoring to reinforce confidentiality.
Limitations
The study was confined to two districts in Uganda. However they represent typical "average" districts in a resource limited setting in terms of the extent to which HIV-related practices and objectives are met. Therefore these findings are likely to be similar across Uganda. We also note that this was a cross-sectional study and therefore we cannot define the temporal relationship between the predictor variables and outcome. Further, to assess presence of an STI the respondents were asked to whether they had had any STI symptoms in the 6 months prior to the study. We however note that self reported STI symptoms are not a definitive indicator for sexually transmitted infections.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
EMM participated in the conception, design, and implementation of the study, statistical analysis, interpretation and drafting of manuscript. ASA and RG participated in conception, design and implementation of the study. SB participated in the conception, design, interpretation and drafting of the manuscript. All authors read and approved the final manuscript.