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Sociodemographic and Clinical Characteristics of Clients Presenting for HIV Voluntary Counselling and Testing in Moshi, Tanzania

Posted on: Saturday, 29 October 2005, 03:02 CDT

By Chu, H Y; Crump, J A; Ostermann, J; Oenga, R B; Et al

Summary: HIV voluntary counselling and testing (VCT) reduces high- risk sexual behaviour. Factors associated with HIV infection in VCT clients have not been well characterized in northern Tanzania. We prospectively surveyed 813 VCT clients in Moshi, Tanzania. Clients were administered a questionnaire on sociodemographic characteristics, sexual behaviour, and health status. Blood was taken for rapid HIV antibody testing. Factors associated with HIV seropositivity were identified using multivariate logistic regression analysis. Of 813 clients, the seroprevalence was 16.7%. The strongest associations with seropositivity were reporting diarrhoea (odds ratio [OR] 10.4, 95% confidence interval [CI] 3.6- 29.9), an ill sexual partner (OR 6.3, 95% CI 3.0-12.9), or being a woman (OR 3.5, 95% CI 2.0-6.3). In a separate regression, the number of symptoms also predicted HIV infection (OR 2.1, 95% CI 1.6-2.6). VCT clients who tested positive had more HIV-related symptoms suggesting presentation at a later stage of HIV infection.

Keywords: Tanzania, HIV seroprevalence, voluntary counselling and testing, sexual behaviour, risk factors, sociodemographic characteristics

Introduction

As of December 2003, there were an estimated 34-46 million HIV- infected individuals worldwide, of whom 90% were unaware of their infections.1 The epidemic has disproportionately affected subSaharan Africa, which bears 70% of the worldwide HIV/AIDS burden. At the end of 2002, HIV prevalence among blood donors in Tanzania was estimated at 9.7%, with 82% of the cases transmitted by heterosexual sex.2 Most AIDS cases fall within the age group 20-49 years, with highest rates of infection in young women aged 25-34 years.3 Estimates of numbers of children orphaned by AIDS range from 1.5 to over two million.4 Epidemic modelling has suggested that when about 5% or more of a country's adult population becomes HIV infected, as is the case in Tanzania, the adult HIV prevalence rate tends to grow exponentially over time.5 In the Kilimanjaro Region, even in a hospital setting, 44% of patients found to be HIV infected in a point prevalence serosurvey on adult medicine and paediatric wards were unaware of their infections.6 With the advent of cheaper, rapid, and simple HIV testing kits, universal voluntary testing in Africa has been advocated.7

Voluntary counselling and testing (VCT) is an effective method of reducing high-risk sexual behaviour in sub-Saharan Africa, ideally identifying infected persons early in HIV disease.8 The development and expansion of VCT centres in Uganda and elsewhere has been associated with significant reductions in HIV seroprevalence.9 Research in Kenya, Trinidad, and Tanzania has shown that unprotected sex with a non-primary partner decreases from 30% to 18% in men receiving VCT and from 22% to 12% among women receiving VCT.8 Those found to be HIV infected may be more likely to protect themselves and others from HIV and to seek medical attention for early symptoms of AIDS-related illnesses.10 Those who test negative are more likely to change their behaviour to maintain their negative status by using condoms and/or by encouraging their partners to test for HIV.8

As well as promoting behaviour change, VCT can also serve as a point of referral for preventive services, including the prevention of mother to child transmission (PMTCT), and as an entry point for treatment of sexually transmitted infections (STIs), prophylaxis of opportunistic infections, diagnosis and treatment of tuberculosis (TB), and initiation of highly active antiretroviral therapy (HAART).7 It is estimated that less than 1% of sexually active urban populations have been tested for HIV,12 highlighting the urgent need to increase access to VCT.

The characteristics of VCT clients and risk factors for infection have not been previously reported in northern Tanzania. Consequently, we conducted a study among attendees of a newly established VCT centre in downtown Moshi, a city in the Kilimanjaro Region of Tanzania.

Methods

Location and context

An existing health-care centre in Moshi, Tanzania known as KIWAKKUKI (Kikundi cha Wanawake Kilimanjaro Kupambana na UKIMWI; Women Against AIE)S in Kilimanjaro) was chosen as the site for the establishment of an HIV-VCT programme and for collection of the sociodemographic characteristics of VCT clients. This decision was based on KIWAKKUKI's strong history of HIV care in the community and the established presence of a counselling network. KIWAKKUKI supports persons living with HIV/AIDS by providing home-based care, counselling and information about HIV infection, and orphan care and assistance. Healthcare counsellors at KIWAKKUKI include both volunteers and paid staff members. Volunteers and staff members are trained with classroom teaching and practical experience in accordance with the Tanzania Ministry of Health Guidelines for VCT testing. KIWAKKUKI VCT charges 1000 Tanzania shillings (US$ 0.95 at 2003 exchange rates) for VCT, and offers free testing for clients whose age is 24 years and younger, and for KIWAKKUKI members (estimated to be <4.4% of all tests). The VCT programme was initiated in March 2003, and data collection for this report began on 19 May 2003.

Voluntary HIV counselling, interviewing, laboratory procedures, and follow-up

Clients presenting for VCT received a confidential pre-test counselling session with a trained counsellor that lasted from 25 to 45 minutes. After obtaining informed consent, the counsellor interviewed each client using a structured questionnaire. VCT was not contingent on patient consent to participate in the survey. The questionnaire was designed to obtain sociodemographic characteristics, reasons for testing, sexual behaviour, including number of sexual partners in the past year, whether a sexual partner has other partners, condom use, alcohol use, exchange of gifts or money for sex, personal risk perception, and health status. Client response data were recorded on a paper questionnaire by the counsellor.

After pre-test counselling, a 2mL blood sample was drawn by syringe into a glass test tube, labelled with a code, and tested using both Capillus (Trinity Biotech PLC, Bray, County Wicklow, Ireland) and Determine (Abbott Laboratories, Abbott Park, IL, USA) rapid HIV1/2 antibody tests. If the two test results were contradictory, the blood sample was sent to the zonal referral hospital for confirmatory testing via Vironostika HIV-1 microElisa assay (Organon Teknika, Charlotte, NC, USA) in accordance with World Health Organization recommendations.13 In addition, for quality control purposes repeat testing was done on every 20th blood sample at the zonal referral hospital using the Vironostika HIV-I microElisa assay. The client received the result of the HIV test in approximately 30min. Appropriate post-test counselling was provided according to Tanzania Ministry of Health guidelines, and clients testing positive were referred to the zonal hospital HIV clinic for care and offered home-based care through the KIWAKKUKI home-based care network.

When HIV test results returned negative, the post-test counselling focused mainly on prevention of transmission of HIV, and each client was encouraged to return for repeat HIV testing in three and six months. Regular testing of the sexual partner was also emphasized.

Ethical approval for the study was granted by the Kilimanjaro Christian Medical Centre (KCMC) Research Ethics Committee, the Institutional Review Board of Duke University Medical Center (DUMC), and the Tanzania National Institute of Medical Research (NIMR) National Medical Research Coordinating Committee.

Analysis

Data from questionnaires were entered into an electronic database constructed with EpiInfo 2002 software (Centers for Disease Control, Atlanta, GA, USA). Data were validated by randomly sampling 10% of the questionnaires, with acceptable error rate being less than one error per five forms. Data analysis was done using Epilnfo 2002 and Stata 8.0 (State Corporation, College Station, TX, USA). Multivariate logistic regression analysis was used to evaluate the association of demographic characteristics, HIV risk factors, and HIV symptoms with seropositivity. The Bonferroni correction, in which a level of significance of P < 0.05 is reduced to P < 0.0014 for these data, was used to account for the 36 comparisons.

Results

From 19 May 2003 to 23 November 2003, 813 (>99%) of individuals who presented to KIWAKKUKI for testing consented to participate in the study. The median client age was 29 years (range 13-80 years). The sociodemographic characteristics of the attendees are summarized in Table 1. Nearly equal numbers of men and women (379 and 418, respectively) presented for testing. A large proportion were employed in business (24%) or farming (21%), educated to the primary level (69%), and either single (48%) or married (29%). The most frequently cited reasons for seeking VCT were for marriage planning, illness, unfaithful sexual partner, and previous high-risk sexual behaviour. A majority of clients reported fewer than two sexual partners in the past year (86%), while 48% had sexual partners with other sexual partners. On direct questioning of symptoms of fever, weight loss, cough, rash, and diarrhoea over theprevious two months, 27% of clients reported experiencing at least one symptom.

The overall seroprevalence of HIV in this population presenting for self-initiated HIV testing was 16.7%. Table 2 highlights characteristics of clients who tested seropositive versus those who tested seronegative. A majority of HIV-infected persons reported symptoms, and 48% presented for testing with symptoms they believed were specifically related to HIV infection. Being women, older, divorced, or not being single; or having an ill child or an ill sexual partner or knowing a person living with or died from HIV; or reporting symptoms or a higher perceived risk of HIV infection were all significantly associated with HIV-seropositivity. In multivariate logistic regression analysis, women were significantly more likely to test positive for HIV, as were clients with children (Table 3). Persons who were previously tested were half as likely to be positive. Having an ill sex partner or child was associated with significantly increased odds of seropositivity. Clients' perceived HIV symptoms and any of the specific symptoms asked about in the survey were associated with higher odds of seropositivity, but the effect was significant only for diarrhoea. Persons who had previously received TB treatment were three times as likely to test positive as those who had not received such treatment. The level of self-perceived risk of HIV infection, ranging from none to high, was independently positively associated with a higher likelihood of testing positive, as was the objective risk behaviour index. The objective risk behaviour index is defined as the sum of the indicator variables for more than one sex partner in the past five years, concurrent partners in the past one year, sexual partner with other partners, and exchange of gifts or money for sex.

In a separate regression in which cardinal symptoms were collapsed into a variable accounting for the number of these symptoms reported, the strongest predictors of seropositivity (P < 0.001) were women (odds ratio [OR] 3.5, 95% confidence interval [CI], 2.0-6.3), reporting an ill sexual partner (OR 6.3, 95% CI, 3.0- 12.9), and the number of cardinal symptoms reported (2.1, 95% CI 1.6- 2.6).

Table 1 Characteristics of clients presenting for VCT (n=813), KIWAKKUKI, May-November 2003

Table 2 Characteristics of VCT clients testing negative and those testing positive (%), May-November 2003

Several important differences in client characteristics were noted by gender. Women clients were less likely to exchange gifts or money for sex (30% of women versus 40% of men, P = 0.003), or to report multiple sexual partners (6% of women versus 18% of men, P < 0.001). Women were more likely than men to cite a reason for testing as 'unfaithful sex partner' (20 versus 9%, P < 0.001) and to report perceived symptoms of HIV (19 versus 9%, P < 0.001). An examination of the HIV-infected clients by gender showed that men who tested positive were more likely than women to report having more than one sexual partner in the past year (27 versus 6%, P = 0.001), being married (43 versus 24%, P = 0.04), and having used condoms (53 versus 29%, P = 0.01). There were no significant gender differences in the other factors associated with seropositivity.

Discussion

In regions of the world where HIV prevalence is high, one of the goals for prevention is to equip sexually active individuals with knowledge of their serostatus, thereby encouraging personal responsibility for their potential acquisition and transmission of HIV.7 The benefits of knowledge of serostatus extend to both infected and uninfected individuals. Those who are infected can access medical care and social support and can learn how to prevent further transmission. Those who are uninfected receive reinforcement of health information and risk behaviour reduction strategies. Balanced against these potential benefits, however, is the risk of stigmatization among clients presenting for testing by spouses, families, and community, as well as the barriers of cost, access, and availability of testing.

Forty-eight per cent of those found to be HTV infected presented with symptoms they perceived to be a manifestation of HIV infection. Previous research has not shown a significant association of reporting 'HIV-related symptoms' with HIV seropositivity,14 although repeated illness and suspicion of HIV was a common reason for testing.15 Nyblade et al. found no association of reporting illness and possible symptoms of HIV (e.g. weight loss, diarrhoea, TB, herpes zoster) with uptake of VCT in men, although the presence of symptoms was associated with greater uptake of services in women.16 This observation is confirmed by our data, which shows that there are more symptomatic women than men presenting for testing. It is possible that clients who are symptomatic feel encouraged to present to KIWAKKUKI for HIV testing because of the range of services that are offered to those who are HIV infected in the form of home-based care, opportunistic infection prophylaxis, and membership in support groups.

Table 3 Correlates of seropositivity among VCT clients presenting for testing (n=807), May-November 2003

Given the high rate of symptoms, in particular fever, cough, and weight loss, in this client population, our VCT centre could also potentially serve as an entry point for TB prevention, identification, and care for both seropositive and seronegative clients." All clients presenting to our VCT centre could be screened for TB. Both HIV-infected and HIV-uninfected individuals with active TB could be referred for TB treatment, while those who are HIV infected with a positive tuberculin skin test and without active TB could be initiated on isoniazid for prophylaxis in accordance with Tanzania Ministry of Health Guidelines. A sizeable proportion of the HIV-positive clients would also likely qualify for trimethoprimsulphamethoxazole prophylaxis for prevention of various bacterial and parasitic infections.17,18 The offer of TB treatment, as well as home-based support services and opportunistic infection prophylaxis, would then serve as a greater incentive to present for VCT.

To be most useful as a prevention strategy, VCT should ideally identify HIV-infected individuals early in infection when risk behaviour reduction and drug treatment are most effective. HIV seroprevalence in this population is 16.7%, compared with a national average of 11 %,19 and a regional prevalence rate of 6.3% in the antenatal clinic population and 6.8% among blood donors.2 Among bar and hotel workers in the Kilimanjaro Region, the seroprevalence rate is 26.1 %.20 By comparing our results with these populations, we can assume that we are attracting an at-risk population that is not necessarily representative of the general population, nor representative of traditionally high-risk groups. In this group, which may benefit from more specific messages than generalized advertising campaigns, the VCT strategy of risk behaviour identification and reduction may be particularly effective.

In our setting, only 40% of the seropositive clients were asymptomatic. This is likely to remain the case in an environment where stigma associated with HIV-infection coupled with the relative lack of drug treatment likely outweighs the possible benefits of early awareness of serostatus. If antiretroviral therapy were available, we believe VCT testing uptake would increase substantially, as lack of available care is a frequently cited barrier to testing.

The increased seroprevalence in women presenting to this VCT centre compared with men may reflect a referral bias. As KIWAKKUKI is a women's organization, women suspecting HIV infection may have found this to be a more accepting environment in which to present for VCT. However, the high rate of infection in women in our population mirrors a trend seen across subSaharan Africa.3,5,18 Although women have increased biological susceptibility to HIV infection,21 this alone does not explain the striking difference in HIV infection rates. The high rate of infection in women is also likely to be attributable to the gender inequality that does not permit women to negotiate sexual relationships.22 Women may not be empowered to insist that their partners use condoms or abstain from sex with other partners. In our study, the characteristics of the seropositive client included being women, having a partner with other partners, and having an ill sexual partner. This suggests that until women are able to reduce risk of HIV acquisition from their infected-sexual partners, the trend of an increasing rate of infections among women is unlikely to change.

The initiation of VCT at KIWAKKUKI has demonstrated that people who have symptoms and perceive themselves to be symptomatic from HIV are willing to present for VCT despite continued economic barriers to universal antiretroviral therapy. The counselling service has provided clients with risk behaviour knowledge and risk reduction strategies. It has linked HIVinfected clients to a package of care, including home-based visits, opportunistic infection management, nutritional support, and associations of people living with HIV/ AIDS. It will, in the future, help provide the framework necessary for the delivery of antiretroviral therapy.

Acknowledgements: We are very grateful to the staff of KTWAKKUKI AIDS Information Centre for their collaboration, and in particular to the VCT counsellors Beatrice Mandao, Eliakesia Shangali, Anna Msuya, Anna Mchaki, Agatha Chuwa, Alexia Mella, Awaichi Malle, B Haule, E Kiwla, Grace Gumbo, Lillian Mtui, Naomi Ringo, Magdalena Lyimo, Sylvia Mlay, and Yesusia Mariki. This study was supported in part by Roche Laboratories. Additional investigator support was obtained from AIDS Clinical Trials Group (UOl AI-39156, Drs Bartlett and Thielman) and Mid-career Investigator (K24 AI-0744-01, Dr Bartlett) awards fromthe National Institutes of Allergy and Infectious Dis eases and from the US Department of State Fulbright Programme (Drs Thielman and Chu).

References

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4 United States Agency for International Development. USAlD/ Tanzania, Annual Report FY 2003. Available at [www.usaid.gov/t/ asept.html] Accessed April 26, 2005

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6 Ole-Nguyaine S, Crump JA, Kibiki GS, et al. HIV-associated morbidity, mortality, and diagnostic testing opportunities among inpatients at a referral hospital in northern Tanzania. Ann Trop Med Parasitai 2004;98:171-9

7 De Cock KM, Mbori-Ngacha D, Marum E. Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century. Lancet 2002;360:67-72

8 The Voluntary HIV-I Counseling and Testing Efficacy Study Group. Efficacy of voluntary HIV-I counselling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomised trial. Lancet 2000;356:103-12

9 Mugerwa RD, Marum LH, Serwadda D. Human immunodeficiency virus and AIDS in Uganda. East Afr Med J 1996;73:20-6

10 Kamb ML, Fishbein M, Douglas Jr JM, et al. Efficacy of risk- reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA 1998280:1161-7

11 Godfrey-Faussett P, Maher D, Mukadi YD, Nunn P, Perriens J, Raviglione M. How human immunodeficiency virus voluntary testing can contribute to tuberculosis control. Bull WHO 2002;80:939-45

12 Kumaranayake L, Watts C. Resource allocation and priority- setting of HIV/AIDS interventions: addressing the generalised epidemic in Sub-Saharan Africa. J Int Deo 2001;13:451

13 Joint United Nations Programme on HIV/AIDS (UNAIDS)-WHO. Revised recommendations for the selection and use of HIV antibody tests. Wkly Epidemiol Rec 1997;72:81-7

14 Gresenguet G, Sehonou J, Bassirou B, et al. Voluntary HIV counseling and testing: experience among the sexually active population in Bangui, Central African Republic. J Acquir Immune Defic Syndr 2002;31:106-14

15 Zachariah R, Spielmann MP, Harries AD, Buhendwa L, Chingi C. Motives, sexual behaviour, and risk factors associated with HIV in individuals seeking voluntary counselling and testing in a rural district of Malawi. Trop Doct 2003;33:88-91

16 Nyblade LC, Menken J, Wawer MJ, et al. Population-based HIV testing and counseling in rural Uganda: participation and risk characteristics. J Acquir Immune Defic Syndr 2001;28:463-70

17 Anglaret X, Chene G, Attia A, Toure S, Lafont S, Combe P, et al. Early chemoprophylaxis with trimethoprim-sulphamethoxazole for HIV-1-infected adults in Abidjan, Cote d'Ivoire: a randomised trial. Cotrimo - CI Study Group. Lancet 1999;353:1463-8

18 Wiktor SZ, Sassan-Morokro M, Grant AD, et al. Efficacy of trimethoprim-sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Cote d'Ivoire: a randomised controlled trial. Lancet 1999;353:1469- 75

19 Country profile HIV/AIDS. Tanzania. Washington, DC: USAID, July 2003

20 Kapiga SH, Sam NE, Shao JF, et al. HIV-I epidemic among female bar and hotel workers in northern Tanzania: risk factors and opportunities for prevention. J Acquir Immune Defic Syndr 2002;29:409-17

21 Glynn JR, Carael M, Auvert B, et al. Why do young women have a much higher prevalence of HIV than young men? A study in Kisumu, Kenya and Ndola, Zambia. AIDS 2001;15(Suppl 4):S51-60

22 World Bank. Confronting AIDS: Public Priorities In A Global Epidemic. Oxford: Oxford University Press, 1997

(Accepted 2 July 2004)

H Y Chu MD1, I A Crump MB ChB1-2, J Ostermann PhD3, R B Oenga2, D K Itemba BA4, A Mgonja4, S Mtweve MD MHP2,4, J A Bartlett MD1,3, J F Shao MD PhD2 and N M Thielman MD MPH1

1 Department of Medicine, Division of Infectious Diseases and International Health, Box 3152, Duke University Medical Center, Durham, NC 27710, USA, 2 Kilimanjaro Christian Medical College, Tumaini University, Moshi, Tanzania; 3 Health Inequalities Program, Sanford Institute of Public Policy, Duke University, Durham, NC, USA; 4 Kikundi cha Wanawake Kilimanjaro Kupambana na UKIMWI (KIWAKKUKI; Women Against AIDS in Kilimanjaro), Moshi, Tanzania

Correspondence to: Dr Nathan M Thielman

Email: n.thielman@duke.edu

Copyright Royal Society of Medicine Press Ltd. Oct 2005

Source: International Journal of STD & AIDS

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