Trends in VCT uptake in a rural ward in Tanzania

Doris Mbata, Alison Wringe, Maria Roura, Raphael Isingo, Milalu Ndege, Basia Zaba

and Mark Urassa.

TAZAMA / NACP seminar

Dar-es-Salaam, September 19th 2008

Overview

• Background

• Research questions

• Research methods

• Findings

• Policy implications

• Future research priorities

Background

Access to VCT should be fair and efficient

PREVENTION TREATMENTVCT

High uptake of VCT

Timely ART initiation

High ART coverage

Research questions

What are the social and cultural factors that underlie observed patterns of VCT uptake?

How has this profile evolved as ART has become more available?

What is the profile of people who are using VCT in relation to: socio-demographic traits, HIV status and risk behaviours?

Methods – surveys

• Every 3 years, HIV serological and sexual behaviour surveys are conducted in Kisesa ward

• Surveys are conducted in temporary village-based clinics.

• VCT services were available on-site in the 2004 and 2007 surveys.

• VCT attendance data can be linked to demographic and serosurvey data - including separate HIV testing conducted for research purposes, without disclosure of results.

Methods - analysis

Univariate and multivariate logistic regression was used to identify factors associated with VCT use:

• socio-demographic factors (age, sex, residence, marital status, marital change, religion, ethnic group)

• clinical factors (HIV status, spouse HIV status and VCT use, BMI decrease, STI symptoms)

• behavioural factors (sex with high-risk partner, # partners past 12 months, condom use past 12 months, perceived HIV risk, VCT knowledge)

Methods - qualitative

Qualitative data were collected during before and after introduction of ART programme:

16 sex, residence and age-specific FGDs:

perceived barriers to accessing VCT (and ART)

4 sex and residence-specific FGDs and 41 IDI with HIV-positive persons:

actual experiences of using VCT (and ART access)

Results: VCT uptake in 2004

31% (1246 ⁄ 3980) of men expressed an interest in VCT

but only 12 % completed VCT

24% (1195 ⁄ 4990) of women expressed an interest in VCT

but only 7% of women completed VCT

VCT uptake: men

Among men:

VCT uptake was higher among those:

– with recent marital status change => aOR = 1.48 – from non-Sukuma tribes => aOR = 1.77

VCT completion was negatively associated with: – having no education => aOR = 0.54 – following traditional beliefs => aOR = 0.54

(aOR = adjusted Odds Ratio, a measure of how likely they are to use VCT)

VCT uptake: women

Among women:

VCT uptake was higher among

– residents of roadside villages => aOR = 1.50– muslims => aOR = 2.14– never married => aOR = 4.98 – separated or divorced => aOR = 6.20

– Odds of VCT completion increased with each additional level of completed education (P < 0.01; test for trend).

Results: behavioural

The following factors were important predictors of VCT completion among men and women:

• Self-perceived risk of HIV• Prior knowledge of VCT • Previous VCT use• Sex with a high-risk partner in past yr

Results: spouse factorsThe strongest predictor of VCT use among both sexes was spouse HIV status and VCT use:

Spouse HIV & VCT status Men Women

No spouse 1 1

HIV-, no VCT 0.73* 2.22

HIV+, no VCT 1.35* /

HIV-, VCT 3.85** 12.71**

HIV+, VCT 11.35** 11.71**

Spouse, no HIV 0.89 3.05

Spouse not identified 0.96 3.54

* p<0.05; ** p<0.01

Results: HIV status

0%

20%

40%

60%

80%

100%

Male HIV- Female HIV- Male HIV+ Female HIV+

Sex and HIV status

Pe

rce

nt

No VCTdesire

VCT desire,no uptake

IncompleteVCT

CompleteVCT

n=3626 n=4521 n=405n=300

Results – VCT trends

Repeat testing in 2007 was high: 1181 persons with previous VCT => 32% re-tested 8144 never-tested persons => 15% opted for 1st VCT

By 2007, men and women ~ 50% more likely to test if HIV+

HIV + HIV-

2004 16% 12%

2007 23% 17%

Results: qualitative

Quantitative Qualitative Policy implications

VCT use initially loweramong women,particularlyamong married.

Little evidence that married women have a perceived low risk of HIV

Women expect negative response from spouse

Men concerned by financial implications of poor health/HIV

Peer support groups, HBC visits may help address concerns among couples

Address financial concerns

- Transport allowance - Nutritional support - IGA for HIV+

Results: qualitative Quantitative Qualitative Policy implications

VCT use was highest among individuals with a spouse using VCT

Family support, and disclosure of VCT desire between partners are important for VCT uptake

Some persons feel pressured to use VCT by partners who have tested.

Couple-counselling & HBC support may promote uptake among partners… ….but counsellors need to assess willingness of both partners to test.

Longer-term follow-up couple-counselling may be needed

Results: qualitative

Quantitative Qualitative Policy implications

VCT use was lower among remote than roadside residents, particularly among women

More stigma associated with HIV in remote areas?

Less exposure to HIV & VCT messages & HBC in remote areas;

Greater access to HBC services, HIV info and HIV services needed in remote areas to promote VCT

Transportation / mobile VCT needed for remote dwellers

Results: qualitative

Quantitative Qualitative Policy implications

VCT lower among men and women following traditional religions

• Traditional beliefs are consistent with care- seeking from traditional healers in preference to biomedical services?

• Beliefs around disease aetiology among people following traditional religions inconsistent with using biomedical services?

Assess feasibility of collaborations with traditional healers to refer persons with HIV symptoms to VCT

Assess feasibility of HIV education interventions with traditional healers

Conclusions

• The proportion ever tested at serosurveys has increased from 12% to X% among men and from 7% to Y% among women between 2004 and 2007.

• Initial discrepancies between the sexes in terms of the % of HIV+ using VCT have closed => good news for equitable access to ART

• Interventions need to increase knowledge about VCT and promote access among groups with lower rates of uptake

• Couple-counselling should be promoted

Future research

Future analyses of VCT uptake in this setting:

Continue to monitor the profile of VCT users as ART becomes locally available.

Assess the impact of VCT on behaviour change and HIV incidence

Investigate differences in VCT uptake at the village, sub-village and household level

Look at the association between ART status of household members, HIV-related mortality in household and VCT use

Doris to insert KISESA picture here

THANK YOU