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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 19 th 2008. Overview. Background Research questions Research methods Findings - PowerPoint PPT Presentation
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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