Individual, household and community factors associated with HIV test refusal in rural Malawi

London School of Hygiene and Tropical Medicine, London, UK.
Tropical Medicine & International Health (Impact Factor: 2.33). 11/2008; 13(11):1341-50. DOI: 10.1111/j.1365-3156.2008.02148.x
Source: PubMed


To investigate individual, household and community factors associated with HIV test refusal in a counselling and testing programme offered at population level in rural Malawi.
HIV counselling and testing was offered to individuals aged 18-59 at their homes. Individual variables were collected by interviews and physical examinations. Household variables were determined as part of a previous census. Multivariate models allowing for household and community clustering were used to assess associations between HIV test refusal and explanatory variables.
Of 2303 eligible adults, 2129 were found and 1443 agreed to HIV testing. Test refusal was less likely by those who were never married [adjusted odds ratio (aOR) 0.50 for men (95% CI 0.32; 0.80) and 0.44 (0.21; 0.91) for women] and by farmers [aOR 0.70 (0.52; 0.96) for men and 0.59 (0.40; 0.87) for women]. A 10% increase in cluster refusal rates increased the odds of refusal by 1.48 (1.32; 1.66) in men and 1.68 (1.32; 2.12) in women. Women counsellors increased the odds of refusal by 1.39 (1.00; 1.92) in men. Predictors of HIV test refusal in women were refusal of the husband as head of household [aOR 15.08 (9.39; 24.21)] and living close to the main road [aOR 6.07 (1.76; 20.98)]. Common reasons for refusal were fear of testing positive, previous HIV test, knowledge of HIV serostatus and the need for more time to think.
Successful VCT strategies need to encourage couples counselling and should involve participation of men and communities.

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Available from: Katharina Kranzer, Sep 12, 2014
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    • "By understanding how uptake varies with testing strategy, non-facility based testing strategies may be optimized to achieve universal testing coverage. Factors found to decrease uptake of home-based HIV testing (HBT) have varied considerably depending on the population studied, and include older age (>25 years) [4], as well as young adulthood [15], having a concurrent partnership at the time of HBT [4], lack of participation by the male head of household [16], single marital status, higher educational attainment [17], and high (>30%) prior rates of HIV testing in a community [18]. In our study population several factors were associated with lower testing uptake, notably younger age and single marital status. "
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    ABSTRACT: The high burden of undiagnosed HIV in sub-Saharan Africa is a major obstacle for HIV prevention and treatment. Multi-disease, community health campaigns (CHCs) offering HIV testing are a successful approach to rapidly increase HIV testing rates and identify undiagnosed HIV. However, a greater understanding of population-level uptake is needed to maximize effectiveness of this approach. After community sensitization and a census, a five-day campaign was performed in May 2012 in a rural Ugandan community. The census enumerated all residents, capturing demographics, household location, and fingerprint biometrics. The CHC included point-of-care screening for HIV, malaria, TB, hypertension and diabetes. Residents who attended vs. did not attend the CHC were compared to determine predictors of participation. Over 12 days, 18 census workers enumerated 6,343 residents. 501 additional residents were identified at the campaign, for a total community population of 6,844. 4,323 (63%) residents and 556 non-residents attended the campaign. HIV tests were performed in 4,795/4,879 (98.3%) participants; 1,836 (38%) reported no prior HIV testing. Of 2674 adults tested, 257 (10%) were HIV-infected; 125/257 (49%) reported newly diagnosed HIV. In unadjusted analyses, adult resident campaign non-participation was associated with male sex (62% male vs. 67% female participation, p = 0.003), younger median age (27 years in non-participants vs. 32 in participants; p<0.001), and marital status (48% single vs. 71% married/widowed/divorced participation; p<0.001). In multivariate analysis, single adults were significantly less likely to attend the campaign than non-single adults (relative risk [RR]: 0.63 [95% CI: 0.53-0.74]; p<0.001), and adults at home vs. not home during census activities were significantly more likely to attend the campaign (RR: 1.20 [95% CI: 1.13-1.28]; p<0.001). CHCs provide a rapid approach to testing a majority of residents for HIV in rural African settings. However, complementary strategies are still needed to engage young, single adults and achieve universal testing.
    PLoS ONE 01/2014; 9(1):e84317. DOI:10.1371/journal.pone.0084317 · 3.23 Impact Factor
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    • "A total of 29 studies (85%) were clinic based [11-16,18-21,24-35,37-40,42] and five (15%) were situated at community level [17,22,23,36,44]. Twenty-four studies (70%) focused on adherence to ART [11-15,20,21,24-30,32-39,41-43], five studies (15%) focused on uptake of voluntary and counselling testing (VCT) [17,22,23,36,44], four (11%) on ART initiation [16,18,19,26] and one (3%) on attrition [31]. "
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    ABSTRACT: Background The role of socio-cultural factors in influencing access to HIV/AIDS treatment, care and support is increasingly recognized by researchers, international donors and policy makers. Although many of them have been identified through qualitative studies, the evidence gathered by quantitative studies has not been systematically analysed. To fill this knowledge gap, we did a systematic review of quantitative studies comparing surveys done in high and low income countries to assess the extent to which socio-cultural determinants of access, identified through qualitative studies, have been addressed in epidemiological survey studies. Methods Ten electronic databases were searched (Cinahl, EMBASE, ISI Web of Science, IBSS, JSTOR, MedLine, Psyinfo, Psyindex and Cochrane). Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Meta-analysis was used to synthesize data comparing studies between low and high income countries. Results Thirty-four studies were included in the final review, 21 (62%) done in high income countries and 13 (38%) in low income countries. In low income settings, epidemiological research on access to HIV/AIDS services focused on socio-economic and health system factors while in high income countries the focus was on medical and psychosocial factors. These differences depict the perceived different barriers in the two regions. Common factors between the two regions were also found to affect HIV testing, including stigma, high risk sexual behaviours such as multiple sexual partners and not using condoms, and alcohol abuse. On the other hand, having experienced previous illness or other health conditions and good family communication was associated with adherence to ART uptake. Due to insufficient consistent data, a meta-analysis was only possible on adherence to treatment. Conclusions This review offers evidence of the current challenges for interdisciplinary work in epidemiology and public health. Quantitative studies did not systematically address in their surveys important factors identified in qualitative studies as playing a critical role on the access to HIV/AIDS services. The evidences suggest that the problem lies in the exclusion of the qualitative information during the questionnaire design. With the changing face of the epidemic, we need a new and improved research strategy that integrates the results of qualitative studies into quantitative surveys.
    BMC Health Services Research 05/2013; 13(1):198. DOI:10.1186/1472-6963-13-198 · 1.71 Impact Factor
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    • "Individuals who accessed VCT were invited to participate in the serosurvey and only informed specifically about the availability of VCT during registration. This may have implications for VCT uptake if some were not prepared to make the decision and if married women felt they needed their husband’s approval (Kranzer et al. 2008). Although this may have led to a reduction in VCT access, it might ensure wider participation in the serosurvey, as agreement to VCT would not be seen as implicit in survey participation. "
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    ABSTRACT: To describe trends in voluntary counselling and testing (VCT) use and to assess whether high-risk and infected individuals are receiving counselling and learning their HIV status in rural Tanzania. During two rounds of linked serological surveys (2003-2004 and 2006-2007) with anonymous HIV testing among adults, VCT was offered to all participants. The crude and adjusted odds ratios for completing VCT in each survey were calculated to compare uptake by demographic, behavioural and clinical characteristics, stratified by sex. Repeat testing patterns were also investigated. The proportion of participants completing VCT increased from 10% in 2003-2004 to 17% in 2006-2007, and among HIV-infected persons from 14% to 25%. A higher proportion of men than women completed VCT in both rounds, but the difference declined over time. Socio-demographic and behavioural factors associated with VCT completion were similar across rounds, including higher adjusted odds of VCT with increasing numbers of sexual partners in the past 12 months. The proportion having ever-completed VCT reached 26% among 2006-2007 attendees, with repeat testing rates highest among those aged 35-44 years. Among 3923 participants attending both rounds, VCT completion in 2006-2007 was 17% among 3702 who were HIV negative in both rounds, 19% among 124 who were HIV infected in both rounds and 22% among 96 who seroconverted between rounds. VCT services are attracting HIV-infected and high-risk individuals. However, 2 years after the introduction of antiretroviral therapy, the overall uptake remains low. Intensive mobilisation efforts are needed to achieve regular and universal VCT use.
    Tropical Medicine & International Health 08/2012; 17(8):e15-25. DOI:10.1111/j.1365-3156.2011.02877.x · 2.33 Impact Factor
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