J Community Health DOI 10.1007/s10900-013-9788-4
ORIGINAL PAPER
Facilitators and Barriers Related to Voluntary Counseling and Testing for HIV Among Young Adults in Bo, Sierra Leone Shalinee Bhoobun • Anuradha Jetty • Mohamed A. Koroma • Mohamed J. Kamara • Mohamed Kabia • Reginald Coulson • Rashid Ansumana • Kathryn H. Jacobsen
Springer Science+Business Media New York 2013
Abstract In 2012, we interviewed a population-based sample of 285 young adult residents (age 18–35 years) of the city of Bo, Sierra Leone, about their attitudes toward and experience with voluntary testing and counseling (VCT) for HIV. In total, 33 % of the participants (44 % of women and 25 % of men) reported having been tested for HIV at least once. More than 85 % of those not previously tested indicated a willingness to be tested in the near future, but untested participants were nearly twice as likely as tested participants to report fears about family/partner rejection, job loss, and other potential consequences of testing. More than 90 % of participants expressed a high desire for testing privacy, and the majority reported a preference for VCT at a facility far from home where no one would know them. Social barriers to HIV testing remain a challenge for HIV prevention in Sierra Leone. Keywords HIV Voluntary counseling and testing (VCT) Health services accessibility Sierra Leone S. Bhoobun M. A. Koroma M. J. Kamara Mercy Hospital, Kulanda Town, Bo, Sierra Leone A. Jetty K. H. Jacobsen (&) Department of Global and Community Health, George Mason University, 4400 University Drive MS 5B7, Fairfax, VA 22030, USA e-mail: [email protected] M. Kabia National AIDS Control Program, Freetown, Sierra Leone R. Coulson Methodist Youth Resource Centre, Bo, Sierra Leone R. Ansumana Mercy Hospital Research Laboratory, Kulanda Town, Bo, Sierra Leone
Introduction Voluntary testing and counseling (VCT) for HIV is a process in which individuals (or couples) undergo pre-test counseling, risk assessment, and a same-day rapid HIV test. They then have post-testing follow-up, HIV prevention counseling and, if necessary, referral for medical and support services by trained counselors. This widely recognized intervention has been implemented successfully throughout sub-Saharan Africa and in other parts of the world [1, 2]. Previous studies have demonstrated that VCT lowers the incidence of HIV by promoting safer sexual practices by both uninfected and infected VCT clients [3– 6]. VCT has also been found to promote HIV prevention and reduce stigma related to HIV [7, 8]. However, despite the advantages of VCT, VCT uptake rates and knowledge of personal HIV status have both been found to be low in parts of sub-Saharan Africa [9–11]. Sierra Leone, a West African nation with a population of about 6 million people, is still recovering from a decadelong civil conflict that ended in 2001 but left devastating impacts on infrastructure and health. Sierra Leone continues to have some of the world’s worst health indicators, especially for maternal and child health [12]. The prevalence of HIV infection among adults age 15–49 years is estimated to be about 1.6 %, up from 0.9 % 10 years ago [13]. Although this proportion is lower than that of many other sub-Saharan African countries, these numbers indicate that a considerable number of persons are living with HIV and AIDS (PLWHA) in Sierra Leone. Given this figure, and given the likelihood that a sizeable proportion of these individuals do not know that they have HIV and are therefore not taking extra precautions to avoid transmitting the virus to others, it is important to increase the uptake of voluntary testing and counseling (VCT) for HIV.
123
J Community Health
Sierra Leone’s 2008 Demographic and Health Survey found that only 13 % of women and 8 % of men age 15–49 years had ever had an HIV test [14]. HIV testing was more common among those with higher levels of education and wealth, those who had never been married, and those who lived in urban areas [14]. This rate is much lower than the rate reported from countries in southern, eastern, and central sub-Saharan Africa, though in line with the lower rates seen across much of West Africa [13]. The goal of this study was to examine the current prevalence of HIV testing in one city in Sierra Leone and to identify barriers to accessing VCT services in Sierra Leone among 18–35 year old adults.
Methods Study Population This community-based cross-sectional study was conducted in the city of Bo, in southern province, which is Sierra Leone’s second largest city and is home to an ethnically diverse population. Besides English, many residents also speak Krio, Mende, Temne, or Fula. This source population for this study consisted of the 18–35year-old residents of two neighborhoods on the northern side of Bo city, Kulanda Town and Njai Town, which are home to approximately 4,000 total residents [15]. Two free VCT centers are within walking distance of the neighborhoods: Mercy Hospital, a private mission hospital located in Kulanda Town on the Njai Town border, and Bo Government Hospital, the main public hospital for the city. Both centers provide free counseling and testing for anyone who desires it. They also both provide treatment services, including antiretroviral drugs, for those who test positive for HIV. Sampling Methodology The Mercy Hospital Research Laboratory (MHRL) maintains a health geographic information system (GIS) system of the city of Bo, and has conducted a door-to-door health census in 20 neighborhoods (locally referred to as ‘‘sections’’) of the city, including Kulanda Town and Njai Town [15]. These household surveys have collected information about the age and sex of all residents, maternal and child health status, and access to healthcare services [16, 17]. The health census in Kulanda Town and Njai Town identified 327 residential structures that were home to 1,027 households residing in these two section. A random sample of 150 residential buildings was identified from the GIS. Interviewers went to each of these houses to ascertain whether any individuals in the eligible age range lived in
123
the house. Age-eligible adults who met the inclusion criteria and consented to participation were interviewed. In order to minimize burden to the community, surveying was stopped after 300 age-eligible individuals had been interviewed; of these 300 interviews, 285 were completed. Survey Instrument The questions for the survey were a subset of items provided by the World Health Organization as part of its research guidelines for studies of HIV testing that were adapted for local use after pilot testing [18, 19]. The questionnaire for this study had four sections, one each for socio-demographic characteristics, HIV knowledge, VCT knowledge and attitudes, and HIV stigma. The first section asked about sex, age, religion, educational level, marital status, and employment status. (In this community, it is common for those who have recently graduated from school or who are seeking admission to a vocational school or university to list their occupation as ‘‘student,’’ even if they are not currently enrolled in a program of study. Many young adults who are unemployed prefer to refer to themselves as students.) The HIV knowledge section consisted of 7 open-ended questions about transmission and prevention. The VCT section contained questions about personal testing history, knowledge about testing locations, and attitudes about the importance of the test and personal willingness not be tested. The section also included a series of 9 yes/no questions about motivators to seek testing, 12 yes/no questions about barriers to receiving testing, and 8 yes/no questions about the conditions that would encourage local residents to seek testing. The HIV stigma section contained 22 yes/no questions about personal beliefs and about observations of how PLWHA have been treated in the local community. Data Collection Data were collected during September and October 2012 by local HIV counselors and others with research experience who were recruited to be interviewers. All had all previously worked as interviewers for HIV surveys, and all participated in a full day of formal training about the study protocol, how to use section maps to locate sampled households (since interviews were conducted in homes), interview techniques, and data recording methods. Interviewers were reminded of the importance of neutrality during the research portion of the study, so that they would not bias the study results by providing HIV information or otherwise influencing the responses of participants during the interview. During home visits to the sampled households, interviewers obtained written consent from each participant prior to conducting a structured interview based on a printed questionnaire. The interviewers included
J Community Health Table 1 Demographic characteristics of those who have and have not been tested for HIV Characteristic
% with characteristic (n = 285)
% of those tested (n = 96)
% of those not tested (n = 189)
%
n
%
n
%
Male
53.3
38
39.6
114
60.3
Female
46.7
58
60.4
75
39.7
0.004
35.1
20
20.8
80
42.3
33.0 19.6
27 28
28.1 29.2
67 28
35.4 14.8
31–35
12.3
21
21.9
14
7.4
% of those not tested (n = 189)
ORIGINAL PAPER
Facilitators and Barriers Related to Voluntary Counseling and Testing for HIV Among Young Adults in Bo, Sierra Leone Shalinee Bhoobun • Anuradha Jetty • Mohamed A. Koroma • Mohamed J. Kamara • Mohamed Kabia • Reginald Coulson • Rashid Ansumana • Kathryn H. Jacobsen
Springer Science+Business Media New York 2013
Abstract In 2012, we interviewed a population-based sample of 285 young adult residents (age 18–35 years) of the city of Bo, Sierra Leone, about their attitudes toward and experience with voluntary testing and counseling (VCT) for HIV. In total, 33 % of the participants (44 % of women and 25 % of men) reported having been tested for HIV at least once. More than 85 % of those not previously tested indicated a willingness to be tested in the near future, but untested participants were nearly twice as likely as tested participants to report fears about family/partner rejection, job loss, and other potential consequences of testing. More than 90 % of participants expressed a high desire for testing privacy, and the majority reported a preference for VCT at a facility far from home where no one would know them. Social barriers to HIV testing remain a challenge for HIV prevention in Sierra Leone. Keywords HIV Voluntary counseling and testing (VCT) Health services accessibility Sierra Leone S. Bhoobun M. A. Koroma M. J. Kamara Mercy Hospital, Kulanda Town, Bo, Sierra Leone A. Jetty K. H. Jacobsen (&) Department of Global and Community Health, George Mason University, 4400 University Drive MS 5B7, Fairfax, VA 22030, USA e-mail: [email protected] M. Kabia National AIDS Control Program, Freetown, Sierra Leone R. Coulson Methodist Youth Resource Centre, Bo, Sierra Leone R. Ansumana Mercy Hospital Research Laboratory, Kulanda Town, Bo, Sierra Leone
Introduction Voluntary testing and counseling (VCT) for HIV is a process in which individuals (or couples) undergo pre-test counseling, risk assessment, and a same-day rapid HIV test. They then have post-testing follow-up, HIV prevention counseling and, if necessary, referral for medical and support services by trained counselors. This widely recognized intervention has been implemented successfully throughout sub-Saharan Africa and in other parts of the world [1, 2]. Previous studies have demonstrated that VCT lowers the incidence of HIV by promoting safer sexual practices by both uninfected and infected VCT clients [3– 6]. VCT has also been found to promote HIV prevention and reduce stigma related to HIV [7, 8]. However, despite the advantages of VCT, VCT uptake rates and knowledge of personal HIV status have both been found to be low in parts of sub-Saharan Africa [9–11]. Sierra Leone, a West African nation with a population of about 6 million people, is still recovering from a decadelong civil conflict that ended in 2001 but left devastating impacts on infrastructure and health. Sierra Leone continues to have some of the world’s worst health indicators, especially for maternal and child health [12]. The prevalence of HIV infection among adults age 15–49 years is estimated to be about 1.6 %, up from 0.9 % 10 years ago [13]. Although this proportion is lower than that of many other sub-Saharan African countries, these numbers indicate that a considerable number of persons are living with HIV and AIDS (PLWHA) in Sierra Leone. Given this figure, and given the likelihood that a sizeable proportion of these individuals do not know that they have HIV and are therefore not taking extra precautions to avoid transmitting the virus to others, it is important to increase the uptake of voluntary testing and counseling (VCT) for HIV.
123
J Community Health
Sierra Leone’s 2008 Demographic and Health Survey found that only 13 % of women and 8 % of men age 15–49 years had ever had an HIV test [14]. HIV testing was more common among those with higher levels of education and wealth, those who had never been married, and those who lived in urban areas [14]. This rate is much lower than the rate reported from countries in southern, eastern, and central sub-Saharan Africa, though in line with the lower rates seen across much of West Africa [13]. The goal of this study was to examine the current prevalence of HIV testing in one city in Sierra Leone and to identify barriers to accessing VCT services in Sierra Leone among 18–35 year old adults.
Methods Study Population This community-based cross-sectional study was conducted in the city of Bo, in southern province, which is Sierra Leone’s second largest city and is home to an ethnically diverse population. Besides English, many residents also speak Krio, Mende, Temne, or Fula. This source population for this study consisted of the 18–35year-old residents of two neighborhoods on the northern side of Bo city, Kulanda Town and Njai Town, which are home to approximately 4,000 total residents [15]. Two free VCT centers are within walking distance of the neighborhoods: Mercy Hospital, a private mission hospital located in Kulanda Town on the Njai Town border, and Bo Government Hospital, the main public hospital for the city. Both centers provide free counseling and testing for anyone who desires it. They also both provide treatment services, including antiretroviral drugs, for those who test positive for HIV. Sampling Methodology The Mercy Hospital Research Laboratory (MHRL) maintains a health geographic information system (GIS) system of the city of Bo, and has conducted a door-to-door health census in 20 neighborhoods (locally referred to as ‘‘sections’’) of the city, including Kulanda Town and Njai Town [15]. These household surveys have collected information about the age and sex of all residents, maternal and child health status, and access to healthcare services [16, 17]. The health census in Kulanda Town and Njai Town identified 327 residential structures that were home to 1,027 households residing in these two section. A random sample of 150 residential buildings was identified from the GIS. Interviewers went to each of these houses to ascertain whether any individuals in the eligible age range lived in
123
the house. Age-eligible adults who met the inclusion criteria and consented to participation were interviewed. In order to minimize burden to the community, surveying was stopped after 300 age-eligible individuals had been interviewed; of these 300 interviews, 285 were completed. Survey Instrument The questions for the survey were a subset of items provided by the World Health Organization as part of its research guidelines for studies of HIV testing that were adapted for local use after pilot testing [18, 19]. The questionnaire for this study had four sections, one each for socio-demographic characteristics, HIV knowledge, VCT knowledge and attitudes, and HIV stigma. The first section asked about sex, age, religion, educational level, marital status, and employment status. (In this community, it is common for those who have recently graduated from school or who are seeking admission to a vocational school or university to list their occupation as ‘‘student,’’ even if they are not currently enrolled in a program of study. Many young adults who are unemployed prefer to refer to themselves as students.) The HIV knowledge section consisted of 7 open-ended questions about transmission and prevention. The VCT section contained questions about personal testing history, knowledge about testing locations, and attitudes about the importance of the test and personal willingness not be tested. The section also included a series of 9 yes/no questions about motivators to seek testing, 12 yes/no questions about barriers to receiving testing, and 8 yes/no questions about the conditions that would encourage local residents to seek testing. The HIV stigma section contained 22 yes/no questions about personal beliefs and about observations of how PLWHA have been treated in the local community. Data Collection Data were collected during September and October 2012 by local HIV counselors and others with research experience who were recruited to be interviewers. All had all previously worked as interviewers for HIV surveys, and all participated in a full day of formal training about the study protocol, how to use section maps to locate sampled households (since interviews were conducted in homes), interview techniques, and data recording methods. Interviewers were reminded of the importance of neutrality during the research portion of the study, so that they would not bias the study results by providing HIV information or otherwise influencing the responses of participants during the interview. During home visits to the sampled households, interviewers obtained written consent from each participant prior to conducting a structured interview based on a printed questionnaire. The interviewers included
J Community Health Table 1 Demographic characteristics of those who have and have not been tested for HIV Characteristic
% with characteristic (n = 285)
% of those tested (n = 96)
% of those not tested (n = 189)
%
n
%
n
%
Male
53.3
38
39.6
114
60.3
Female
46.7
58
60.4
75
39.7
0.004
35.1
20
20.8
80
42.3
33.0 19.6
27 28
28.1 29.2
67 28
35.4 14.8
31–35
12.3
21
21.9
14
7.4
% of those not tested (n = 189)
