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Health services research

ORIGINAL ARTICLE

Evaluating the effect of HIV prevention strategies on uptake of HIV counselling and testing among male most-at-risk-populations in Nigeria; a cross-sectional analysis Sylvia Adebajo,1 George Eluwa,1 Jean Njab,1 Ayo Oginni,1 Francis Ukwuije,1 Babatunde Ahonsi,1 Theo Lorenc2 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ sextrans-2014-051659). 1

Population Council, Abuja, Nigeria Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK

2

Correspondence to Dr Sylvia Adebajo, Population Council, 16, Mafemi Crescent, Utako District, Abuja A10000, Nigeria; [email protected] Received 6 May 2014 Revised 1 April 2015 Accepted 4 April 2015 Published Online First 28 April 2015

ABSTRACT Objective The aim of this study was to evaluate the effects of three strategies in increasing uptake of HIV counselling and testing (HCT) among male most-at-riskpopulation (M-MARPs) using programmatic data. Design HIV prevention strategies were evaluated in a cross-sectional analysis. Methods Three HCT strategies were implemented between July 2009 and July 2012 among men who have sex with men (MSM) and people who inject drugs (PWIDs) in four states in Nigeria. The first strategy (S1), involved key opinion leaders (KOLs) who referred M-MARPs to health facilities for HCT. The second strategy (S2) involved KOLs referring M-MARPs to nearby mobile HCT teams while the third (S3) involved mobile M-MARPs peers conducting the HCT. χ2 statistics were used to test for differences in the distribution of categorical variables across groups while logistic regression was used to measure the effect of the different strategies while controlling for confounding factors. Results A total of 1988, 14 726 and 14 895 M-MARPs were offered HCT through S1, S2 and S3 strategies, respectively. Overall, S3 (13%) identified the highest proportion of HIV-positive M-MARPs compared with S1 (9%) and S2 (3%), p≤0.001. Also S3 (13%) identified the highest proportion of new HIV diagnosis compared with S1 (8%) and S2 (3%), respectively, p≤0.001. When controlled for age, marital status and occupation, MSM reached via S3 were 9 times (AOR: 9.21; 95% CI 5.57 to 15.23) more likely to uptake HCT when compared with S1 while PWIDs were 21 times (AOR: 20.90; 95% CI 17.33 to 25.21) more likely to uptake to HCT compared with those reached via S1. Conclusions Peer-led HCT delivered by S3 had the highest impact on the total number of M-MARPs reached and in identifying HIV-positive M-MARPs and new testers. Training M-MARPs peers to provide HCT is a high impact approach in delivering HCT to M-MARPs.

INTRODUCTION

To cite: Adebajo S, Eluwa G, Njab J, et al. Sex Transm Infect 2015;91: 555–560.

HIV counselling and testing (HCT) is a key intervention strategy for effective HIV control in most developing countries including Nigeria.1 It increases access and knowledge of HIV status, encourages safer sex and is an entry point for HIV care treatment and support services.1Several studies have highlighted the potential benefits of knowing one’s

HIV status through HCT including the adoption of risk reduction strategies (correct and consistent condom use, reduction of sexual partners), accessing palliative care, psychosocial support and antiretroviral treatment, all resulting in increased survival and labour productivity.2–6 Furthermore, HIV-positive individuals who undergo HCT are reported to practice safer sex more frequently and reduce their risky behaviours, thereby decreasing their likelihood of transmitting and acquiring sexually transmitted infections (STIs).7 However, poor access to health facilities, fatalism, HIV-related stigma, inadequate confidentiality, fear of receiving an HIV-positive test result, long distances to HCT sites and long delays in returning HIV test results have been reported to limit access to conventional HCT services.2 8 9 These constitute barriers to effective scale-up of HCT services in African countries.2 8 9 Strategies for implementing HCT can be influenced by varying factors such as donor targets, target population and access to the communities. Routine testing in hospitals and other healthcare facilities, for example, significantly increases uptake and case-finding among attendees of these facilities.1 10–12 Alternative HCT delivery models, such as mobile HCT, provider initiated HCT and homebased HCT have been shown to increase access to and uptake of HCT in the general population.9 13–17 However, there is limited information on the impact of these models on HCT uptake among male most-at-risk-populations (M-MARPs) such as men who have sex with men (MSM) and people who inject drugs (PWIDs). Despite the higher risk and burden of HIV among MSM and PWIDs,18–20 access and coverage of HCT services targeted at these subgroups are very limited in Nigeria. The 2007 Integrated Biological and Behavioural Surveillance Survey in Nigeria reported that less than 50% and 30% of MSM and PWIDs, respectively, had ever had an HIV test and received their results.21 A follow-up Integrated Biological and Behavioural Surveillance Survey in 2010 reported similar rates for ever tested and received HIV result among MSM, and less than 40% for PWIDs. Moreover, less than 40% of MSM and PWIDs had had an HIV test in the year preceding the survey.22 With data from programme implementation activities, we describe the characteristics of M-MARPs and evaluated the effects of three HCT strategies

Adebajo S, et al. Sex Transm Infect 2015;91:555–560. doi:10.1136/sextrans-2014-051659

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Health services research deployed in delivering mobile HCT to M-MARPs. Such information is vital and provides evidence to guide funding, programming and policy for HCT delivery services among M-MARPs in Nigeria.

METHODS Setting Men’s Health Network, Nigeria (MHNN) is an HIV prevention programme implemented by the Population Council with funding from the Centers for Disease Control and Prevention, Atlanta, USA. Prior to the initiation of the programme, HIV prevention services in Nigeria were all tailored towards heterosexual HIV prevention with no focus on higher sexual risks (such as unprotected same-gender and heterosexual anal intercourse) and injecting risk behaviour. Furthermore, no sexual diversity training had occurred among healthcare providers either in public or private institutions, which was thus a limitation in the provision of stigma-free and non-judgmental services for MSM. Recognising this gap, the MHNN was designed to provide and make accessible, quality HCT, STI syndromic management, condoms and lubricants for men with a focus on M-MARPs by harnessing private and public health sector service providers through a social franchise service delivery model.

need for referral to facilities. The ratio of KOLs to clients in S2 was 1:20 per day and S2 ran from January to December 2011. The third programmatic strategy (S3), a peer-based outreach service, engaged a network of mobile HCT teams which consisted of KOLs who were trained to become counsellors and testers and also trained to deliver the MPPI. Thus, MPPI and HCT services were delivered by KOLs within M-MARP communities. The ratio of counsellor and tester to clients in S3 was 1:20. S3 ran from January to July 2012. In each programmatic strategy, the MPPI was designed to create demand for HCT services. The programme was implemented in Lagos and Oyo states in western Nigeria, Kaduna state in north-western Nigeria, and the Federal Capital Territory (FCT) in north-central Nigeria. These states were chosen based on high state-specific HIV prevalence21 among MSM in Lagos (25%), FCT (34%), Kaduna (16%) and Oyo (3%).

Study population MSM were defined as men aged ≥15 years who had engaged in anal sex with another man in the past year prior to entering the MHNN programme. Male PWIDs were defined as men aged ≥15 years who had injected prescription and psychosocial drugs recreationally in the past year prior to entering the MHNN programme.

HIV counselling and testing strategies

Data collection and management

Three programmatic strategies were deployed in an integrated service delivery model in this study. A standard advocacy approach was employed in all three strategies to raise awareness among M-MARPs and solicit the support and cooperation of community leaders prior to entering any community. The first programmatic strategy (S1), a standard mobile outreach service, was designed to provide HCT services through a network of mobile community-based key opinion leaders (KOLs). KOLs were M-MARPs community influencers and mobilisers who were trained as peer educators to deliver the minimum prevention package intervention (MPPI) to community members (clients). Clients reached with MPPI (including messages focused on abstinence, being faithful to a sexual partner, condom demonstration and distribution, as well as HCT promotion) in their communities were referred to MHNN designated M-MARP friendly health facilities for HCT. Each referred peer was issued a referral card with a unique identification number. The referral cards were in triplicates, two copies were issued to the peer with instructions to keep one and issue one to the HCT service provider while the KOL kept the third copy. The service provider was instructed to write the unique identification number on the card on the HCT client intake form to enable referral tracking. Each state had 10 KOLs trained to deliver the MPPI and HCT promotion through interpersonal communication and small group discussions to community members. The ratio of KOLs to clients per day in S1 was 1:25 per day. S1 ran from June 2009 to December 2010. Since S1 was the first intervention deployed within the M-MARP communities, it was assumed to be the baseline against which other strategies have been compared. The second programmatic strategy (S2), an integrated mobile outreach service, brought together KOLs providing the same MPPI with dedicated HCT mobile teams (counsellors/testers). The combined team of KOLs and mobile counsellors and testers were deployed to deliver HCT services within MARP communities. While the KOL’s role was to promote and create demand for HCT, the role of the teams of counsellors and testers was to deliver HCT to clients from site to site thus, eliminating the

Between July 2009 and July 2012, data were obtained using a structured precoded HIV counselling and testing client intake questionnaire. The questionnaire captured data on sociodemographic characteristics, sexual risk behaviours including type of sexual acts (vaginal and anal), unprotected sex with different types of sex partners, number of sex partners, engaging in transactional sex, history of STIs, as well as knowledge of HIV. All clients were offered HCT, thus uptake of HCT was measured as the proportion of all those offered HCT who were counselled, tested and received their results in keeping with the national indicator of complete HCT service provision.23 24 Informed consent was obtained and documented on the client intake forms from all clients who opted for HCT in keeping with the National HCT policy.23 Non-monetary incentives for using the service during each strategy were provided such as wrist bands and condoms valued at less than $1 and T-shirts valued at about $2. Data collected from clients were entered into Epi Data 3.1,25 coded and reviewed for completeness.

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Laboratory testing Rapid testing using blood samples obtained from a finger prick was used to conduct HIV test using the serial algorithm with Determine (Alere Medical, USA) and Unigold (Trinity Biotech, Bray, Ireland) simultaneously in accordance with Nigeria’s national HIV testing protocol.23 Discordant results are subjected to another rapid test using Stat-Pak (Clearview, USA) as a tiebreaker. All participants received pretest and post-test counselling, and respondents who tested positive were referred to local M-MARP friendly persons in designated National comprehensive HIV care and treatment facilities for further management. Clients who declined testing were given a referral coupon to access free HIV testing and STI syndromic management in any of the health facilities partnering with MHNN at any time of their choice.

Statistical analyses Data from Epi Data 3.1 were exported into Microsoft Excel and then into STATAV.12.1 software.26 We evaluated the Effects of the

Adebajo S, et al. Sex Transm Infect 2015;91:555–560. doi:10.1136/sextrans-2014-051659

Downloaded from http://sti.bmj.com/ on April 9, 2017 - Published by group.bmj.com

Health services research different strategies in a cross-sectional analysis. Analyses included descriptive statistics of demographic, behavioural and biological variables. χ2 statistics were used to test differences in the distribution of categorical variables across groups. Logistic regression analysis was used to assess associations between HCT strategies and HCT uptake. Crude associations were adjusted for sociodemographic variables (age, occupation, marital status) and key target population in multivariate analysis. Since MSM have different risk profiles from PWIDs, we conducted separate analysis for each key target group to assess the effect of the different HCT strategies on HCT uptake. Variables significant at p

Evaluating the effect of HIV prevention strategies on uptake of HIV counselling and testing among male most-at-risk-populations in Nigeria; a cross-sectional analysis.

The aim of this study was to evaluate the effects of three strategies in increasing uptake of HIV counselling and testing (HCT) among male most-at-ris...
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